Evaluation of the Sandyford Initiative

Having Your Voice Heard –

Interim Report April 2002

Louise Lawson Mhairi Mackenzie Jane Mackinnon Mulu Ayana Jon Shute Health Promotion Policy Unit Department of Public Health University of Glasgow

2

Contents

3

4

Chapter One - Background to the study and introduction to

the Sandyford Initiative

During recent years there has been a shift in thinking and policy regarding the health

of the population. It has become widely acknowledged that in order to improve the

health and well being of individuals there is a need not only to improve and

modernise services, but it is also vital to tackle the wider determinants of health. This

was taken on board by The Public Health White Paper ‘Towards a Healthier

Scotland’ (1999) which highlights the need for public health policies to tackle these

wider determinants of health that affect quality of life. In order to work towards this it

also states the importance of the role of Health Boards in protecting and improving

the health of their population and in demonstrating clear reductions in health

inequalities. This move towards a focus on inequalities is reinforced in The White

Paper ‘Designed to Care – Renewing the NHS in Scotland’ (1997). This also aims to

refocus health care provision in order to create a shift towards patient centred care,

emphasising the role of primary care and the need for improving health and reducing

health inequalities.

In line with this shift in policy, work has been carried out by The Family Planning and

Sexual Health Directorate of the Greater Glasgow Primary Care Trust to develop a

social model of care. This model is based on one first tested and evaluated in

Castlemilk, a large and deprived housing estate situated on the outskirts of Glasgow.

This model involves a holistic approach to women’s contraception and reproductive

health as well as encouraging health promotion, referral to other statutory and

voluntary agencies and a client driven approach to health care.

In addition to these developments within the family planning services there was an

acknowledgement by the Genitourinary Medicine (GUM) services within Glasgow

that there was a need for strategic change. This was based on the need within

Glasgow to provide a highly accessible service to the population which would not

only fulfil clinical needs, but would also have a focus on health promotion in order to

improve knowledge of sexual health in those who used the service.

The third service that was in place in Glasgow was the Centre for Women’s Health,

which had a history of multi-agency working since it began in 1993. This was

5

providing a well-used service that was built on a more holistic approach to the health

of its users. Following a review of these three services alongside the implementation

of a multi-agency sexual health strategy led by Greater Glasgow Health Board a

decision was reached to merge these three services and form the Sandyford

Initiative.

The Sandyford Initiative is the development of a collaborative and integrated sexual

health service that encompasses the principals of the social model of health, which

opened in July 2000 in Sandyford Place, Glasgow. It brings together Family Planning

and Sexual Health, Genitourinary Medicine and the Centre for Women’s Health,

alongside the Steve Retson Project and the Routes Out of Prostitution Social

Inclusion Partnership Intervention Team. The inception of the Initiative was due to the

desire for the three core services to further develop a social and holistic model of

health care. In addition to the services provided within these main clinics and centres

the Sandyford Initiative also incorporates the delivery of community-based services.

Following the opening of the Sandyford Initiative a series of work was carried out to

look at the integration of management structures. This included a staff consultation

exercise by Greater Glasgow Primary Care Trust (April 2001). Following this the

Sandyford Initiative now has a single directorship for all services, and four Associate

Directors support this position.

Overall Aim and Strategic Objectives of the Sandyford

Initiative

The overall aim of the Initiative is to implement a citywide initiative to enhance the

promotion of sexual, reproductive and women’s health and the quality of health care

using a social model of health.

The strategic objectives of the Initiative are:

� Maximising the integration of clinical and social aspects of health in each of the

three main services

� Creating an innovative model of barrier free health which builds on existing

collaboration between the three services

6

� Implementing ways of working to address unmet needs of current and potential

service users

� Pro-actively informing policy development in different organisations to promote

sexual, reproductive and women’s health (see Sandyford Initiative Development

Plan)

There are currently five different services provided within the three main branches of

the Sandyford Initiative. Although the services are outlined separately for the

purposes of this introduction, the delivery of these services is an integrated process

in which the three branches work closely together. In addition to the three main

services the Sandyford Initiative also runs individual projects such as Roots Out of

Prostitution, which aim to reach individual communities with specific sexual and

social health needs.

Family Planning

This service aims to provide a welcoming environment for individuals to come and

receive family planning support. It is based on the holistic approach to women’s

contraception and reproductive health first developed in Castlemilk. The service also

actively encourages health promotion and a more patient-centred approach to health

care. The centre provides appointments and a drop-in service at a range of times

with the aim of increasing the accessibility of the service.

The Place

Within the family planning services this drop-in centre provides a service dedicated to

young people aged between 12 and 25. It aims to encourage young people,

particularly those who may not otherwise visit their doctor, to come and get help and

advice in a non-threatening and confidential environment. It provides a range of

services including clinical, nursing and counselling input together with support

services. The place also provides young people with a wide range of information

covering many aspects of life that may affect their health and well being, such as

sexual health, substance misuse and problems at home or in schools and the

workplace.

7

Genito-urinary Medicine

The GUM clinic provides a sexual health service to individuals on both an

appointment and drop-in basis. The service has been designed to provide a more

approachable and accessible service in order to encourage an increase in the

number of people accessing sexual health services in Glasgow. Within the centre

users receive their care from doctors, nursing staff and health care workers. Health

promotion plays an important part in the running of this service with information to

improve the knowledge of users and to give them greater control over their own

sexual health in future.

Steve Retson project

This specialist branch of the GUM service, the Steve Retson Project, provides a

range of services for gay men and men who have sex with men. As with the GUM

clinic this service provides information, testing and treatment of sexually transmitted

infections. It also provides a support system for those using the service and advice

on living a healthy life. The Steve Retson Project has its own website which provides

a range of information about the service and life in Glasgow. This can be found at

http://www.steveretsonproject.org.uk .

Centre for Women’s Health

This centre aims to provide direct services to women, training and education to staff

in statutory and voluntary agencies and informs policy and decision making agendas

that impact on the lives and health of women (Scott et al, 2000). The Centre for

Women’s Health runs a strict women-only policy in order to provide a safe and non-

threatening environment for women attending the service. Women can be seen

individually by counsellors at the centre. The centre also provides a range of support

groups and focus groups in which women can discuss issues that are of importance

to them, whether they are health related or concern other aspects of their life. This

provides a mutually supportive environment for women with a wide range of issues

such as abuse or domestic violence.

Discussions are currently underway at the Sandyford Initiative around making

counselling services a core stream of the work at the initiative. These discussions are

presently at a very early stage and will develop during 2002.

8

Together, these services provided by the Sandyford Initiative aim to improve the

health and well being of individuals by encompassing the social model of health. This

model and its applications are explored in chapter two.

9

Chapter Two - Literature Review

Towards Developing a Social Model of Health Care

In the Interim Report of the Evaluation of the Sandyford Initiative (Mackenzie,

Lawson and Mackinnon 2001) we conducted a literature view exploring the social

model of health in the context of health care. In the following report we summarise

some of the key issues arising from that review, and further develop the idea of a

social model of health care by incorporating new ideas including sections on

women’s health, and lay health beliefs. This review then has the following thematic

approach:

� Revisiting the social model of health

� Lay and professional health perspectives

� Women’s health

� Development of the social model of health care – structure, process and

outcome

Methodological constraints

The information contained in this review is from the theoretical literature and

published research studies. However, there are relatively few studies which have

been undertaken with health service users, and much of the available data relates to

findings from studies undertaken with health professionals, particularly doctors.

Social model of health

In the Interim Report of the Sandyford Initiative we summarised the key aspects of

the social model of health and illustrated this through the various models that have

been reproduced in theoretical and policy literature about health promotion

(Whitehead 1995, Labonte 1998 and Evans and Stoddart 1994). Generally, the

social model proposes a holistic approach and a multi-causal model where people

are more than bodies. A healthy life suggests not only a healthy body but also a

healthy mind and a safe environment – health becomes a concept that embraces all

the dimensions of human existence (Hughes, 2000). The only social model

developed to date that includes the health care system is that by Evans and Stoddart

(1994).

10

In terms of health care, it has been argued that the social model of health is

ideologically opposed to the biomedical model. The biomedical model can be seen

as that offered by a service dominated by a specialised profession, providing medical

solutions to medically interpreted problems. The social model, by contrast, seeks to

lessen medical domination, places greater emphasis on holistic health care, and

proposed non-medical treatment to clinical problems as well as emphasising

preventive health.

In the context of the Sandyford Initiative, the social model of health care has been

coined to define a model of health care delivery that recognises two main issues.

Firstly, the detection and management of health problems should take into account

social and economic determinants of health. Secondly, the provision and practice of

health care should reflect the social needs of the user although the quality of care

depends not only on the quality of the interaction between user and professional but

also on the organisational environment in which care is delivered (Laughlin et al

2001). Thus the social model is concerned not only with health consciousness

raising but also with the creation of a service framework that allows medical problems

to be tackled by social solutions (Craddock and Reid 1993).

Broader perspectives

The social model recognises that people are complex beings and that a wide range

of factors impact on their health and feelings, from age and gender, to life

circumstances and wider economic and environmental influences. Whereas the

medical model focuses on the ailment or disease, the social model aims to treat the

person as an individual. This means taking into account the factors in a person’s life

that might affect their health. It also needs to be acknowledged that the process of

treating the whole person is not always relevant or appropriate depending on the

individuals’ reasons for accessing a service. This aspect perhaps needs further

exploration.

There is a wide literature on the ways in which poverty and socio-economic

disadvantage affects health (for example Whitehead 1995). In the way that we can

see a connection between life circumstances and health, there is the awareness that

many health problems have a social or economic root cause. In the context of HIV,

for instance, many biomedical scientists have come to recognise the importance of

social and cultural factors in explaining the epidemic (Doyal 2000). Mental health

11

problems can also be the result of women’s unequal position in society (Doyal 2000).

In the following section we use gender as an example to show how being female in

society can determine health status, and how a social model is more appropriate in

the context of women’s health care than the biomedical model, or in the context of

men’s health care.

Women’s health

Gender is a determinant of health; not only through the biological distinction of sex,

but also because of socio-economic differences associated with gender (Hills et al

2002). Thus women as a group not only experience different types of health issues

than men, they also experience the same health issues differently than men. Women

are more likely to be living on lower incomes, to be employed in lower paying and

less stable jobs, and to be encouraged by societal gender expectations to be the

primary givers of support to others, even if this is detrimental to their own needs and

health (Graham 1998, Janzen 1998). Also, women are confronted by barriers to the

health care system. Poverty and lack of childcare or transportation are examples of

barriers faced by women (Broom 1998).

In recent years a large body of work has demonstrated the interrelationship between

gender inequalities and both mental and physical health (Annandale and Hunt 2000,

Doyal 2000). As well as looking at life expectancy they have looked at more

qualitative dimensions of wellbeing, and have shown that many of the health

problems women face are not related in any direct way to their specific biological

characteristics. Rather they reflect the discrimination and disadvantage that many

continue to experience as they carry out gendered activities making up their daily

lives. Anxiety and depression, for instance, are more common among females than

males yet there is no evidence that women are constitutionally more susceptible to

these problems than men (Busfield, 1996).

As previously discussed, the traditional model of health, based on a biomedical

model, gives primacy to biological factors over psychological and societal factors. A

New York survey found that women were more than twice as likely as men to change

doctors because they were dissatisfied and because they felt patronised or ‘talked

down’ to (Broom 1998). Australian studies suggest that doctors often do not respond

appropriately to women’s psychological problems or physical assault by partners

(cited in Broom 1998). As an alternative to this biological reductionist view, the

women’s health movement has adopted a ‘holistic approach’ that involved a

12

fundamentally different vision of health and illness. Such a client-centred type of

healthcare based on a social model can prevent health problems from being unjustly

attributed to either medical or psychological causes, and treatment being exclusively

or unnecessarily sought in the medical or psychotherapeutic sphere. This calls for

major changes in the training, attitude and beliefs of healthcare providers and for a

restructuring of existing, segregated health care services.

Lay and professional health perspectives

Another perspective we consider is the meshing of lay and professional beliefs and

the relevance of lay beliefs to the social model of health care. Research from

different social science perspectives has explored the complexity of lay models of

health (for example Blaxter 1990, Calnan 1987). Given that doctors are trained

within the framework of a more unified medical perspective and that differences exist

between patients’ models of health and those held by medical profession, then this

has wider implications in terms of communication and understanding. Differences in

ways of conceptualising health can potentially result in difficulties in reaching a

shared understanding within the consultation with GPs and patients speaking a

fundamentally different language (Ogden 2001). Although often at variance with

medical models of disease, patients’ explanatory models of illness and causes of

illness have been shown to be plausible, rational and sophisticated (Blaxter 1983,

O’Flynn 2000).

A study by Ogden et al (2001) operationalised some of the constructs identified in the

qualitative literature as a means to compare patients’ and GPs’ models of health. The

results from this study suggest that doctors and patients not only have different

models for specific health problems such as depression and obesity, but may also

have very different ways of conceptualising health. Such a difference could

potentially result in difficulties in reaching a shared understanding within the

consultation with GPs and patients speaking a fundamentally different language.

This emphasises the need of the importance of communication and partnership in a

doctor-patient consultation. It has been suggested therefore that the key to

successful doctor-patient partnerships is to recognise that patients are experts too

(Balint 1957, Coulter 1999). The doctor should be well informed about diagnostic

techniques, the causes of disease, prognosis, treatment options and preventive

strategies, but only the patient knows his or her experience of illness, social

circumstances, habits, behaviour, attitudes to risk, values and preferences. Both

13

types of knowledge are needed to manage health problems successfully (Coulter

1999).

Developing a social model of health care

In the Interim Report of the Sandyford Initiative Evaluation (2001) we started to

explore some of the key factors that were seen as important in developing a social

model of health care. We have already described some of the key theoretical

concepts: holistic and multi-causal models, recognising the wider health

determinants, factors such as gender, disadvantage and discrimination, the

importance of lay knowledge. These are all important aspects that must underpin a

social model of health care delivery and must be at the heart of it. These might be

described as the ‘intangible’ aspects in the model.

As well as acknowledging these wider issues, we started to unpack some of the more

‘tangible’ aspects of the model that can be incorporated into a social model of health

care framework. These include aspects such as organisational structure and

physical layout, providing support and a comfortable environment, a wide range of

staff and accessible information. We previously identified four factors – which were

not discrete but closely inter-woven – patient-centred care, access, understanding

culture/ideology and health promotion (Mackenzie, Lawson and Mackinnon 2001).

While still relevant we would like to propose a social model of health care using a

different themed approach based around structure (organisation and environment),

process (patient centred care, communication, decision-making, time, inter-personal

skills) and outcome (health, user involvement) into which we will incorporate the

previous factors. These separate themes are inter-linked and access can be said to

underpin them all. These themes mesh well with the Sandyford Initiative’s definition

of the social model of health care which states that the provision and practice of

health care should reflect the social needs of the user, although the quality of care

depends not only on the quality of the interaction between user and professional

(process) but also on the organisational environment in which care is delivered

(structure).

Structure - Organisation and Environment

Campbell and colleagues (2000) in defining quality of care identified structure as the

organisational factors that define the health system under which care is provided.

Two domains of structure were identified: physical characteristics and staff

14

characteristics. The physical characteristics relate to resources and environmental

organisation whereas staff characteristics relate to the mix of staff, including non-

medical personnel.

Previously we introduced the notion of space, place and boundaries. In the context

of women’s health centres, buildings and their occupants were sometimes referred to

as ‘home’ incorporating images of family, security, safety and being welcomed. A

gender delimited space was welcomed by some, particularly women who had been

subject to abuse by men (Broom 1997). Young people expressed the need for

privacy and respect in a safe environment (West 2000). The spatial boundaries of

social relationships, of open communication and non-hierarchical encounters were

regarded as equally important as the physical spaces to people’s experience of care.

Craddock and Reid (1993) in discussing the implementation of a well woman clinic in

Glasgow discuss structure and organisation in a typical clinic (based on a biomedical

model) as institutional, lacking in ornamentation, badly designed waiting areas,

separate areas for each part of consultation process, official areas and marked

territories. The Women’s Health Movement has seen a move towards non-

hierarchical environments, breaking down the boundaries with less bureaucracy.

This approach was reflected in the Ballantay Project (a well woman clinic) in Glasgow

that introduced various innovations to break down the bureaucratic format. It

‘domesticated’ the waiting areas, provided more literature and information and

altered physical layout. Certain organisational aspects of the clinic service were

altered leaving less reliance on the doctor such as the setting up of non-medical and

counselling services and self-help groups.

Location of premises, availability of outreach services, car parking facilities or

situation close to public transport routes can predict access to services. Similarly the

availability of childcare facilities, and appointments, sessions or classes to meet

individual needs (to fit with working patterns, home/family commitments) can greatly

enhance people’s opportunities to access services. Language interpreters and

facilities for disabled people, such as the availability of personal assistants, are also

important considerations.

Process

In terms of process, we are concerned with the ways users interact with health

workers. However, process factors directly relate to structure and whether the

15

structures are in place to enable meaningful interactions between users and staff.

Much of the literature in this area focuses on the concepts of patient centred care,

decision-making strategies and communication. The main focus is on interactions

between user (or patient) and doctor, with little available information about

interactions with other personnel, including non-medical personnel, in the system

(e.g. receptionists, nurse, counsellor). However, ease of accessing the service in the

first instance (for example through a receptionist) may be an important consideration

for some and be an important predictor of whether they continue to use a service.

Patient-centred care

A key element of process is the interaction between user and health care worker. In

our previous report we discussed some of the components of a ‘patient-centred

approach’ to health care. Although the patient-centred model of doctor consultation is

widely advocated, its use in practice is probably rather limited (Little et al 2001). The

model encompasses five principal domains: exploring the illness experience or

expectations, the whole person, finding common ground, health promotion and

enhancing the doctor-patient relationship. In an observational study by Little et al

(2001) to identify patient preferences for patient centred care, the study provided

empirical evidence that there are at least three important and distinct domains of

patient-centredness: communication, partnership and health promotion.

Treating the ‘whole person’

In terms of exploring the illness experience and treating the ‘whole person’ (cited as

principal domains of patient-centredness) there is little data about how this can be

achieved during a consultation and whether people expect, or want, to share this

information about themselves. The notion of treating the whole person might be

more relevant to certain types of treatment or in certain settings such as women’s

health centres, services for gay/bisexual men and counselling? Some of these

issues were explored in the Interim Report under ‘Understanding culture/ideology’

(Mackenzie, Lawson and Mackinnon 2001).

Social research with HIV positive people in Australia suggests an alternative

approach in which doctors and patients are seen as agents operating in clinical

space that is wider than the consultation (Hurley 2002). The consultation is a key

element in the constitution of clinical space, but it is not definitive of it. HIV positive

people in Australia rely heavily on specialist HIV general practitioners for information

about their pharmaceutical treatments, but they distinguish between information and

16

wider perspectives on living with HIV. Their negotiation of decisions about treatment

occurs in a framework of self-care. Patients may pre-empt the consultation at

different times and on different issues. For example, decisions about adherence,

drug holidays, and the use of recreational drugs seem to be made in the context of

mostly well informed self care practices than on the basis of a clinical consultation

alone.

Communication

In her comprehensive review of health outcomes, Stewart (1995) concluded that four

key dimensions of communication were related to positive patient or user outcomes

(emotional health, symptom, resolution, function and physiological health):

� Provision of clear information

� Questions from the patient or user

� Willingness to share (discuss) decisions

� Agreement between patient and doctor about the problem and the plan

Communication also has relevance in terms of the knowledge that the patient or user

brings to the consultation; the recognition that patients or users are also experts and

that lay knowledge is valid needs to be accepted. Both professional and lay

knowledge are needed to manage illness successfully (Coulter 1999).

Partnership and Decision-making

There is a wide literature on the different types of decision-making in a consultation

(Guadagnoli 1998). For many decades, the dominant approach to making decisions

about treatment in the medical encounter has been one of paternalism. In recent

years this notion has been challenged by doctors, patients, medical ethicists and

researchers who advocate more of a partnership relationship between doctors and

patients. In broad terms, three models of doctor-patient interaction have been

described – paternalism, informed choice and shared decision-making. (Elwyn et al

1999). ‘Shared decision making’ describes the middle ground, but exactly how the

principle of ‘involving’ patients or users resonates with practice has not been

explored (Guadagnoli 1998, Elwyn 1999).

A qualitative study by Elwyn et al (1999) explored the views of general practice

registrars about involving patients in decision-making and to assess the feasibility of

using the shared decision-making. The barriers to sharing decisions included a lack

of available information, the nature of the decision with different decision-making

17

approaches required depending on individual circumstances, and issues around time

and timing. However, although not all patients or users will want to take control, it is

still important that their concerns, desires and values be incorporated into decisions

about their health care (Guadgnoli 1998).

Time

In order to fully endorse a social model approach to health care, there needs to be

the time and willingness for this to happen which can be against the capacity of the

system. In a typical eight minute consultation how feasible is it to determine patient’s

or user’s preferences and sensitivities and provide full and unbiased information?

(Coulter 1999). Lack of time was cited as a barrier to sharing decisions by general

practice registrars (Elwyn 1999) although it was agreed that ‘sharing a decision is a

process not an event’.

Time is especially important for certain groups. Having an extended time frame is

important for those whose first language is not English (Peberdy, 1997). For

disabled people, particularly those with communication difficulties, time may be

required. For people with emotional difficulties, time may again be required to get

through the issues in a consultation.

The importance of inter-personal relationships

We previously discussed the importance of inter-personal relationships (Mackenzie,

Lawson and Mackinnon 2001). Examples were provided of the value and importance

of staff who were understanding, listening, non-judgemental, helpful and supportive.

The importance of time to allow communication (both listening and speaking), trust,

compassion, understanding, confidence and care to be displayed were seen as

important ingredients of the collaborative relationship between service users and

health care providers in women’s health centres (for example West 2000).

An Australian qualitative study involving interviews with lay people about their

experiences with medical practitioners over their lifetime (in Lupton, 1996) found that

communication was a major factor when participants were discussing notions of a

‘good’ or ‘bad’ doctor. The majority of participants considered the inter-personal

features of doctors most important, over and above their medical knowledge or

expertise, particularly their ability to ‘listen’ and ‘communicate’, their willingness to

‘spend time with you’ and ‘talk things over’. According to the participants, trust is built

largely on communication, on a doctor having the ability to ‘draw out’ a patient as well

18

as the interest to go beyond the symptoms to the patient’s emotions and personal

relations. In this study there was resentment about doctors who did not treat

individuals as ‘real people’. This has resonance with the social model ideal of

treating the whole person and seeking to understand the wider issues in a person’s

life.

Consistency of care

An ethnographic study of patients with human immunodeficiency virus/acquired

immunodeficiency syndrome (HIV/AIDS) in Lothian found that people wanted to see

the same general practitioner, and that the GP-patient relationship was valuable for

being familiar and ongoing. As with people with HIV/AIDS, different aspects of care

are likely to be important to people depending on the problem they need to deal with

and the context of their life circumstances (Adam and Guthrie 2001).

Outcome

Outcomes are consequences of care and may be influenced by structure as well as

process, indirectly or directly. In adopting a social model of health care, there is an

emphasis on non-medical solutions where relevant and appropriate. Little has been

written about health outcomes in a social model context. Perhaps the best examples

are from women’s experiences of using women’s health centres. However, we can

pose some questions that might be relevant to the concept of a social model of

health care. To what extent did the user feel that he or she was treated as an

individual? To what extent did the user have a say on the best treatment route? Was

it a partnership approach based on shared decision making? Did the health worker

seek to find out if broader issues in the person’s life had any effect on the reason for

attendance? If so, was this reflected in the course of treatment offered?

User involvement is also an important outcome and has been identified as having

two purposes. Firstly, to contribute to the development of services that are sensitive

to the needs of users and secondly, to contribute to the empowerment of users both

in respect of their control over the services they receive and their lives more

generally (Truman and Raine 2001). User involvement is also a key part of the

process of health care.

Conclusions

In the Interim Report we discussed some of the issues raised by Scott et al (2001). It

was noted that tensions could arise in treating the varied and competing needs of

19

clients, such as in a rape case where there could be competing pressures to provide

both medical care and counselling support. A further issue was the feasibility of

implementing all domains in practice, and whether a targeted approach could be

used for particular patient or user groups. Further work is required therefore to

explore issues around the ‘appropriateness’ of adopting a social model of health care

in different environments and for different circumstances.

We have only just started to further develop some of the issues associated with a

social model of health care and there is further research required in this area,

particularly around what users expect from health care delivery and how they would

like to experience a social model of health care. The Sandyford Initiative Evaluation

findings (Users’ Voices) will make a valuable contribution to the model, particularly in

relation to expectations and experiences of health care, and ways of experiencing a

social model approach to health care. It would also be of interest to explore health

workers’ perspectives in relation to adopting a social model; by this the wider

personnel operating in a health care system and not just doctors. Thus, this is the

starting point for developing a social model of health care, and there is the potential

to undertake a more detailed exploration of all factors that will contribute towards it.

20

Chapter 3 - Aims and Methodology

The Sandyford Initiative Evaluation Framework

This investigation of users’ views is being conducted within a wider evaluation

framework for the Sandyford Initiative. It will be used by the service in addition to two

other pieces of work that have already been undertaken. The first of these is a

before-and-after patient satisfaction survey. The baseline survey was carried out at

the Family Planning Centre in Claremont Terrace, prior to the opening of Sandyford

and was followed up one year later in all the clinics within the Sandyford initiative.

This survey collected quantitative data including information about accessibility,

facilities, attitudes of staff, and the quality of service delivered. The second piece of

work was a process evaluation carried out with the aim of collecting baseline

information from key staff involved in the restructuring of services. In-depth semi-

structured interviews were conducted to gather individual perceptions and

experiences of the development and potential of the initiative including barriers to

taking a progressive approach to health care delivery. In addition to these pieces of

work there have been a number of workstreams developed around the counselling

services at the Sandyford Initiative. These have taken place in 2001 and are

continuing into 2002.

In addition to these pieces of work there have been ongoing user involvement studies

at the Sandyford Initiative, most recently during the week of Valentine’s Day 2002.

The services within the Initiative also contribute to the collection of information with

ongoing monitoring, evaluations and use of comments sheets to collect the views of

service users.

Aims of the current study

This evaluation will complement data already collected to give a further perspective

to the Sandyford evaluation framework. The main aim of this piece of work is to elicit

users’ views of the Sandyford Initiative and to add to the information presented in

Evaluation of the Sandyford Initiative, Having Your Voice Heard- Interim Report

(Mackenzie et al, 2001). The objectives of this study are:

21

� To describe users’ experiences of the more ‘intangible’ social model of health

within the Initiative

� To ascertain users’ views of good practice in terms of user involvement in service

planning and delivery.

The aim was to collect the views and personal perceptions of the social model of

health from the various user groups at the Sandyford Initiative. The study included

users from each of five services within Sandyford; the Centre for Women’s Health,

Family Planning, Genitourinary Medicine, The Place for young people and the Steve

Retson Project.

Interview Schedule Design

From a review of the literature and through discussion with Health Board leads, key

issues which could inform the development of the interview schedule were identified

in Spring 2001. The key issues arising were organised into themes for the purposes

of this study. The idea of the social model of health is included throughout the

interview, with particular reference to perceptions of staff attitudes, satisfaction with

the holistic nature of care and accessing users’ voices. The issues of access also

emerged from the literature review as a key issue when developing new services.

This interview included a number of access issues such as geographical access,

telephone access and factors which may affect people’s ability to attend the service

such as childcare and expenses. Access was also investigated in terms of the

degree of cultural sensitivity and appropriateness of language.

Users’ views on the surroundings and relationships with care givers are highlighted

as important issues in the literature review and are incorporated in this interview by

asking service users to give their views of the surroundings, both in the waiting areas

and consulting rooms, and similarly to give their perceptions of staff attitudes towards

them. It was hoped that this would also highlight any areas which could be seen by

individuals as potential barriers to receiving appropriate care or returning to a service

in the future.

As highlighted in the literature, one of the important aspects of the social model of

health is consulting with service-users with the aim of involving them in the

improvement of both their own health and well-being, and also to contribute to the

22

development of services. For this reason it was important to gather views and

perceptions on individual care. However, it was also important to seek the views of

service users on how best to collect the views of Sandyford users’ in future and how

to access those not currently aware of the services available.

A total of six key themes were included in the semi-structured interview schedule

(see Interim report, Mackenzie et al, 2001). From the results the Having Your Voice

Heard study conducted in Spring 2001 these six key themes were modified and

further developed. The purpose of this was to incorporate issues that participants

raised during previous interviews and to further describe individual perceptions of the

social model of health and expectations of health care. From this information a

modified version of the semi-structured interview schedule was designed and the

following seven key themes included.

Box 1: Key themes included in interview schedule

1. History of service use

2. Access Issues: including how individuals feel about getting to and contacting

the service, and any barriers to attendance

3. Satisfaction with surroundings: general feelings about the centre, privacy,

comfort and facilities

4. Satisfaction with health care: individual perceptions of the staff, how they

were treated during a visit, e.g. sensitivity, confidentiality, respect and

professionalism by reception and health care staff; how individuals feel about

the care they received at the Sandyford initiative, e.g. time for explanations

and discussion during consultations; communication amongst staff about an

individuals care; extent to which an individuals own views of care were taken

on board

5. Individual needs: ability to discuss aspects of life which may affect an

individual’s health, if this was encouraged, and if it is perceived to be an

important or relevant part of an individual’s care.

6. Health promotion: how information or care/treatment received has improved

knowledge of services, helped individuals to access services, helped improve

knowledge of own health and given individuals greater control of own health.

7. Expectations of the Sandyford Initiative: how it may differ from other health

23

care services; do experiences at the Sandyford meet with individual

expectations of the initiative; any additional services or improvements

highlighted by users.

A full copy of the interview schedule can be seen in Appendix 1.

Sampling

Interviews were conducted with a sample of individuals from each of the five

services. The original aim was to contact and arrange interviews with participants

from the study in Spring 2001 who had consented to take part in this follow-up study.

However, researchers were unable to make contact with any of these individuals.

Subsequently the modified aim was to obtain a sample of five clients from each of the

clinics and to conduct a focus group with one of the existing support groups within

the CWH. Sampling was purposive and was carried out over a six week period.

Researchers aimed to recruit individuals who had visited the Sandyford Initiative on

more than one occasion in order to give a broader perspective of users’ views of the

services. At the end of this period a cut-off was imposed in order to complete the

study on schedule.

A variety of methods were used to approach potential participants depending on the

nature of the individual clinics:

� In the Centre for Women’s Health counsellors employed by the centre

identified and approached three suitable participants from individual

counselling sessions or from support groups. The researcher also

approached two participants directly and the potential participants for a focus

group.

� At the Steve Retson Project individuals were approached informally in the

clinic waiting room by a ‘host helper’ who briefly explained the purpose of the

study using materials provided, and identified those who were willing to take

part.

24

� In the GUM, The Place and Family Planning individuals were approached

directly by the researchers in the waiting areas.

It is recognised that in the instances where individuals were identified by staff from

the centre this may have introduced some bias. However, this was largely reduced

by the fact that staff did approach all service users for recruitment. They did not

exclude any individual unless there was a specific reason not to do so (for example,

where individuals receiving counselling were felt to be particularly vulnerable).

Consent

Before any interview was conducted full written consent was obtained from all

individuals. A small amount of socio-demographic information about each of the

service users was also collected at this stage. This included age and service

attended. The interview consent form can be seen in Appendix 2. A copy of the

consent form with the contact details of the researcher who carried out the interview

was given to each participant. This was in order to give them the opportunity to

contact their researcher, to withdraw from the study or to put forward any queries

they may have had about the study.

Interviews

Each of the centres provided a room within which interviews could be carried out in

privacy. All of the interviews except one were conducted with the individual service

user alone. Two young women attending The Place requested to be interviewed

together. The interviews were all taped and later transcribed for analysis. All

interviews were confidential and the results anonymised. For the purposes of this

investigation the interviews were analysed thematically, and emerging key themes

identified by service.

Interview Data

Table 1 provides a summary of the numbers of individuals approached for interviews

along with the numbers who consented and those who declined to take part in the

study.

25

26

Table 1: The number of individuals who were approached to participate in the study

Service (sex) Approached Consent Declined

Young Persons (f) 8 5 3

GUM (m) 11 2 9

(F) 5 3 2

Steve Retson (m) 12 5 7

CWH (f) 5 5 0

Family Planning (f) 17 5 12

Total 58 25 33

The highest rate of decline was by individuals attending the GUM clinic. Of those that

declined in the GUM clinic two were female and the rest were male. This higher rate

of decline amongst males may have been due to the interview being conducted by a

female researcher.

The total number of females interviewed was eighteen and the total number of males

was seven. Whilst the Centre for Women’s Health and Steve Retson Project would

provide single sex participants, it had been anticipated that we might achieve a

gender mix within the GUM clinic – within this two of the five people interviewed were

male. There may have been instances at both the Family Planning Clinic or the

Young Persons clinic where males may have been present as a user or

accompanying a female partner. However, no males were interviewed during this

study as they were not present at these services during recruitment.

The average age and age ranges of those individuals consenting for interview in

each of the clinics are summarised in Table 2. As can be seen from Table 2, a wide

range of age groups were represented. Although they were from various clinics this

range of ages is still important as it gives a wider perspective of views and

perceptions of the Sandyford Initiative overall.

27

Table 2: Age (by sex) of individuals attending each of the clinics

Service (Sex of

interviewee)

Median Age Range

Young Persons (F) 17 15-22

GUM (M) 24 22-26

(F) 33 27-40

Steve Retson (M) 34 22-47

CWH (F) 48 28-54

Family Planning (F) 29 21-41

In order to try and gain a better understanding of users’ views of the service

researchers tried to recruit individuals who had been users of the Sandyford Initiative

for a range of timescales. Box 2 summarises the attendance profile of participants in

the study. Further details of service attendance at the Sandyford Initiative and

elsewhere prior to this are discussed in the individual service chapters.

28

Box 2: Summary of participant attendance at the Sandyford Initiative

Centre for Women’s Health

The six participants from the CWH had all attended the service on a number of

occasions. The time-span ranged from a few weeks to eighteen months.

Steve Retson Project

Three users of the SRP had attended for health checks between two and six times.

Two users had been attending counselling and had visited the SRP around twelve

times.

Genitourinary Medicine

One of the GUM users was attending the service for the first time, two users had

attended twice and the final two participants had attended the service on a number of

occasions.

The Place

Of the young women attending TP two were attending the service for the first time.

The three remaining participants had been attending the service for around one year

and had visited TP on a number of occasions.

Family Planning

All women attending FP had done so numerous times and had attended the service

at Claremont Terrace prior to the opening of the Sandyford Initiative. The longest

history of use was a woman who had been attending FP for seven years.

Chapters four to eight of this report now present the findings from each service and

discuss their implications. Common themes across services are summarised in

chapter nine along with a discussion of how the social model of health is being

applied and received by users of the Sandyford Initiative.

29

Chapter Four - Centre for Women’s Health

History of service use

Five women using counselling services at the Centre for Women’s Health

participated in interviews. Two of these were also attending a group. A further woman

was interviewed who was attending a group only; a modified schedule designed for

group purposes (which omitted the questions around experiences of a one-to-one

consultation/session) was used. Length of service use ranged from three counselling

sessions to eighteen months. The group user had attended five classes and was half

way through the course.

Respondents had found out about the Sandyford Initiative through a range of sources

– from GP and word-of-mouth to morning TV and victim support. Respondents varied

in terms of their use and experience of similar services. Some were or had been

receiving treatment from the GP, two had attended self-help groups previously and

others had attended counselling services in other venues.

Access and Environment

A range of approaches were used to contact the Centre initially – internet/email,

phone, calling in person and through a third person. Finding and getting to the Centre

was an issue for one respondent who was disabled and had to take two buses to

reach it. Others either lived locally or travelled long distances but felt that reaching

the Centre not an issue. In the previous evaluation, car parking close to Sandyford

was raised as being problematic. Some felt that the Sandyford Initiative was difficult

to find initially because it was not well sign posted.

The waiting time to get an initial appointment at the Centre varied from two weeks to

over four months and seemed to vary depending on the type of counselling

requested. The group respondent had waited four months before getting a place.

One respondent had phoned the Centre every Wednesday morning to try and get a

place on the waiting list:

30

The centre you have to phone on a Wednesday morning at 9

o’clock and I had to do that for three or four weeks before I got on

the waiting list, and that is just the way they run the system (CWH1)

One respondent felt very unhappy with the initial wait of between three and four

months to get an appointment:

I think it was the hardest thing I’ll tell you waiting all that time. I had

no one to talk to, discuss my problems, I was quite demented

(CWH4)

On making contact with the Centre all respondents found staff to be helpful and

friendly, although the length of time to secure an appointment was frustrating for

some. A similar picture was portrayed in the previous evaluation where there was

initial frustration at the length of time before a first appointment. The systems in place

to support women whilst waiting for an appointment, however, were regarded as

good. The phone back service (where a counsellor phones back and allows the user

to talk for half an hour) was experienced as reassuring for one woman. Another

woman had called into the Centre (without an appointment) on the advice of her GP

and was pleased that there was someone there to listen (the Listening Ear service).

Once in the system one respondent’s counsellor left to move jobs after several

counselling sessions. This meant that the user had to wait another lengthy period

(between five and six months) for an opening with another counsellor, during which

time she was severely depressed and felt that she had no one to speak to:

It is terrible you are left high and dry and I was just starting to open

up and then I was left with nobody you know and it was quite

devastating at times (CWH4)

For most users the availability and timing of appointments seemed adequate.

However, one respondent noted that because she was aware of the long waiting list,

time was quite precious, and therefore she felt she wasn’t able to take up too much

time. Issues were also raised around the timing of appointments to suit people’s

individual needs. One user, for instance, could only get an appointment late

afternoon. As she was disabled and had to take two buses to reach Sandyford, this

proved difficult for her as it meant that she would be arriving home when it was dark

31

and this posed a personal safety issue. Another had to change arrangements

because she got a new counsellor who worked on a different day. However, one

respondent felt that the staff aimed to work around the needs of the user:

They tend to try and work round you yourself, my first appointments

used to be 4 o’clock which meant I had to get a child minder for my

wee girl coming in from school, and I explained it to them and they

worked round it for me now (CWH5)

Environment

I was very anxious about coming but once I was in about five

minutes I settled (CWH5)

No respondents experienced any physical barriers to accessing services. There was

unanimous agreement from all respondents that the environment and surroundings

at the Centre were relaxing, friendly and comfortable. Respondents used adjectives

such as ‘safe’, ‘calm’ and ‘private’ to explain how they felt about the overall ethos of

the Centre. This relates well to findings in the previous evaluation where the majority

of respondents found the surroundings pleasant:

I call it the little house on the prairie (CWH2)

I think it’s very relaxing, it’s very private and the people in the place

make you feel so welcome you know (CWH4)

The warmth…quite big sofas, it’s lovely and clean, it’s private, it’s

not noisy, it’s not people bashing about the place, it’s not like you

know when you go to the doctors you walk in you smell the doctor

don’t you, you smell the hospital, it’s like walking into somebody’s

nice wee lounge (CHW5)

The privacy of the waiting area was also regarded as a key feature of the Centre and

was compared to the waiting areas in doctors’ surgeries - “I imagined like sitting in a

big doctor’s waiting room you know with people, [but] it is so pleasant, so private you

know” (CWH5). Although the seating area was described by one respondent as

32

being quite small, another noted that it was always relatively quiet so you were never

in a situation where you were crammed in with lots of other people. In relation to the

Centre’s place within the Sandyford Initiative, another respondent was pleased that

there were no big signs or notices saying where the service was, as this was viewed

negatively in terms of the stigma associated with attending such services. This is an

interesting contrast to users’ experiences of other services at Sandyford and the

desire for clearer sign posting.

Some respondents also noted that they felt safe in view of the fact that it was a

women only space:

I feel very safe in the surroundings. The fact that there are no men

around is a great idea to make you feel safe (CWH1)

Perceptions of care and support

General perceptions of staff at all levels at the Centre were regarded in a very

positive light. Unlike findings from the previous evaluation, none of the respondents

had experienced any negative encounters with staff:

Very friendly, they go out of their way and they can’t help you

enough (CWH4)

The receptionist sort of showed me where everything was and just

sort of said mull about and make yourself feel at home, so basically

I did (CWH3)

Users’ perceptions of the care they received frequently related to their expectations

of previous experiences of care in other settings. Most felt that the Centre for

Women’s Health offered something different from more medical approaches offered

by GPs. Indeed some of the women had already been to see their GP in relation to

the reason they were attending the Centre:

[been] trying to get on the system for such a long time. I had a

previous traumatic experience which the health service did not give

counselling for and I had a couple of interviews with doctors but it

33

was not to give me support or counselling it was to give me medical

treatment…(CWH1)

Time is a crucial element of the care that users receive at the Centre. Some

comparisons were made with the time allowed for a consultation with a GP and the

time given in other settings. As well as having a one-hour counselling session, there

was a feeling that staff in the Centre took the time to listen, it wasn’t a case of being

rushed in and out:

They have got more time for you and you are not getting a

prescription, they understand you, it’s private and confidential, it’s

comfortable, other women (CWH2)

She listens and in a lot of major problems you don’t have people

who will listen to you and she listens, she takes time, she is like

your best friend (CWH5)

Although being ‘given time’ was seen as a positive feature of the Centre, some

respondents felt that a one hour session was often not long enough to get through

everything. Others mentioned that one hour was a good balance as your needs for

counselling varied from week to week:

Yes you would like more time because you are in such a waiting list

and there are so many people here, at the moment I am here once

a fortnight because the second one is for a group, so if you are cut

short that week, you think I am not going to see her for two weeks

(CWH2)

‘Being believed’ was also raised as an issue. This was in relation to the way one

woman had been treated previously in other services; as she did not present with a

recognisable medical complaint she had the impression that her concern was not

valid. Some respondents felt that most doctors do not fully believe or understand you

if you have a mental health problem, and they can be dismissive of such concerns:

When you go in whether you have got a sore leg or a sore knee

you always go and get a wee bit of paper, that’s your cure the wee

bit of paper and you go to the chemist. When you come here they

34

are so understanding, for about the first six months every time I

came in here I was in tears and you can just feel the warmth. You

don’t have to have a bandage, they understand your mental health

problems…(CWH2)

I mean you go to your doctor and you are only allowed about ten

minutes there, you can’t speak about everything, about how you

are feeling and when I got this counsellor I thought it was great she

believed me (CWH2)

It’s so cold in a GPs and you are just a number, you are in and out.

Here they make you feel special and you feel that even if you are

the lowest of the low, I have seen some very depressed people out

there, they make you feel very warm and caring (CWH5)

The Centre was also seen to be more open and non-judgmental than other services.

Respondents felt that this applied to all staff at the Centre, not just the counsellors:

It’s a far more open atmosphere, it appeared less judgemental than

other places, everyone seems nice and they are not interested why

you are here if you know what I mean, it’s just kind of you’re

welcome here and it doesn’t really matter why and no-one seems to

be nosey or anything (CWH3)

[compared to experiences of using other services] it is more

welcoming and it is accepted that you have got a right to be here,

and they are not really trying to shove you back out the door

(CWH3)

A concern was expressed in relation to confidentiality. Although one respondent felt

assured that she was being treated in the strictest confidence, because she was

revealing so much about herself then she was slightly concerned that this information

was open to others, even if this meant the counsellor’s supervisor or the wider

system:

35

That was the only thing that worried me, the confidentiality, she has

to talk to someone and the boss but other than that she’s told me

it’s confidential (CWH4)

Another respondent felt that it was reassurance of the confidential nature of the

service that enabled her to be completely at ease and open with her counsellor:

I think the confidentiality thing you know, that clinches it for you

(CWH5)

Three respondents used a group at the Centre. In relation to expectations of the

group, one respondent felt the group was not meeting her needs. She had expected

the group to be practical rather than supportive:

It’s not what I expected, I thought it would be totally different, I

thought it would be more to do with how to cope if you have got low

self-esteem and how to go about it, but this class is not like that.

We just talk about our problems and it is not really telling you how

to cope (CWH6)

Despite these comments, the user had still enjoyed attending the class and enjoyed

certain aspects such as the social interaction aspect and hearing about the ways

other people have coped to overcome situations in their lives. Other respondents

who used the group found it beneficial, for instance through the sharing of

experiences and mutual support:

What is good you realise going to this class, we have all got

problems you know you think you are the only person in the world

that has got a problem because you’re looking outside, it is a

fabulous thing. I hope they do more classes like self-esteem,

confidence building, assertiveness (CWH4)

36

Wider issues

There was recognition that a range of issues – relationships, work, children, money -

are brought into the counselling session at the Centre and that time was required to

discuss some of these issues. This was contrary to the service offered by most GPs:

…he’s a pretty young doctor I’ve had him two years now and he

knows what I have went through from the beginning and he has

sometimes spent twenty minutes with me and I am embarrassed

because he has got a big load of people waiting and he won’t rush

you out the door, but then other doctors when I don’t see him they

have got me in and out in two minutes…but [anyway] he wouldn’t

have time for all these issues that you could get to talk to in a place

like this (CWH4)

The Centre for Women’s Health has a history of adopting a social and holistic model

of health. At the same time one of the aims of most types of counselling is to take

into account the wider things happening in a person’s life. Furthermore, the

Counsellor Service in the Centre is underpinned by a feminist analysis and

understanding of women’s position in society. From this perspective, therefore, taking

into account the woman’s ‘whole person’ should be an intrinsic part of the service

offered. In this section of the interview we aimed to understand whether respondents

felt able to discuss the wider issues in their lives, and to what extent they felt this was

an important or relevant part of their health care.

One respondent was aware that there were many things happening which were

affecting the way she felt, yet at the same time saw this as being quite separate to

the actual counselling session – if she discussed these things (“junk”) then there was

less time for the counselling:

Time is of the essence you know sometimes I have a lot of things

that I feel I have to off load which doesn’t leave any time for her to

instigate any form of counselling (CWH1)

I feel that I need to off load junk before I get down to the nitty gritty,

whereas I sometimes get the impression that [the counsellor] would

37

prefer that I left that at home and got on with the initial [counselling]

(CWH1)

Another respondent recognised the importance of the wider perspective and saw this

as an important part of her care, yet felt at the same time that the counsellor kept her

focused and prevented her from going off too much off course:

Yes I rabble on about work quite a lot and stuff like that and she is

quite open and sort of discusses anything. If she feels like you’re

going off on a tangent she will sort of hem you in again but you can

talk about anything, yes (CWH3)

I think most of the concentration is on the reason why you are here

but without constantly checking on other things as I go along then it

would be pointless (CWH3)

It seem that on the whole a flexible approach is adopted. One respondent spoke

about having the choice to discuss things. You are not under any pressure to give

everything about yourself, and what you choose to give will depend on the way you

are feeling, yet there is the freedom to discuss wider issues if you choose:

I think just opening up and being honest about how you are feeling,

for me it works to speak about everything…you are not under any

pressure when you come here and if I only wanted to speak about

one thing then that’s fine. As I said with me I have spoke about

everything that has happened in my life (CWH2)

Because I felt comfortable I could talk about personal issues that I

might not talk about to my doctor, you know something for women

as well (CWH4)

It does vary, how you feel yourself and have they got time (CWH2)

38

Closure

In relation to the notion that the Centre is a safe place where people can feel

completely open and relaxed, the issue was raised of moving on and extending this

feeling once outside the Centre. The respondents who had been in counselling long-

term (some were coming to the end) talked about the procedures in place for moving

on and viewed them positively whilst acknowledging that it could be a difficult

process. Most respondents were also actively engaged in the process of deciding

the best route of moving on:

If I unload, if it’s a day that you speak about everything, before if I

went to the doctors I would get medication and I would think put this

key in the door I don’t want to go in here I am so depressed. I can

look at it now, looking through different eyes, it’s just totally

changed my life and I hope that when I do become a lot better I will

still come up here (CWH2)

Information and Empowerment

The wider environment of the Centre for Women’s Health (and the Sandyford

Initiative) provides information about other groups, classes and services that relate to

women’s health needs and wider health needs. Most users were aware of things

happening from the posters, information and resources in the centre. However, few

of the users had accessed the services that were advertised, although their

awareness had been raised about availability.

[in terms of accessing services] for me personally no because I

have already got the information of where to go, but I think for

others coming without the background that I have, I think they do

supply as much information as possible related to women’s health

and wellbeing (CWH1)

One respondent raised the fact that she would like to know more about the

Sandyford Initiative and felt that there was a lack in terms of promoting classes:

39

I don’t really know much about the centre because I haven’t really

used it before, I have only really used the library but I would like to

know more things that go on in the centre (CWH6)

The library was seen as an excellent resource by one respondent:

They do go out of their way to try their best to try and accommodate

you. There are so many interesting books, you wouldn’t get them in

the library or if you did you wouldn’t see them, what I like is what

they have got under headings and I can go straight to that heading

(CWH4)

In discussing how users’ experiences at the Centre had changed the way they felt

about themselves and their health, some agreed that they had moved forward since

attending services there:

I am a bit more confident, not 100%, but I am a bit more

confident…when I came here I could say how I was feeling, why I

was upset and there was somebody there to listen, they believed

what I was saying, what was going on in my life and it has made a

big difference to me… (CWH2)

It is always better pouring it out to someone else anyway instead of

keeping it to yourself so in that sense it has been quite cathartic

(CWH3)

Other respondents were less clear, or felt that it was too early to tell:

Well I don’t think I am progressing but she thinks I am and other

people think that I am, but I have to see it myself, but I probably am

because a year ago I would never even be sitting here I was crying

all the time so I probably am (CWH4)

I think I still feel the same but I like coming to the group and quite

enjoy it (CWH6)

40

One respondent felt that her experience at the Centre had made a very positive

impact on her life:

Fantastic, I mean I’ve been ill for three years and the last six

months I’m a brand new person… I feel like I am a person again,

where I used to run after everybody else it has made me take stock

of my life, to know that I am an individual (CWH5)

Summary

Findings from the interviews compared well with those in the previous evaluation of

the Sandyford Initiative, although we managed to delve further into some of the

issues raised. The majority of respondents had positive experiences of using the

Centre for Women’s Health and most felt that this had helped them move on in some

aspects of their lives. Some respondents had experienced previous negative

encounters when seeking help, for instance not being taken seriously or believed, or

feeling that they were dismissed because they had a mental health problem which

could not be medically labelled. In view of this, experiences at the Centre for

Women’s health were viewed in a new light. Positive features were identified as the

safe, private, relaxing and comfortable environment, treatment by staff in terms of

respect and a non-judgemental approach, and having the time to be listened to. The

Centre adopts a holistic approach to health and most felt that they could discuss the

wider things happening in their lives, yet there was no pressure to do so.

Some of the key issues raised include:

� Centre for Women’s Health is seen as a service in its own right. It is unclear

whether people regard the Service as being within the Sandyford Initiative or

as part of the Sandyford Initiative.

� The length of wait to see a counsellor was problematic for some users; some

had been on the waiting list for several months which was particularly difficult

in times of crisis.

� One respondent expressed a concern regarding assurances about

confidentiality.

� Provision of information prior to attending a group (re. aims and content)

could be beneficial for some, as one user felt that the group she was

attending did not live up to her expectations.

41

� More classes for self-esteem, assertiveness, confidence building, anxiety and

depression, and the provision of alternative therapies such as aromatherapy

and homeopathy, were raised as suggested ways of improving services at the

Centre.

� Some felt that services at the Centre were not well promoted and that more

people could benefit from them, yet it was acknowledged that there was

unlikely to be the capacity to meet this need.

42

Chapter Five – Family Planning

History of Service Use

Of the five women interviewed, three were attending the Family Planning Clinic whilst

two were attending one of the specialist clinics1 within Family Planning Clinic

(Colposcopy, Medical Gynaecology). The length of time these women had been

using the services ranged from three visits in the space of a month to eight years

(which includes the services which were available previously at Claremont Terrace).

Four of the women had previously used the service at Claremont Terrace whilst one

woman had been referred to the Sandyford Initiative by her GP. Only one woman

had used services other than Family Planning within the Sandyford Initiative, the

Genito-Urinary Medicine Clinic.

Some of the women had decided to use the services at the Sandyford (and

previously those at Claremont Terrace) because of negative encounters with health

professionals elsewhere:

You know the reason why I came here was I didn’t particularly want

to discuss this with my own doctor because she is patronising and

you know I am not going to be patronised by a doctor. (FP 2)

For one woman in particular, previous experiences had been particularly worrying:

They must think everybody has got a mammy at home who knows

the ins and outs of everything you know, but that isn’t the case with

me, every time I left, I was worried about the worst case scenario

which was thinking that I had cervical cancer. (FP 1)

A couple of the women chose to use the services offered at the Sandyford Initiative

because they believed they were being seen by experts in the area of family

planning:

1There are five specialist Family Planning clinics: Colposcopy, Medical Gynaecology,

Psychosexual, Vasectomy and Menopause.

43

[Although] I have a good doctor now – this is what they do. This is

what they are most knowledgeable with and the important thing is

to come for guidance here all the time. (FP 2)

Access to the Sandyford Initiative

Physical Access

In general those interviewed reported little difficulty in accessing the service choosing

either to walk or drive to the clinic, although one person mentioned that parking could

be a problem:

The only problem is parking here. I was half an hour late recently

because I couldn’t get parked and I tried to get parked and just

zoom in and get it like car wars (laughs) access isn’t so good for

parking. (FP 3)

One woman felt that the signposting at the entrance was a bit confusing:

It’s a bit confusing because when you come in the first place you go

to, is it the meeting place for the young people? I think that is really

confusing, there should probably be a central reception to guide

you” (FP 3)

Facilities/services

A fundamental aspect of employing a social model of health care is to ensure that the

facilities and services provided meet the needs of individuals. One woman felt that

the clinic provided a service that was more easily accessible than other services:

Well I think it is positive in that, I think that you know when young

people come in they get free condoms and you get advice. I don’t

know how much they use that younger people but, yes I think there

is a lot less sort of red tape involved in going through a GP for the

same information. (FP 4)

44

Childcare was only an issue for two of those interviewed although this did not hinder

attending appointments as alternative arrangements were made. However neither of

these women was aware that a crèche facility was available to them at the Sandyford

Initiative.

One woman raised the issue of patients being offered the choice of non-medical

treatments, although these had not been offered to her:

It is quite common for a lot of women to have menstrual problems

when they are having emotional problems. The two are quite

closely linked and especially if everything looks normal, you know,

and a person is continuing to have physical problems, well, yes,

why not have a counsellor. (FP 3)

Availability and Length of Appointments

None of the interviewees had any difficulties in making appointments to be seen at a

clinic and all reported that they arranged this by phoning the clinic in advance.

I always make a telephone call. They are fine, they are all fine.

(FP2)

Most of these women were satisfied with how quickly they were taken for their

appointment. One woman had noticed a difference between daytime and evening

appointments, having experienced a longer wait in the evenings. Another commented

that she expected to wait if she used the drop-in clinic and that she usually made a

fixed appointment for this reason. However one woman had been kept waiting for a

fixed appointment on a number of occasions:

I don’t mind waiting like five, ten minutes, but I get annoyed when it

is like an hour or an hour and half sometimes. I just think, why

have they made these appointments? (FP 4)

One woman had been kept waiting during an appointment which she found

disturbing:

I had waited at least twenty to thirty minutes and I thought, have

they forgotten about me? (FP 3)

45

There was general satisfaction with the length of their consultations:

I don’t feel you are rushed out, they are usually quite quick, but…I

go in wanting to be in and out anyway. (FP 4)

All these women felt able to ask staff questions, although one woman commented

that she was aware that the staff’s time was limited:

…and where you can ask a question and you feel, I had better not

ask another one, you know. But I do anyway, I remember to, but

some people might not. (FP 3)

Only one woman reported feeling rushed and she felt that this was due to her arriving

late for an appointment.

Satisfaction with Surroundings

It is recognised that the environment of a clinic should be comfortable and make

people feel at ease. The women interviewed provided for the most part positive

comments about the surroundings at the clinic. The atmosphere was felt to be

welcoming yet professional:

Yes I think its trying to be a bit more informal for a start, so it is

more user friendly, people want to come, it is trying to have a kind

of relaxed, obviously professional environment. (FP3)

One woman compared the surroundings favourably to those of a previous experience

elsewhere:

It’s a lot calmer. I was flung in a visit room like this in the (hospital);

there was probably about 14 chairs and it was full, crammed full.

(FP 1)

Most of the women interviewed felt that they had enough privacy, although one

woman did feel that this wasn’t always the case:

46

Yes I mean they do shout, because they have got to shout. The

only thing where you would say, I hope she doesn’t shout my

details across the middle of the room, but that’s all. (FP 2)

When asked to consider issues around safety none of these women felt these to be

relevant to them.

Perceptions of patient-centred care

The expectations of women using the service are important in gauging whether the

social model of health care used is one that women appreciate or want. Most of the

women interviewed expected a professional service and in the main felt they

received this at the Family Planning Clinic.

I mean it provides a very useful service, very professional and that’s

what it should be. (FP 2)

Providing a service that was pleasant and welcoming was also viewed by these

women as being important and again something which they felt was provided:

I would expect to sort of get, I don’t know, a sort of friendly service,

making people comfortable and they always do that. (FP 4)

One woman had firm expectations about confidentiality:

Confidentiality, that’s the biggest thing I think and you get that here,

you definitely get that here. (FP 5)

However, one woman described how when having a smear, her request to see her

cervix was met with discomfort by the health professional treating her, something that

the interviewee was surprised at given the type of service she was using:

I asked if I could see my cervix and I actually thought they would be

able to let me see my cervix, but she said, ‘oh no we can’t do that’,

and seemed a bit flustered. And I thought that was a bit unusual

47

because especially in a place like this I thought they would be

prepared for that. (FP 3)

One woman reported negative past experiences in services provided out with the

Sandyford Initiative. However she described her experiences at the clinic as being

completely different and positive and comments on how her expectations of what a

Family Planning of service should offer have altered:

Came here and it is just day and night … I just feel as if I have got

more control…I now realise that this isn’t the way people are

treated. (FP 1)

Perceptions of Staff Attitudes

The approach taken by staff will very much determine whether women feel

comfortable and able to talk to them. All the women provided a very positive account

of the staff they encountered at the Sandyford Initiative. The reception staff were

described as friendly and pleasant. Within consultations staff were also considered to

be friendly as well as helpful and professional:

She asked me before the treatment and after the treatment, was

there anything that you want to ask me. And basically she had

covered every angle, so therefore I didn’t have to ask her anything

so she had done her job most efficiently. (FP 1)

Those interviewed felt that they were treated with respect:

Yes they are never nasty to you or make you feel uncomfortable or

anything. (FP 5)

Staff were also described as being discreet:

I feel much more comfortable coming here, you know, no questions

asked, you just kind of feel, get your smear test or whatever. For

me that’s quite comforting. (FP 4)

All those interviewed commented on how the staff made them feel comfortable:

48

...they make you feel at ease, very comfortable. (FP 5)

A couple of the women who had had bad experiences in the past commented on the

staff’s ability to address their anxieties:

Because the very first time I ever came in they made me feel totally

at ease, because they are picking up on your body language, they

know that you are anxious about this, you know. (FP 1)

The Consultation

Most women reported that the health professional they consulted with had introduced

his/herself. However one woman could not say with certainty whether they had or

not. However for all the women, the health professional’s manner was more

important to them:

No, but I know her from the last time I was here and she

remembers how anxious I was. Her name is not important, just that

she dos her job efficiently. (FP 1)

There were mixed views regarding the issue of continuity of care. The importance of

seeing the same person was felt by two participants to be unimportant whilst it was

felt to be important but generally unfeasible by one woman:

Because it’s unrealistic you never see the same person twice, so

you don’t build in the sense that you build a relationship with your

doctor, you don’t build a relationship here because I haven’t seen

the anybody twice. Em, because it’s routine I don’t mind (FP 2)

Yet the same person believed that it would be important to know the member of staff

if a less routine, more serious problem was being dealt with:

…But I think if I had something wrong, like say for instance that I

had something that was wrong then I would want to get to know the

person that was dealing with me. (FP 2)

49

Two of the women had seen the same person on more than one occasion, although

this was believed to be a chance occurrence. However for one of these women it

was felt to be important:

The first time I came in it was the colposcopy thing which was

obviously my main concern. It was the lady who dealt with me

today and it was good to see her face again, because I think that it

is pretty tough sometimes. (FP 1)

Most women felt that the staff took time to explain things and answer their questions.

… they do explain it. (FP 5)

The one exception to this was one woman who felt that the explanations she got

were inadequate and that assumptions were made about what she understood, when

in fact she felt she did not understand why things were happening:

…what is polycystic, you know. I was a bit panicky to ask at the

previous appointment, but I did ask her … and she pointed it out,

what the ovaries look like as they are, but it was nice for her to

explain all that to me, but I didn’t know what to ask. (FP 3)

Information

Providing information and an opportunity to ask questions and be a part of the

decision making process is one way of ensuring a patient-centred approach is

applied. Most women felt that they got enough information and that things were

explained to them:

The pill that I am taking…there was a few years ago a lot in the

press about it and again we would have a long conversation

explaining the pros and cons of being on that particular type of pill.

So I always felt that when I needed information I got it and I got

very objective information. (FP 2)

However this experience was not one shared by another of those interviewed:

50

I mean I was asking about polycystic ovaries because they were

suspecting that, and she said, ‘oh your scan looks normal’. What’s

normal? What does that look like? And she tried to explain to me a

little about that later. But initially when they said we will give you a

scan because it might be this, she didn’t really explain what that

was and I thought, my God what is that, you know. (FP 3)

Holistic Approach

In order to employ a social model of health, it is essential for staff to provide patients

with the opportunity to discuss issues that are relevant in the wider context of their

lives. These women differed in their opinions as to whether staff should take this

more holistic approach to health. One woman felt that this would have been useful

for her:

I know they are not here to treat you for that but it would be a lot

easier if there were people like this. (FP 1)

For most women discussing social issues that might impact on their health had not

arisen within consultations and some felt that this was not why they used the service:

It has never really come up. I wouldn’t have thought of bringing it

up. If there were things in my life, if I was having a problem, I would

normally go to my doctor. (FP 4)

Another woman felt that the opportunity to discuss matters was there if she wanted to

take it:

I am not one to start discussing my sexual relationships…but I

would probably be happy doing that here than anywhere else

because they are not going to be judgemental. (FP 2)

However, one woman described how only the clinical aspects of her care had been

dealt with (not only at Sandyford but also prior to her referral) something she was

clearly unhappy about:

51

Yes it is sad in a way because obviously what triggered it was

emotional and they never really touched on that, especially now

that they have checked everything and everything is fine.

Obviously it was emotional and your emotions will cause your

hormones to rise up and down and cause upset in lots of different

body systems but you know, they never even asked me. (FP 3)

One of the positive things that some of women talked about was the personalised

approach taken by the staff towards their care:

They are more educated, they treat you as an individual, they have

got time to talk to you. They are reading your body language from

the minute you come in the door and they are putting you at ease.

(FP 1)

Feelings about own Health

A few women felt a greater sense of control over their own health as a result of their

experiences at the Sandyford. This was largely to do with knowing what was

happening and being aware of the options available:

Yes a bit. There was a thing I was talking to her about today,

something I have been wondering about for a while and now I know

that upstairs, [there’s] somewhere you can actually go and find out.

(FP 5)

Most of those interviewed did not feel that they had a greater knowledge of their

condition as a result of using the Family Planning clinic. For a couple of women this

was because their appointments were routine visits to collect the pill. However one

woman searched for further information elsewhere about her condition in order to

provide her with what she felt was sufficient information to ask the ‘right’ questions:

I was a bit, not in shock, but I was kind of taken aback and I didn’t

really know what to ask and then I went and I did some research to

tell me what to ask by the time I went back. (FP 3)

52

Satisfaction with Services and Treatment

All the women interviewed expressed high satisfaction with the service provided:

…And especially getting the scan, it was really quick, I thought I

would have to wait months to get a scan, months to get a result, but

it was really quick. I got the scan, I got the result, I got the follow up,

it was all very quick. I thought that excellent. (FP 3)

However despite one woman’s bad experience whilst having a smear at the

Sandyford, this did not discourage her from using the service again:

The person who is going to be with the doctor had seen what the

first person had done so they would naturally know what state I was

likely to be in for that one and the second one was completely

different, but she was just spot on. She knew what she was doing.

(FP 2)

Recommendations for Improving the Service

On the whole, those interviewed were happy with the current service. When asked

about any changes they might recommend making to the current service, most felt

that the service was fine as it was:

I don’t think I would improve anything. It is pretty good the way it is.

(FP 5)

However a couple of women suggested a few improvements. One woman felt the

issue of long waiting times needed to be addressed. Another felt that the services

offered at Sandyford should be advertised more widely:

So they need to get their information out there, about times,

appointment times and drop-in clinics. But not just here, if you don’t

know this exists, how are you going to find out? It needs to be

hospitals and doctor and GPs and health centres. (FP 3)

53

This woman also felt that the medical staff should provide more unprompted

information:

…Doctors I think could be aware that patients would like to know

more and they should be more willing to come up with information

even without having to ask. A lot of the times people are afraid to

ask, because they don’t know what to ask. (FP 3)

Most of the women stated that there were no other services they would like to see

provided by the Sandyford Initiative in addition to those currently provided. Only one

woman said she would like to see alternative therapies:

The complimentary therapy that would be good because people are

interested in that, people would take than on board. (FP 3)

Summary

The general satisfaction reported here reflects those of the findings in the previous

evaluation of the Sandyford Initiative (2001). It is clear that the aspects that most

women appreciate are very much a part of the patient-centred approach taken by the

Sandyford Initiative. In the main, the respondents felt able to access the services

available to them and most women felt happy with the length and availability of

appointments. These women were very complimentary about the surroundings

describing them as friendly and relaxed but also professional. Participants had clear

expectations of the service; that it was professional, welcoming and confidential and

these were largely met. As with the findings of the previous evaluation, the

participants were positive about the staff and their professionalism. Furthermore the

women made many references to the ability of the staff to make people feel at ease.

Most participants felt that the staff provided enough information, explained things well

and took time to answer questions. Being informed of what was happening in their

treatment and being aware of available options led to some of the women to feel a

greater sense of control over their own health. These findings reflect those of the

previous evaluation where respondents for the most part did not feel the need to

raise social issues that may have impacted on their health, but felt that they had the

opportunity to do so. Nevertheless it is clear that most participants did not see this

54

as part of the consultation process but something additional. That women do not

expect this to be part of the process suggests that the social model of health is

perhaps not being adopted in its fullest extent.

Even though women were mainly positive about the service, some aspects were

criticised. While some of the points relate to the experiences of one particular

participant they raise some general concerns about the overall social model of health

care and ‘patient-centred approach’ taken by the Sandyford Initiative:

• The lack of opportunity to see a counsellor - raises concerns about why one

user was unable to access support when counselling services are available

within the Sandyford Initiative.

• Not providing adequate explanations - despite asking questions she left the

consultations confused. This experience illustrates the importance of taking

time to explain and make sure patients are aware of what is happening

particularly in less routine consultations where decisions are harder to make

and outcomes are more serious.

• Only having the clinical aspects of care dealt with - leaving her feeling that her

emotional health was not considered nor was she asked about her views

about what the problem was. Again this experience clearly illustrates that in

order to embrace a social model of health that all aspects of a patient’s needs

must be explored and not just the physical. Furthermore, this example

emphasises how crucial it is to listen to patients.

Other issues

• Waiting times for fixed appointments need to be addressed.

• Privacy could be compromised in an open waiting area.

• Parking close to the initiative was raised as being problematic.

Suggested improvements

• Provision of more unprompted information from staff during consultations

• Provision of complementary therapies

55

Chapter Six – Genitourinary Medicine

History of Service Use

All five participants from the GUM service were interviewed individually. Two of the

participants had previously used the same service at the Royal Infirmary and had

since visited the GUM clinic at the Sandyford Initiative on a number of occasions.

Two participants were visiting the GUM for the second time. One of these users had

previously been using the Family Planning (FP) services at the Sandyford, and at

Claremont Terrace before that, for several years. She had heard about the GUM

clinic through the FP service. The final participant was visiting the Sandyford Initiative

for the first time and had previously used the Brownlee Centre at Gartnavel General

Hospital.

When asked to think about previous experiences of using health services and their

resulting expectations of the Sandyford initiative users did not express any real

expectations of the Sandyford Initiative other than thinking it would be more relaxed:

Not really. I mean I didn't, I just kind of assumed that it would be

relatively laid back and relaxed and, you know, that was based on

my experience at FP and everything. So, it was fine. (GUM1)

The only potential barrier to attendance highlighted by one of the users was the

potentially long waiting times at the drop-in services. However, having used these

services this young woman simply commented, “I know I have to come really early if

I'm coming to one of the drop in sessions, but that's just par for the course then”

(GUM1). A second user (GUM3) highlighted the same problem with the drop-in

service. She now just attends the GUM with an appointment. Users did not report any

barriers that had previously prevented them attending services at the Sandyford

Initiative. The participant who had previously been to the Brownlee Centre

commented:

I found the service in general much better at the Sandyford…I have

got a lot of good things to say. (GUM4)

56

Access to the Sandyford Initiative

Three of the five users of the GUM service had walked to the centre and access was

not a problem. One user had travelled by bus, which she found relatively easy,

compared to travelling by bus to the Royal Infirmary. This woman reported being

particularly satisfied with access to the centre. Having rescheduled an appointment

from the previous week there was no record of her appointment on arrival at the

centre, but she was still seen very quickly by a doctor:

So they saw me, which was quite good, I mean they could have

said I had to come back but the doctor saw me and I was attended

to. (GUM 2)

This same participant also suffers from Rheumatoid Arthritis (RA) but did not have

any problems accessing the centre and could use the lift whenever necessary. The

final participant had travelled to the GUM by car. Although this woman lived thirty

miles away and had to arrange childcare she did not find these to be barriers to

attending the GUM. She had not needed to use the crèche facilities at the Sandyford

Initiative, as visits were times during her child’s nursery hours. One access issue

highlighted by only one respondent was difficulty in contacting the GUM by telephone

as the line was “constantly engaged” (GUM3).

Satisfaction with surroundings

In relation to the responses given by users in the evaluation of 2001, all of the

participants in 2002 also found the general atmosphere at the GUM to be very

relaxed. This was stated by a number of the users:

I think the surroundings are fine I think they are really good, the

staff are very good, it’s very relaxed, very welcoming. (GUM5)

A second user described the GUM:

I don’t feel like I am in a hospital I feel more like I am somewhere

else. (GUM6)

57

Another of the users felt the service was very friendly and found it to be “much more

approachable than the one down in Glasgow Royal” (GUM3). The décor, reading

materials and the water machine were also highlighted by a number of the

participants as contributing to a more pleasant atmosphere. One of the key issues

highlighted was the level of privacy in the GUM. All users were satisfied at the high

level of privacy in the waiting areas and within their consultations. The presence of

separate male and female waiting areas and the attitudes of the GUM staff were both

raised as a key issue by all of the respondents:

…they seem to be very respectful that people do feel a bit

uncomfortable. Like you've got the male reception and female

reception, they address you only by your first name and you can

give another name if you want to, so – they're pretty considerate.

(GUM1)

One of the users (GUM2) had attended the GUM prior to the separation of the male

and female booking-in and waiting areas and felt that the system now provided much

more privacy for service users. Another user stated:

I think the fact that the male and the female [waiting areas] are kind

of screened off. I mean it doesn't bother me but I can understand

why it would make some people feel more comfortable, that's a

good thing. (GUM1)

Satisfaction with health care

The following responses relate to the experiences of care that the users have had at

the GUM. When participants were asked to consider the way they had been treated

by staff at the centre the responses were unanimously positive. Although the

responses by participants in the 2001 study were also mostly positive there were

some issues raised in relation to reception at the waiting area and confusion as to

whether a consultation had ended or not. Responses in 2002 suggest a more

positive overall view of the GUM by service users.

One respondent described how she had been treated:

58

I'd say really, really well. You know, they're very sympathetic and

non-judgemental… (GUM1)

All of the other users felt they were treated with respect and made to feel very

comfortable. Participants were also satisfied that appropriate language had been

used and everything well explained. This was of particular importance for one user

whose first language was not English (GUM4). Another of the users felt that

explanations were given when requested:

Yeah, I mean obviously if they do come up with something they

explain it, I usually ask if I don't understand what they're saying.

(GUM3)

When asked to describe their experiences during consultations, again responses

were positive. One particular issue highlighted was in relation to an examination:

I mean I had one, you know, especially when it was for an internal

examination, the one I had, I mean she was really good, you know,

it was very, very laid back and relaxed and that was fine. (GUM1)

The participant who suffered from RA was also positive about the way staff

responded to her needs:

Because I've got rheumatoid arthritis and sometimes I need to get a

lift here if I'm bad and they're dead good, you know, they know I've

got this illness and that…But aye, that doctor there, she's

absolutely brilliant – they've all been brilliant, they're dead nice! I've

never felt uncomfortable or anything with any of them. (GUM2)

One less positive experience highlighted was in relation to a visit to FP:

Yeah, they're quite friendly towards you and they make you feel a

bit more at ease…I've never had any problems. Apart from once in

the Family Planning Clinic when they put me in a room and forgot

about me, and about ¾ of an hour later they eventually

remembered about me. (GUM3)

59

More positive feelings were extended to the amount of time participants had during

their consultations with all respondents feeling they had enough time and had

“…never felt pushed for time” (GUM1). This is a continuation of the positive

responses given by users in 2001 in relation to the length of time they were given in

consultations. Another user expressed his satisfaction about the consultation:

Yes they are quite good at explaining exactly what’s been

happening. There’s always plenty time. (GUM5)

Participants were also satisfied that they were given plenty of opportunity to ask any

questions they had. One particular example given by the woman with RA is:

Because I've asked that doctor a lot of questions about me and my

husband and that – and she just gave me the answers I was

looking for. Like my husband came here last year with me thinking

– because I've got this, you know, maybe it's him, and he's fine, it's

only because my resistance is low because of the rheumatoid,

that's when this flares up. You know, and she's explained

everything there, she's showed us everything. (GUM2)

Users were also asked to describe the extent to which they felt their own views about

their care had been asked for and taken on board. Two of the users felt that they

were given plenty of opportunity to ask questions, but on this visit had not felt it

necessary or appropriate to express their own views. Both of these users were

satisfied with this level of interaction:

Yes they listened to what I said, I had a question for the reason for

coming here and I got what I was looking for…I felt that if I had any

questions they would be answered. (GUM4)

And the second participant commented:

I don’t know if they have asked my views but they certainly have

asked me questions round the reason why I am here. (GUM5)

Although this level of interaction with user GUM5 may not be considered as applying

the social model of health, he went on to explain that he had attended the GUM for a

60

very simple problem. For this reason the participant did not feel it would have been

appropriate to discuss further issues regarding his life on that visit. Similar views

were expressed by some of the participants of the 2001 evaluation. It is this balance

between accessing individual needs and respecting an individuals’ right to privacy

that the services provided by a centre like the Sandyford Initiative are working

towards.

A further two of the participants were also satisfied that their own views had been

considered and that staff had made them feel comfortable:

As I say, they're usually quite good at making you feeling at ease,

so I've never had a problem with that. (GUM3)

Another of the participants compared her experience of having her views listened to

at the GUM service to a visit to FP:

I remember I went to FP and I'd enquired about something…I kind

of got the impression that they were sort of discouraging me from

going ahead with it, but when I came to the GUM they were very

much, well, yeah, let's just do it. So, but that didn't come over as

sort of feeling very negative about it, I think it just maybe sometimes

happens.

The participant attending the GUM who has RA was also very satisfied that her own

views about her care and lifestyle were asked for. This will be discussed further in the

following section. All participants reported being happy with the outcome of their

consultations and did not feel there was any stage of their visit at which they could

have been treated with more sensitivity or respect.

Individual needs

The aim of this section of the interview was to see whether users felt able to discuss

things happening in their lives that might affect their health or the way they were

feeling. There were mixed responses to the question. Three of the users had not

discussed any other issues, but simply because it had not been appropriate to do so

for them. However, they did all comment that they felt they would be able to discuss

61

other issues with the staff that they had seen at the GUM. One of the users did not

feel this was the right place to discuss the wider issues that may impact on his

health:

I wouldn’t feel that this would be the place to sit and talk about

things…I thought the purpose of the Sandyford Initiative was for the

Family Planning Clinic and testing for STDs. If I wanted to talk

about other problems then I feel I would go somewhere else.

(GUM4)

Two of the participants had discussed other aspects of their lives with their health

workers, and had felt encouraged to do so due to their personal circumstances. One

woman stated:

Oh aye, there's nothing I can't say to them. I do it about my RA

which they always ask me about. I think if you were like stressed

and all that I think you could say because a lot of these things may

be like part of what you've got, do you know what I mean…they

would take it on board, aye, definitely. (GUM2)

Another woman had also discussed aspects of her home life during her consultation

(GUM3) and had received information about the services available at Centre for

Women’s Health (CWH). Although she would like to use the service she feels unable

to do so at the moment as she lives near Stirling. These last two users of the GUM

feel that the ability to discuss specific needs with their health workers was an

important and relevant part of their care and had been “very helpful” (GUM3).

Another of the users felt that it was a relevant part of care at times:

Well I think it is important to a degree but I suppose it just depends

on sort of why you're there, really. I mean there was one instance

when I came to the GUM and the interviewer asked me if anyone

had forced me to have sex, and I was quite taken aback. But I

thought well that's really good that they do, they acknowledge that.

(GUM1)

This participant was clearly not expecting to be asked questions like these. However

when she was she felt that it was important. As this woman and other users did not

62

express any real expectations of the service, through consultations like these staff

are asking different questions and raising wider issues about an individuals’ life and

health. This application of the social model of health will help to raise the

expectations of individuals and the type and level of service they can expect from a

centre like the Sandyford Initiative and health services in general.

The woman who had been advised about the services at the CWH felt that these

types of discussion were both important and relevant “…because a lot of it can be a

side kick from what's happened and in my case it has been – they have been quite

emotionally good when it comes down to being like that…and they listen to you as

well and offer you advice” (GUM3).

One user felt he could discuss other things but “I don’t want to keep them busy with

problems that I should be going to somewhere else [with]” (GUM4).

Health promotion

Three of the users of the GUM found that visiting the centre had improved both their

knowledge about their own health and also the other services available at the

Sandyford Initiative. These users all felt this had helped them to manage their own

health better. One participant commented on the leaflets available:

Well there are a lot of leaflets, they're all quite helpful the leaflets to

read. Obviously when you come the first time you don't know what

you're coming to and a lot of the leaflets explain what you're here

for and I found that quite good. (GUM2)

Another comment regarding the leaflets was:

Yeah, the leaflets, they always give you if there's something wrong,

then somebody comes in with a leaflet…and again, it's quite good,

they explain what it is and how to treat it and things. (GUM3)

The two male users of the GUM did not feel that visiting the service had improved

their knowledge. However, this was not presented as a criticism by either user and

was simply because they had found out the information for themselves prior to

63

attending the service. One of the participants did make an important statement about

the affect of his visit:

It’s made me feel more confident, I mean it’s up to me to not come

back in a sense, but I would feel no hesitation to coming back if I

should. (GUM4)

Expectations of the Sandyford Initiative

The final section of the interview asked users to consider how the Sandyford Initiative

differed from other health services and clinics they had attended prior to coming to

GUM and how this met with any expectation they may have had about the centre.

Three of the users compared their experience at the Sandyford to their own GP. One

of these participants had only visited a GP in this country and one occasion so felt

that “I haven’t got much to compare with, but yes it seems to be professional, but so

does my GP” (GUM5).

At the start of the interviews the participants had been asked to think about their

expectations of a service like the Sandyford Initiative compared to previous

experiences of health care settings. None of the users had any real expectations

other than thinking that the service would be more relaxed than the more traditional

settings. In these cases the experience of the users had met with their expectations

and users felt that the Sandyford Initiative offered a different type of service to their

own GP, for instance:

…because I certainly feel more comfortable coming here than going

to my GP about sort of sexual health issues. And with the fact that

it's specialist and you know, it makes a real difference…I think that

sort of specialist training and expertise is really needed for

something like sexual health. (GUM1)

Another user had negative perceptions of the views of some GPs:

It's a bit more personal; GPs tend to refer you to something like this

anyway because GPs don't want to know. In some case they do

and some cases they don't. The last one did and was quite happy

64

to take swabs and things, but it takes longer. Whereas if you come

here you get a result virtually straight away…So that's the good

thing about it, I'd rather know straight away than having to wait.

(GUM3)

Similar views were expressed in the 2001 evaluation when users preferred the

Sandyford Initiative to other sexual health services and their own GPs. One of the

participants in the current study compared his experience at the GUM to attending a

similar service at the Brownlee Centre at Gartnavel General Hospital. His experience

at the Sandyford Initiative was more positive than at Brownlee:

There are much more leaflets everywhere here than there was at

Brownlee, nice colourful information and stuff, and this place is

closer to the centre of town its more convenient for me to get to…I

also feel the speed of the results was much faster here as well so I

liked it here a lot more. (GUM4)

The final issue that participants were asked to consider was if there were any other

services or general improvements they would like to see at GUM and the Sandyford

Initiative in general. Two of the participants felt there were no improvements that

could be made. One user raised the issue of waiting times at the drop-in sessions:

Well I mean it's only just sort of like logistical, like it's a shame that

waiting times are so long…and this is like the drop in session,

which is unfortunate…On the grand scale of things it's quite low

down on my list [of] priorities. The services are very successful.

(GUM1)

One of the users felt that it would be good to have “…a few more magazines or

books, a bit more diverse” as the ones there at the moment were “not very

interesting” (GUM4). Other than these comments the only other issue raised was one

of advertising and PR for the Sandyford Initiative and the GUM services:

I don’t know about PR, you know, just making you aware that its

here because I was kind of told by friends and the yellow pages.

Maybe there could be more advertising at the university? (GUM5)

65

Summary

The overall picture emerging from the interviews conducted with the five users of the

GUM service is a positive one. This compares well with the results of the previous

evaluation of users views of the Sandyford Initiative conducted in 2001, and users

are still expressing a high level of satisfaction with and confidence in the service

provided.

Although initially the participants from GUM did not express any real expectations of

the service, they all found it to be a very relaxed place to be. One user had previously

attended sexual health services at the Brownlee centre at Gartnavel General Hospital

and the GUJ service at the Sandyford Initiative compared favourably with his

experience there.

No problems regarding access were raised by respondents. All found the centre

accessible, including one woman who has RA, and another who travels around thirty

miles to the centre. The surroundings within the centre were found to be relaxed and

welcoming and far more approachable than services based in hospitals such as the

Glasgow Royal Infirmary. Users who participated in the 2001 evaluation reported

similar satisfaction with their surroundings. Participants of both studies have also

expressed satisfaction with the high level of privacy in the GUM, both at the reception

area and within the consultations. The separate male and female waiting areas was

raised as an important factor in this privacy and also as an acknowledgement to the

GUM service sensitivity towards individuals who visit the service.

Whilst responses in the 2001 evaluation were positive regarding satisfaction with

health care in GUM, participants in 2002 were unanimously positive regarding the

care they have received. Staff were described as sensitive and non-judgemental and

individuals felt they were treated with respect and made to feel comfortable.

Participants felt they had plenty time within consultations and were able to ask any

questions they wanted to, in addition to which any explanations were clear and

understandable to users.

In relation to health promotion respondents reported a greater increase in knowledge

of services and health issues than they had done in 2001. Although some of the

66

participants were unsure what the Sandyford Initiative was and what services were

included, they had never had any cause to visit the other services and received all

the care they needed within the GUM. However, two of the participants were aware

of other services. one had become aware of the GUM service through attending FP,

and one was told about the CWH whilst attending the GUM. In these instances a

more holistic approach to health care was appropriate and where other services were

required they were provided.

Two users who did not feel attending the GUM had improved their knowledge of their

sexual health felt this was not a fault of the service, but simply that they had found

information for themselves prior to attending the service. One important issue

highlighted by one of these users was the increased confidence he now felt in

relation to his sexual health and attending the GUM. His visit had raised his

expectations of the service he could receive.

In relation to increasing the expectations of service users and acknowledging

individual needs a number of points were raised by the participants at the GUM:

• In comparison to their own GP services, the Sandyford Initiative had met with

their expectations and their experience had been more comfortable and

relaxed than visiting a GP.

• The provision of a specialist service was a key issue that service users felt

was better than a GP service

• The Sandyford Initiative was also preferred to other settings in hospitals such

as the Glasgow Royal Infirmary and Gartnavel Hospital.

• All users felt able to discuss individual needs, although not all felt they had

needed to. Some felt this was not the appropriate service to do that.

• Where users had discussed individual needs they were satisfied that staff had

responded to them well and they had received the advice and help they had

needed.

Suggestions for improvements

• Two of the participants at GUM felt there were no improvements to be made

to the service.

67

• The length of wait at the drop-in sessions was raised as an issue. However,

users acknowledged that this was just a symptom of a busy service rather

than a fault of the system.

• A wider variety of reading materials in the waiting rooms for users was

suggested.

• Improved advertising of the services available at the Sandyford Initiative.

68

Chapter Seven - The Place (Young Persons’ Service)

History of Service Use

Of the five users who participated in the study two were attending the service for the

first time. Of these one had heard about the service through her sister and the other

through a friend who had previously attended The Place (TP). The three remaining

users had all been using the service for around one year and had made a number of

visits. One user had previously used the services provided at Claremont Terrace and

two had been to their own GP to talk about family planning. The final two users had

not previously used any other similar services prior to attending the Sandyford

initiative.

When asked to think about previous experiences of using health services and their

resulting expectations of the Sandyford initiative two users did not have any per-

existing expectations of the service. The remaining three users all used their GPs as

the points of comparison on which their expectations were based. Two young women

had high expectations of The Place due to the fact that it is perceived to provide a

more specialist service than their own GP. As one user explained:

I would expect them to be quite sort of gender sensitive, you know,

in a way that you should but might not expect your GP to be. I think,

yeah, definitely, you know, to be quite gender sensitive and morally,

I don't know, non-judgemental I suppose. (TP3)

Another user expected TP to be more approachable than her GP service:

I think you feel a bit more comfortable because you know it's a

place especially for [young people] and that they're that used to

hearing it all the time, it's not new to them. So that's how I think I felt

a bit more relaxed than when I was going to my doctor. (TP2)

The final user of TP voiced concerns around attending her GP due to her age and

how she perceived this might affect her patient confidentiality while she was under

the legal age for sexual consent:

69

Because your GP has got the right to tell your parents or whatever.

So if you end up there and say you're pregnant, they've got to say

something to them. (TP1)

Access to the Sandyford Initiative

Three of the interviewees had reached the Sandyford Initiative by bus and two had

walked. Those who had reached the centre by bus felt it was “quite far out” (TP1)

from their homes and they “didn’t know this end of town” (TP5) but were happy to

travel there due to the level of service they received. One user had got lost on the

way and had phoned the centre to get further directions.

None of the users had had any problems contacting the centre by telephone when

they needed to. One of the users had found the telephone help line very useful and

had used it on a number of occasions for queries she felt did not warrant the time she

would use up in a consultation:

…what I've done is I've 'phoned and I've said "Is there a nurse

there and could I ask just a quick question" or ask about a service

or whatever. And they've been great, they just put you through to

the medical folk and that's good, you know. (TP3)

One of the users felt that the Sandyford initiative was more accessible for sexual

health advice than other health services:

I prefer to go somewhere like the Sandyford because I just feel that

they know, kind of know, what they're doing a bit better. So when it

comes to kind of looking after particularly like female health, or for

sexual health then I do prefer to go somewhere like the Sandyford

because I just feel…they take it a bit more seriously as well.

The only access problem raised by a user of TP was in relation to the Family

Planning service:

The reason I have come into the drop in is because it is quite hard

to get an appointment soon, there is quite a long wait. (TP3)

70

On attending Family Planning she had also been told, “…if you're under 25 just pop

across and go to The Place and that would be quicker”.

None of the users of TP had experienced any other barriers to attending the

Sandyford Initiative.

Satisfaction with surroundings

When users were questioned on their views of the environment and surroundings at

the Sandyford Initiative the majority of responses in 2002 were good, as found

previously in 2001. In relation to the actual surroundings users described them as

being “very nice” (TP1) and “brilliant” (TP4).

In relation to the privacy of a visit the general responses were again positive. All

users felt that privacy in the consultation was good:

Aye, your privacy's really good, it's just you and the lassie. (TP1)

Only one user had a slight concern over privacy in the waiting area:

I don't think you get enough privacy to fill in the forms. I think there

should be a wee booth for you to fill in the forms.

The other four users were quite satisfied with privacy. As one user explained, “…it's

not bad, I think they do their best. I think it is really difficult to have absolute privacy”

(TP3). She related her experience to when she had accompanied a friend to the

GUM service and liked the system where “…you get a number and then you actually

go round yourself and they take details and stuff. I thought that was quite

impressive”.

Overall users of TP were happy with the surroundings:

It's good, it's quite relaxed, well it's as relaxed as it's ever going to

be in those kind of circumstances. It's bright and it's airy and it's

really got quite a nice sort of atmosphere. (TP3)

71

Satisfaction with health care

The following responses relate to the experiences of care that the users have had at

the Sandyford Initiative. In relation to first contact with members of staff users were

overall quite happy with the way they were treated, although one user felt that “it

depends on which doctor you see” (TP1). Another participant described one incident

that had made her feel uncomfortable on arrival at TP:

…it's like when you go to the front desk…and I was in for a

pregnancy test and you know how you've got to do the urine

sample in the wee bottle? Well this woman shouted it out in front of

everybody and I was quite embarrassed – "Right, just go and get a

urine sample from the toilet"! (TP2)

However, this appeared to be an isolated incident as the same young woman, who

had attended TP on a number of occasions, described overall that she was “…happy

I had been treated with respect” (TP2). This relatively positive overall response was

similar to that given by respondents in 2001. Another interviewee was very satisfied

with the system on arrival at TP:

I mean when I first came I didn't have to like say what I was there

for, just my name and I didn't have to tell her or loads of different

people why you're here. (TP5)

Users were also satisfied that staff spoke to them in simple terms and explained

everything well.

They're always very careful so that I understand what's going on.

They tell you as much as you need to know, they don't kind of over

do it. (TP3)

One of the younger users was very happy with the way staff spoke to her on the

same level:

They make it as if you can understand your position in the, they talk

in the same language as you…they don’t talk with loads of medical

terms. (TP5)

72

Another of the users was a medical student and felt that she was “… was treated with

respect and the language was fine” (TP4).

The experience of users during the consultation with staff was also viewed positively.

All users felt they had been treated with respect and made to feel comfortable. As

one user highlighted:

I can't remember going and being uncomfortable or more

uncomfortable than you would be anyway, that goes for any kind of

consultation. I think the staff generally have been great. (TP3)

As with participants in the 2001 evaluation, users also felt they had been given plenty

of time in their consultation to discuss everything they wanted to and ask any

questions:

Aye, because they always ask you at the end, are there any

questions you'd like to ask? or, do you need anything? (TP2)

Users were also asked to describe the extent to which they felt their own views about

their care had been asked for and taken on board. The response was that they had

where it had been appropriate:

My own views? Yeah, I think so; I think they've been quite sensitive.

(TP3)

One of the users also described a positive experience within her consultation:

She did know what she was talking about and she didn't try to make

you do anything you didn't want to. Yeah, she let me know the good

points and the bad points of everything, she didn't just kind of steer

me towards one thing. She let you make up your own mind. (TP5)

Participants from TP were all satisfied with the outcome of their consultations. One

user who had only gone along for contraception stated:

73

I was happy to get the pill there and then, I didn’t even need a

prescription. (TP4)

It is evident from these comments by users that the overall level of satisfaction with

care in TP was high. One user described how she felt after the consultation:

I couldn’t have been treated with any more sensitivity…you don't

feel embarrassed by it, it makes you feel more, I suppose

comfortable. They don't treat you as if it's anything to be

embarrassed about. (TP5)

Individual needs

The aim of this section of the interview was to see whether users felt able to discuss

things happening in their lives that might affect their health or the way they were

feeling. All of the users from TP felt that they would be able to discuss any such

problems because “they don’t make it just like rushing in, you can talk about anything

else that could affect you” (TP5). Other users would be happy to discuss things in

future if they needed to:

If I had any other sort of problem I would definitely come back.

(TP4)

The general consensus from the users of TP who participated in this study was that

being able to talk about these other issues in your life was an important part of your

care.

I think if you want to bring things up, you know, that are relevant to

your health and the reason that you're there or whatever to put

things in a better context and that kind of, you know, if it is sort of

important and, yeah, you should be able to bring that up. (TP3)

Another of the users felt that it was an important part of your care but was unsure

where it was best to place this type of service. She was relating her experience of her

and her mother seeing a counsellor through her school:

74

They’ll have my mum in one session and then me in another and try

and work things out so they can see it from the point of view. When

you come in here they're not – I'm not really sure but I think it's

good for people who can't get that elsewhere. (TP1)

Although this young woman had been able to access the counselling services

through her school she was aware that this not be available to other younger people.

However, she was also unsure whether a centre like the Sandyford Initiative that

provides sexual health services, would be a place she would come with her mother

for counselling. This is the type of preference that is likely to vary between individuals

and a centre such as The Place is just one medium for providing this type of service.

This is likely to be a personal preference whether an individual would want to come

to Sandyford or see a counsellor elsewhere. The final user of TP felt that being able

to discuss any other difficulties with staff at the Sandyford was an important part of

the care package:

I think, well, if there's not really anybody you can talk to in your

family or your friends or anything, then it's quite good that you can

come here. You can even come here just to talk about it and I think

that's quite good, suppose you've got a problem you can get it off

your chest without telling somebody like a sister or a brother, you

know. (TP2)

Health promotion

Users were also asked to think about how any information and care they had

received at TP had improved their knowledge of services available to them and

helped them understand their own health better. All users agreed that they had been

given plenty of information. This was a similar response to that given by participants

in the 2001 evaluation who felt they had received useful information on services and

health issues. One user in the current study described how her level of knowledge

had increased:

I am more aware of my health. I'm much better aware of the

services, of the kind of things that are available to me. (TP3)

75

Another user described her experience within the consultation:

It was all very straight forward but she went through everything to

make sure I understood. (TP4)

Another user raised the point that once you’ve been to the Sandyford Initiative once

you are much more likely to go back in future with any problems as you know what is

available and how you will be treated:

But I think once they've been a few times, you are more likely to

actually go and get things sorted out. I think I'm a little bit more

aware of what's kind of going on and I am much more likely to go in

because I think once you've been in a few times you realise it's not

really that scary and everyone's very nice and they don't think

you're stupid. (TP3)

Expectations of the Sandyford Initiative

The final section of the interview asked users to consider how the Sandyford Initiative

differed from other health services and clinics they had attended prior to coming to

TP and how this met with any expectation they may have had about the centre.

Users were generally happier with the service they received at the Sandyford

Initiative. This was the case in relation to the general atmosphere and also the more

specialist treatment they could offer.

I think it's got a better atmosphere and I think the, I think the

reception staff are definitely better than when you go to your GP's

office. But yeah, I think it is a more relaxed kind of atmosphere.

And I think for the sort of things that I go for…that's where their

skills lie, that's where their kind of specialist. I just feel that they are

more specifically kind of tailored for that because they have more

experience and they're more likely to pick things up (TP3)

This more specialised care was also highlighted with particular reference to the

needs of the younger users:

76

I think it's just the people – young people do things more but they

don't make a big thing about them. But if you went to your GP he'd

be shocked. But because a lot of people come in and they're used

to, you know, young people, and it takes a big weight off your

shoulders. (TP1)

Another of the users who had previously had a physical examination at both her own

GP and TP felt that staff at TP were more experienced and made her feel more at

ease:

I think they're just better practised. You know, whenever I've had

examinations and stuff I've felt more comfortable and I've generally

– it's been a lot more comfortable because they're just, they kind of

do it the whole time. (TP3)

The general feeling amongst users was that TP was better to go to than their own

GP, “…this is far better, it's much more easy to come here than to go to your doctor

about it” (TP4). Users of TP in 2001 had also described their feelings of being more

relaxed and feeling more comfortable at the TP than at their own GP.

The final issue that participants were asked to consider was if there were any other

services or general improvements they would like to see at TP and the Sandyford

Initiative in general. The two main issues raised were waiting times and the

availability of other services around Glasgow. Two users felt there were no changes

they would make to the current service:

No, I think they've got everything that you would ever need to come

for. (TP5)

One of the users raised the issue accessing minority ethnic groups at the Sandyford

Initiative:

I've always been impressed with their kind of attitude towards

ethnic minorities as well, that come in. It's just good, the fact that

they've got, everything's kind of printed in different languages.

(TP3)

77

As raised earlier in this chapter the issue of waiting times was more in relation to the

family planning service. Although users had sometimes had a longer wait at TP drop-

in service than they would have liked, it was accepted that this was just the nature of

a very busy drop-in service. As all users were happy with the care they had received

this was not raised as a major issue for users of TP.

In relation to further services, two of the users expressed an interest in seeing the

same kind of services provided in other parts of Glasgow as TP is providing an

important service for younger people:

I think they should do this in a couple of more places like maybe in

Shawlands or like other parts throughout Glasgow that's more easy

for other people to get to. (TP2)

Other than this users felt satisfied with the care they had received at TP. As one

participant highlighted:

The staff are really good, they make you comfortable, they don’t

make judgements of you. Like, I'm sure I'm not the only person that

has come here and thought you're going to get treated, they're

going to make you feel really bad. But they don't, they probably see

it every day but I mean they don't make it as if it's another case,

sort of thing. It's a very personal treatment. (TP5)

Summary

Summary

The young women using TP all responded positively to most of the questions.

Participants were very satisfied with the service provided by TP. Some of the key

issues raised by the young women were:

• Access had been simple and the availability of a telephone help line service

had been very useful on a number of occasions.

• The service was seen by users to be more accessible than other sexual

health services.

78

• There can be a longer wait at the drop-in service, but users realised this was

just as it was a busy service.

• Participants liked the surroundings and described the centre as relaxed,

bright and having a nice atmosphere. Privacy was felt to be high most of the

time, although one user felt she would like more privacy to complete forms at

the reception area.

• Overall, participants were happy with the health care they received at TP. The

‘checking-in’ system was preferred by some users as it did not mean having

to tell a number of staff why they were attending TP.

• Participants felt staff treated them with respect, made them feel comfortable

and were non-judgemental. Users were given plenty of time in consultations

and felt encourage to ask any questions they wanted.

• Participants were asked for their own views on their care and felt staff were

sensitive to these. One user discussed how staff had not pushed her towards

any decisions, but let her make up her own mind with the support and advice

she needed.

• Users felt they were given plenty of information and it had increased their

knowledge of their health and the services available to them at the Sandyford

Initiative. Staff took the time during consultations to make sure their clients

understood everything well.

• One participant felt that visiting TP meant that she was far more likely to seek

help in future due to the service she had received there.

When asked about their individual needs participants felt they had been able to

discuss them with staff where appropriate, and all felt they would be able to if they

needed advice. Participants also felt that this was an important part of their care

package. Previous experiences of health care services had left some users with no

high expectations of TP, whilst others expected a more relaxed and specialist

service. Some of the younger women who were under the legal age for sexual

consent also had higher expectations of the level of confidentiality they would receive

at TP. All users seemed to have their expectation met, and expectations appeared to

have been raised by experiences at TP. Users were generally much happier with the

service at TP than their own GP on a number of levels.

Suggested improvements

Users raised a small number of issues for improvement:

79

• Two service users felt there were no improvements to be made at TP.

• One user raised the issue of having difficulties getting appointments at FP,

and some under-25’s being sent across to TP. This has implications for TP

staffing levels for an already very busy service.

• Two users also discussed the possibility of developing other similar service

around Glasgow, in different parts of the city where more young people may

be able to get to.

Overall in relation to the evaluation of users views in 2001, the participants

interviewed in 2002 were more vocal in their responses. The poorer response in

2001 was raised as a key issue for consideration in this follow-up study. The

responses that were given in this second part of the evaluation may have been

longer for a number of reasons:

• The individuals being interviewed were more confident and vocal than those

interviewed in 2001.

• During the interview the researcher was less ‘prescriptive’ with the

questioning and used examples relating to experiences to explain questions

further. The examples used were dependent on the individual respondent, for

instance school or work, exam pressures, problems with parents or problems

with money for those who may be living away from home.

• Another reason may have been the presence of a friend at the time of

interview for the younger women who participated. Two friends were

interviewed together, and one of the younger women who was interviewed

wanted her friend to stay with her. The presence of a friend seemed to

increase the confidence of these young women in answering questions.

These may be important considerations for any further user involvement work that

takes place involving younger clients at the Sandyford Initiative.

80

Chapter Eight - Steve Retson Project

History of service use

In contrast to the first interim report, all interviewees had prior experience of sexual

health clinics – either outside Glasgow or at the Steve Retson Project (SRP) when

based at the Sandyford Initiative and other venues.

Previous use of services other than SRP

Three respondents had previous experience of sexual health services other than the

SRP: two had taken tests at clinics in Glasgow (Brownlee Centre and Ruchill clinic);

the third had regularly attended a variety of clinics over a number of years whilst

living in England. The remaining participants had only visited their GP prior to

attending the SRP.

Use of Sexual Health Services at other venues

Three respondents had used the SRP at different locations (either Royal Infirmary or

the Gay and Lesbian Centre).

Number of visits

This varied according to which aspect of the service had been used: those using it for

discrete check-ups, testing and/or follow-ups had visited between two and six times;

two respondents were currently receiving weekly counselling sessions and had

therefore visited over a dozen times.

Reasons for attendance

A variety of reasons were cited, ranging from routine health checks and treatment of

specific complaints to the desire for simple reassurance.

[I] initially came here because my ex partner had a bit of worry

about an STD, so I came along to support him more than anything

else but I thought I may as well get everything checked out myself

[SR1]

Two respondents had also sought out the project’s counselling service for help with

life crises.

81

I have a rather robust health generally….so I tend only to come to

the Steve Retson when I have things I want resolved, such as piece

of mind [SR5]

I had a sexual health problem that I wanted to have checked out. I

had that done and there was some follow up testing needed, and

also I had a personal crisis last year and wanted a counsellor [SR3]

Whilst all interviewees openly criticised aspects of their GP visits (see below), only

one mentioned this as a factor in their initial choice to attend the SRP:

I went to the doctor, he examined me and then he put me on a

waiting list for the genitourinary unit at the hospital. I was on that for

ages, not getting very far and then I bumped into someone who told

me about Steve Retson, so I came along that following week…..I

went along, really out of desperation because I was in some pain at

the time! [SR2]

Awareness of service

Two respondents had seen the service advertised in local gay bars (the SRP

distributes promotional materials and free condoms), others had had it recommended

to them or had become aware of it through attending with a partner.

Initial expectations

Although all interviewees who expressed an opinion seemed to have difficulties

answering this question, expectations seemed to centre on the fact that the project

was solely for gay men:

I thought it would be a bit more focused on specific gay men’s or

gay women’s, well gay men’s health issues, but apart from that I

didn’t know that to expect [SR2]

I didn’t have any particular expectations no, well I guess I did, I

thought it would be tailored to be more specific because it was a

gay men’s health clinic, and I guess I felt slightly less embarrassed

about going [SR4]

82

The opinion of a frequent and longstanding user of sexual health clinics was more

definite:

Yes I did have some expectations without using words like

expectations so much, I knew what to expect - I was prepared for

the experience of going into a facility which was specifically for

sexual problems, or sexual health issues [SR3]

Access to the Sandyford Initiative

Comments relating to access were broadly very similar to those made in the first

interim report, with the majority of respondents praising the convenience of the both

the clinic location and timing of the weekly session. A small number of heavily

qualified criticisms were made regarding the making of appointments. Several

possible barriers to attending were highlighted.

Ease of making appointments

Generally, as experienced users of the service, all appointments were made by

telephone. Whilst this was described as the most ‘convenient’ method, views were

mixed as to the experience. Some respondents found it quick and friendly:

It is relatively quick, five minutes sometimes ten minutes,

depending how busy the reception is; how many appointments are

available. Yes they [staff taking calls] are very friendly and I have

never had any adverse reaction [SR5]

Others had difficulties getting through or had found aspects of the receptionist’s

manner problematic:

I telephoned and it was fairly easy, though when I called up I was a

bit confused because they asked for my patient number… They

didn’t seem very friendly on the phone, but when you come here,

everyone is really lovely. I made an appointment once more

recently and it was messed up….I probably had to wait just over a

week or so, but it’s fine [SR4]

83

It has been really difficult actually…I have got trouble keeping track

of numbers, so I expect to be able to get them from the phonebook

or the internet/ but I have noticed one of the phone numbers on the

website here is wrong, you know, and you ring it and it is just rather

embarrassing. [SR3]

The experience of telephoning contrasted with that of making an appointment in

person, which had been the initial (and very positive) contact of two interviewees:

I just came in it straight off the street….- I expected three or four

hours, but I was quite surprised it took about and hour and a half

two hours….I had forgotten I think it was my second appointment,

and they sent me a letter the next day to remind me you know

“Please come back” and that’s something my doctor doesn’t do,

you know you might wait like another month or so before they

actually get back in touch with you, but it was the next day that I got

the letter saying you know you missed this appointment please re

appoint. I thought that was quite good [SR1]

I actually came along on spec - I didn’t have an appointment, I just

turned up one Tuesday evening, explained the situation and I was

squeezed in and that was that - I mean I was very, very impressed

[SR2]

Timing of the clinic sessions

Virtually all of the participants described the Tuesday evening session as ‘fine’,

‘pretty ideal’ and being suitable for both the ‘nine-to-five person’ and shift workers.

When asked whether other times were preferable, one respondent gratefully stated

If it was available during the day then I certainly would make use of

it when I was free, but the fact its in the evening between half five

and half eight or whatever it is, is fine. It’s good that we have got it

at all quite frankly [SR2]

Only one small limitation was pointed out relating to the difficult of cancelling early

appointments:

84

The facility is not open until 5.30pm to the public…so, if something

comes up and I have to cancel a 5.30 appointment with the

counsellor or something, by the time I have contacted [him] to let

him know that I am not going to be there, the hour is wasted and

nobody else can take the appointment [SR3]

Ease of access

General approval was given to the central and therefore (at least for this group of

users), convenient location of the service. Four out of the five men described it as

being either ‘on the way’ to work or ‘near to’ home. Three out of the five had driven

and one walked. The only problem identified related to the proximity of early

appointments to rush hour:

It took me like about twenty minutes to get here [for a 5.30

appointment] because of the traffic. I can imagine that’s a big

problem for people with regards to parking the car and it’s that five

o’clock mark - the rush hour time. It’s a nightmare. [SR1]

Barriers to attendance

Despite the fact that several respondents admitted to a degree of embarrassment in

attending a sexual health service, their repeated attendance suggested that they

themselves had not been put off by this fact. When asked if there had been any

barriers to their attendance, two typical remarks were:

Not in the slightest [SR1]

No, nothing has every put me off I have always known it was here

and I have always felt perfectly able to come along and see

somebody [SR2]

A number of subtle and revealing obstacles to clinic attendance for the gay

community more generally were identified - both explicitly and implicitly - including

cultural and generational factors.

85

Glasgow isn’t as easy a place to be gay; everyone here is aware of

that and there are lots and lots more people here that are in the

closet, and it is really important for them to have a place like this

where they can come and find these services you know another

setting that is completely different, separate from their GP. No-one

who’s in the closet is going to see their GP [SR3]

There is always that uncomfortability when you first come along -

they know it’s a sexual thing you’re coming for. I think that’s actually

taboo anyway in the West Coast of Scotland, its very much so –

you know, we don’t talk about it; we don’t even indulge in those

things [SR1]

[I’ve been] around since the time of the aids coming to the fore and

all that, my generation are more than aware of the need to be safe

[but] you forget how time has gone on and there is a new

generation - the increase in sexually transmitted diseases, you

know, lack of contraception information, lack of people using it…

people should be educated, but if you keep people ignorant it is

going to be more of a strain on the National Health Service

eventually, because people are exposed to all those things without

protection [SR5]

Satisfaction with surroundings

A high degree of satisfaction was expressed regarding the general appearance and

atmosphere of the clinic. Words like ‘bright’ and ‘modern’ were used frequently and

attention drawn to the quality of promotional artwork. These comments, combined

with both the noted geniality of host helpers and availability of refreshments, were

seen as important factors in creating a relaxing and friendly environment that helped

reduce the intrinsic anxieties of attending a sexual health clinic.

Well here it is really nice its very luxurious with all the food and fruit

and stuff its great, and its great that they have someone who sort of

welcomes you and takes you to reception and stuff because I guess

86

it could be quite intimidating, showing up and not knowing the drill.

[SR4]

Privacy and space

Whilst virtually all respondents recognised that the waiting room/reception area was

fairly cramped, this was generally seen as a minor problem, if at all. One interviewee

did find the seating lay-out and lack of space compromised his desire for anonymity

but acknowledged that this was more of a comment on the size of the local gay

scene:

It’s to do with Glasgow being so small: every time I have been here

I have seen somebody I know and they haven’t necessarily been

people I have wanted to see, not because I have slept with them or

not because they are friends of mine or whatever, it’s simply that

my anonymity is comprised…you like to keep various areas of your

life, you know, private. [SR3]

The same respondent suggested a different seating arrangement (back to back rows

of seats as opposed to the existing ‘U’ shape) but was aware that this could not

counter the stated problem effectively.

Décor, comfort, atmosphere

These aspects of the reception and waiting areas attracted common praise. Far from

being incidental, they were seen as key to promoting a reassuring and soothing

environment for worried (and perhaps first time) service-users:

It was a very relaxed atmosphere when I came in that was one of

the things that first struck me, they had tea, coffee, conversation; it

was a very relaxed environment. [SR1]

It is very welcoming and modern, tastefully decorated, quite

fashionably decorated, you know, all the things that make it

appealing; makes you come in and relax. It does its feng shui

pretty well I’d say! [SR5}

87

Refreshments

Similarly, the availability of fruit, cakes and hot drinks was much appreciated:

Well I mean when you come in there is the prospect of various

things - you could be getting probed or getting results back, and

neither of those are particularly pleasant prospects so its really

nice, it puts you at ease and I appreciate it…. it [also] kind of gives

you something to do instead of sitting looking about and trying not

to catch anyone’s eye [SR4]

‘Welcome Host’

A key part of checking-in to the service involves being greeted by one of several

volunteer ‘hosts’, who direct users to the various parts of the service, serve

refreshments and are available for general support and conversation. Users

consistently described the host(s) as ‘very welcoming’, ‘great’, ‘friendly’ and ‘helpful’:

Who wants to go to something, especially when it is their first time,

walk in not know what to do? So it’s good to feel welcomed, and it

is good for somebody to be attentive to you, making sure you have

something to eat, something to drink, it just sets the scene, and

particularly for those who are nervous, or a bit jittery it puts them at

ease. I think we would still get a good service professionally if they

weren’t here but the fact they are here is a great benefit [SR2]

Participants were also mindful of the difficulty in being both friendly and appropriate,

given the nature of some users’ concerns:

You get seen, you get checked in, they have a nice system here,

with, I don’t know what you call them, the helpers. That is an

interesting one because there are always different ways at looking

at these things you know, and it is a difficult balance to strike in

terms of people being intrusive or people being helpful you know?

But the host helper idea is obviously there to help put people at

their ease, so even if it actually doesn’t always work, the fact that

it’s there is a statement that you know this is something we’re

looking to do, so that is a major plus point I think [SR3]

88

Satisfaction with health care

Participants were consistently very positive about the service in general, drawing

particular attention to the qualities of the staff and the general effort made to make

people feel at their ease (see also previous section):

I am happy with the service, more than happy and it is a great

peace of mind to know that it is there, it’s local, it’s discreet the

people are very friendly, very professional the doctors are

extremely approachable I couldn’t be happier with the service and

the treatment I have received. [SR5]

One participant attending counselling also drew attention both to the quality of the

service and to the difficulty of obtaining it more generally in Glasgow:

Counselling in Glasgow is actually quite hard to come by…[so] this

was a good resource to turn to. [SR3]

For a number of respondents, the prime criterion of service satisfaction was simply

‘did I get well because of the treatment provided?’:

[I am] very satisfied, I mean, any kind of disorder or problem has

been satisfactorily resolved, so as far as I am concerned the

decisions that they took were the right ones because I got well.

[SR2]

Whilst interviewees echoed the concerns expressed in the first interim report

regarding the appropriateness of the informality of staff for all service-users, none

had felt their treatment to be inappropriate. Moreover, each had confidence in the

ability of all staff – from host helpers to doctors – to tailor their approach to particular

clients. This included level of formality and directness, appropriate language use and

sensitivity to personal priorities regarding time and need for reassurance vs.

treatment.

The ability to tailor the service to individual circumstances was seen as key to striking

the correct balance between informality/putting people at ease and the desire to be

treated in a direct, professional manner; both considerations inspire confidence in the

service in different ways but may be mutually exclusive. The optimal mix of these

89

ingredients were summarised by one respondent [SR2] as ‘Professional, fast and

friendly’.

Professionalism

This was one of the more frequent comments from participants and generalised to all

roles (host, nurse, doctor, counsellor, health adviser): ‘because I rate the service as

professional, anybody who sees me, I just give them that benefit of the doubt you

know - that I am going to be seen professionally’ [SR2]. An experienced service user,

who was currently attending counselling session, rated the service as more

professional than it had been when offered at the Royal Infirmary (although he did

not rate the previous service as unprofessional).

Respect and putting at ease

Respondents felt they were accorded respect; an important consideration given the

traditionally perceived ‘Doctor-dominant’ power relation of the consultation setting:

The doctor was fine, made me feel very relaxed, explained

everything and he actually made the experience humorous up to a

point… I came in feeling a bit nervous, a bit apprehensive but I

came out feeling really relaxed and thought ‘that was such a laugh

in there [SR1]

One doctor I saw was really very, very chatty. Some people I know

would be put off by that [but]…I felt that was great and I also

appreciated the informality. [SR4]

The positive role of health workers was also highlighted:

The helpers and the health care workers are very adept at putting

people at ease, and that is very important I think…[especially] for

people who perhaps are having the trauma of being diagnosed HIV

positive. [SR5]

90

Sensitivity and confidentiality

Respondents felt that health-workers were sensitive to their anxieties and expressed

problems; they did not feel that they could have been dealt with more sensitively.

Confidentiality was an issue of general concern for a number of reasons. Firstly,

anonymity was felt to be vital given the stigma and embarrassment associated with

attending a sexual health clinic. The interaction of a small local gay scene and a

cramped reception area occasionally compromised the anonymity at least one

participant (see above). Secondly, several interviewees felt that their confidentiality

was better preserved by the SRP than at their regular GP practice, because their

visits to the former would not be recorded on their GP-held medical records. This was

felt to be important in the context of the requirement to disclose details of HIV testing

for insurance purposes. Finally, despite the fact that all of the men interviewed

trusted the service, one respondent felt that the use of actual names by waiting room

staff was problematic and for this reason, used a false name. This was articulated

with a more general concern about the long-term confidentiality and potential use of

data relating to sexuality and sexual health:

Names – [I have a problem with staff] using names: when I started

going to clinics they used numbers, you were called out by your

number but, you, know there is a balance between it being

impersonal and being clinical and making people more tense

because its an anonymous thing. I also gave a date of birth that

wasn’t mine and I remember both the alias’ DOB and mine,

because you know that laws can be changed, registers can be

suddenly implemented, governments change whatever, there is no

way of saying that this is going to be confidential for your lifetime.

[SR3]

Language use

The formality of language used by health workers was felt to be pitched at the correct

level and no respondents had experienced problems either understanding staff or

feeling patronised by them. Service-users had faith in the ability of doctors to tailor

their language use to the ‘level’ of the particular client, using formal and informal

terms as appropriate. No one had experienced use of judgmental language by staff.

91

[On language use] Oh very easy - it was like banter. He wouldn’t be

too serious about it but again that might be about his experience

with patients and how to read them. [SR1]

I think some guys will come along and they might not know the big

fancy words for it and as long as the nurses and doctors are able to

judge or match their description with theirs it should be ok. I have

noticed that some doctors are a bit more colloquial than others and

it is just knowing when to use which. [SR2]

I think they respond quite well and I think that is quite important

when you are dealing with such a vast cross section of public… its

fine using some of the jargon, whatever, that you would be aware of

and studying it, but if it’s a nineteen year old you know or younger,

all of that might be over their head. [SR3]

Consultation time

In contrast to their experience of attending GP practices, participants felt that a lot

more consultation time was available if necessary. This extra time was valued and

provided the opportunity to chat, express concerns and opinions and ask questions:

And again I feel more comfortable coming here than I do with my

own GP; again the local GP would be seeing, one would imagine, a

lot more people, and again its like ‘get them in, get them out’ and

you are not made to feel like that when you come here. Its not ‘oh

there’s a customer or client, in 5 minutes, do this, administer that,

do that, take a blood test and get them out, you are not made to

feel like that. You are important enough and he values what you are

saying to give you that time. [SR1]

The doctors - they have people to see so, there is a bit of a, you

know obviously they can’t spend forever and a day with you, which I

appreciate. So I think basically I would describe it in the main as a

no nonsense, professional and friendly service. [SR2]

92

One respondent, whilst not complaining of a lack of time, was aware of the pressure

staff were under in terms of numbers of appointments and therefore tried to keep his

consultation times to a minimum:

You get you know there is no sense of being hurried, there is no

sense of not being given anything you need. [SR3]

Participation

Another distinguishing feature of consultations at the SRP related to the opportunity

for active participation in health-care decisions. Whilst most respondents recognised

and deferred to the authority and knowledge of the health professional (doctor, nurse,

health adviser), they felt that they were able to ask questions, clarify concerns and

were helped to come to a decision regarding their health. Whilst the patient-doctor

dynamic varied according to the nature and complexity of the presenting concern2,

several respondents described a mutuality of approach and a model of listening,

enabling and supporting, as opposed to being very directive:

I suppose it is mutual but if anything I would say I was leading him

[the doctor]; it was at my prompt. I would ask certain questions, I

would say, you know, ‘and how do you think it will go, what will I

look for?’ So I felt as if the doctor has been happy to kind of advise

me. [SR1]

Well to be honest I don’t know what I’m wanting so I am very happy

for the doctors to say ‘just to say take this and go away’. It seems

that if I voiced an opinion that they would take it on board but I

haven’t. [SR4]

One participant made the point that the potential for participation was limited by

‘personality’ factors, with more confident, articulate or experienced users being able

to demand more of the health professional:

I think there is a good balance between practitioners and service-

user. Inevitably the situation boils down to personality: you go and

see a professional and the professional is going to know probably

2 Being more doctor-led in ‘simple’ cases like a repeat prescription.

93

better than yourself, otherwise you wouldn’t be asking, but then

again saying that, I come from a place whereby I have sixteen,

seventeen, eighteen years of using sexual health services so I can

speak from maybe a more informed view on my own behalf. [SR3]

Individual needs

The majority of respondents felt that they could speak about broader aspects of life

that were impacting on their health although very few of the men had actually done

this with doctors or health advisers. The major barrier to this was a very definite view

of professional boundaries: problems with relationships, finances, work etc, were felt

to relate to mental well-being and therefore the preserve of counsellors; physical

health problems were taken to traditionally defined health workers (doctors). Some

respondents felt encouraged to talk about their individual circumstances, although

opinions were mixed regarding the value of this:

That’s never come up [talking about individual circumstances] but I

would feel comfortable enough to do that. [SR1]

I don’t know because I have never done it, I know the limitations,

but I know that if I was to break down and say ‘listen I am having

problems with my boyfriend’ or something, I am sure they would be

receptive to that. [SR3]

If I arrived saying I couldn’t sleep and I was having pains in this part

or that part of my body whatever, you know, I would expect

someone saying ‘what kind of stresses have you been under

recently? Do you think this could be caused by such and such?’ –

by the fact you’ve just been fired or whatever, but then you know I

haven’t been presented with anything like that that would lead to

that kind of questioning but then again, you know, if I had things

that I particularly wanted to talk about in terms of my lifestyle and

stresses then I would see a counsellor to do this. [SR3]

Another user felt it helped to put him at his ease but was not important for his health:

94

Well certainly with the health advisor in my last visit, we talked

about relationships and things and I was quite happy with that. It

was relaxing for me but I don’t think it was important for my health.

[SR4]

One participant felt it approximated to a more holistic service:

Well I have [talked about my individual circumstances] but that has

been the counselling side. I haven’t done that with nurses or

doctors, because to be honest, that’s not what they are there for, it

really isn’t, I mean and it is not that I feel intimidated by doing it, I

just think, well you wouldn’t go to a pub and ask to buy a set of

curtains! I don’t want a jack-of-all-trades; I want a master of each

one. A doctor who is a bit of doctor, a bit of a nurse and a bit of a

counsellor and a bit of this and a bit of that, on the one hand it’s

very holistic, but on the other hand it could be he is spreading

himself far too thinly. I want my doctor to be a great doctor, who

knows a lot about other things, but who then refers me on to a great

therapist or a great urologist or whatever. So I think it is important

but I don’t’ think a holistic approach is from one person, I think a

holistic report comes from the whole centre and I think that is what

we are getting towards. So you come here it is not just individuals it

is the whole service. [SRP 2]

Two interviewees had been referred to counselling within the SRP by a health

adviser, one of whom had also been referred to a urologist and to another specialist

for a scan.

Health Promotion

This section of the interview aimed to assess the broader educational and reflective

impact of service-use. Respondents consistently reported knowledge gains from the

various information sources available. These gains, together with the nature of some

of the services offered within the SRP (e.g. counselling) had caused some to reflect

on aspects of their lifestyle and increased respondents’ sense of control over their

health.

95

Improved knowledge and source(s)

All participants felt that they had increased their knowledge of sexual health issues

and specific conditions by attending the clinic. This included an experienced user

who felt that risks had changed over the years. Some had deliberately sought out

information for themselves (or for friends) or had achieved learning through

treatment. Attention was consistently drawn to the quality and quantity of educational

literature available in the clinic:

Yes, I mean chlamydia, gonorrhoea, hepatitis ‘A’, HIV and urinary

tract infections, epididimitis, I mean I have only heard these

expressions and learned about them by coming here, so it has

increased my knowledge of medical terminology and medical

illnesses and what they are all about. So yes I have learned a lot

from that as well; from the leaflets and just from chatting really.

[SR2]

Doctors, but especially Health Advisers were also seen as important sources of

information:

A partner of mine has had herpes and I needed some information

about that and it was readily available here. So I think you know if

there is information, there are plenty of leaflets around. You know,

you can talk to the health advisors about risks which seem to have

changed since I have been visiting sexual health services. [SR3]

Altered perceptions of self regarding health

In common with the views reported in the first interim report, most participants

reported feeling that attending the clinic had increased their sense of control

regarding their health. Regular discussions with health advisers and counsellors had

also encouraged a degree of reflectivity regarding aspects of sexual lifestyle,

although this often occurred after the ‘problem’ event.

[I feel] more empowered…Sometimes you get a bit lax about your

sexual life style, you know, Friday, Saturday night – you’re a wee bit

pished, and you’re out and you think ‘he’s quite nice looking’. I

96

mean that happens, but coming into contact here, you kind of revisit

past experiences and think ‘I shouldn’t have done this, I shouldn’t

have done that’, and you are aware of your sexual health. [SR1]

You know in terms of feeling in control of your sexual sort of health I

think it offers you all the things that you need to do that, from

information, from accessories, from having people to talk to who are

around your own age. [SR3]

Well a combination of it [attending the service] and health problems

that I have been diagnosed with, I guess has changed my attitude

to sex a bit, yes. Also, I have been starting to feel like this is sort of

like coming to confession; the very fact that I have to say it out loud

makes me realise ‘Well! that was really fucking stupid’. [SR4]

Expectations and suggestions

Although many participants had few specific expectations of the service before using

it for the first time, all found key aspects of the service to be surprisingly good and

therefore in some sense, to exceed expectations. Many of the reasons for this have

been described above, yet another defining characteristic of the service (in contrast

to regular GP visits) was perceived to lie in its ability to personalise care and treat

people as individuals instead of minor elements of a service:

Again my ordinary doctor, the receptionists are so stand offish they

are so cold, so, you know, I’m just another client to them; here they

are a lot more kind of personal in the way they respond to you.

[SR1]

The overall service had raised expectation of what the NHS could offer more

generally, although participants were aware of the resource implications of doing this

combined with the institutional barriers (coldness, formality, treatment of symptoms

not people) associated with traditional models of service provision:

I was amazed, I just went right through the system from start to

finish. I was seen, I was examined, I was analysed, I was

97

prescribed antibiotics there and then and then so I thought wow-

this is the business! So it was a huge contrast between the

conventional GP route and this specific route and I was very

impressed. A lot more personal and just very professional - going to

your GP, they see lots of people, you are just a number really, they

don’t have time to personalise it at all. [SR2]

Going to the GPs or whatever it’s just so faceless and kind of

minimal then you come here and get free medication and it is just

really pleasant surroundings and nice people. [SR4]

Suggestions for change were relatively minor in general (see ‘Access to service’

section, above) although one substantive comment was made regarding the

provision of a wider range of complementary treatments in the centre, in order to

strengthen its capacity to deliver a holistic service.

What about offering holistic treatments here like massage,

reflexology, therapies, face therapies, tai chi you know –

somewhere that people could go and, you know, maybe

hypnotherapy, acupuncture you know different things like a whole

range of services under one roof that people can come and pick

and choose and pay for, so the mind, body, spirit, everything can be

catered for. I think it would be holistic if I could see my doctor, my

nurse, my counsellor, my aromatherapist, my reflexologist I mean

everything, the whole caboodle situated in the one place. Yeah!

Like a huge big hypermarket of health! [SR2]

Summary

A clear and detailed picture has emerged from the five interviews of a valued,

modern and progressive service. Various barriers were identified that obstructed use

of ‘traditional’ sexual health services. These included:

• Institutional/service-culture barriers: NHS services perceived as rushed,

impersonal and involving long waiting times

98

• Cultural barriers: Sexual health still considered a taboo subject on the west coast

of Scotland; gay men ‘in the closet’ unlikely to go to GPs with sexual health

problems

• Generational barriers: ‘post-AIDS’ generation of young gay men not as sensitised

to sexual health issues as those first affected by the disease. Therefore less likely

to attend clinics for testing, check-ups, etc.

Although participants had overcome these barriers, it was clear that key

characteristics of the Steve Retson Project had helped them to do so. Furthermore,

their overwhelmingly positive views of the service ensured that they would both

continue to attend and recommend it to others. Key characteristics/good points

included:

• Good geographical and temporal accessibility of the service

• The availability of appointments ‘on spec’ and a brief wait for those made by

phone

• A physical environment conducive to relaxation and the minimisation of anxiety,

including bright, modern décor and refreshments.

• An informal, friendly and personalised service, incorporating a number of health

professionals tackling various dimensions of well-being (physical functioning,

lifestyle and mental health) under the same roof.

• The sense of there being enough time to express opinions, ask questions and

participate in treatment.

• The availability of health-promoting information from workers and literature

Whilst the opinions expressed by respondents is likely to be biased for a number of

reasons (articulate, middle-class, repeat users, working centrally and agreeing to

take part in the research), it is clear the SRP provides the kind of service

environment that is well placed to deliver a ‘social’ model of health.

Suggestions for change

• A larger waiting room with thought given to the seating arrangement, in order to

minimise unwanted encounters/improve anonymity. More sessions might also

achieve similar results, although this was not suggested.

• The option to withhold details such as name and date of birth (re: protection of

confidentiality).

99

• A more flexible system for cancelling early appointments in advance of the clinic

opening.

• Greater or more co-ordinated provision of alternative and complementary

therapies such as aromatherapy and reflexology.

100

Chapter Nine – Conclusions

As with the interim report the individual service chapters within this report present a

summary of the key findings that emerge from each service in turn. This final section

of the report pulls together the key themes and findings from the interviews with

participants across the five Sandyford Initiative services in relation to the experience

of a social model of health and, building of the interim report, considers the

usefulness of the current methodology as a means of assessing users’ views on an

ongoing basis. The decision to present the results by service as well as across the

Initiative as a whole is guided by the fact that whilst some findings are related to the

overall philosophy and organisation of the Initiativ, others are more service specific.

Whole System Issues

The following section looks at three separate themes emerging from the interviews

that have implications for the Sandyford Initiative as a whole. The first of these

concerns access issues and is discussed in relation to potential selection bias. The

second theme is the expectations that users have about health care and the third

relates to perceptions of the Sandyford as a cluster of services rather than a more

holistic service.

Access

The interim report discussed users’ views of the experience of accessing the

Sandyford Initiative. Once again, perceptions of ease of access were high with only

a small number of users finding it difficult to reach using public transport or finding

parking to be problematic. A small number of users did express the desire for

outreach services to be available in other areas of the city. The caveat that was

raised last year applies to the current findings – clearly those with major access

difficulties would not be those attending the service and therefore their views are not

represented. A detailed analysis of postcode information for all users would allow a

systematic assessment of whether the service is accessible to those in different

areas of the city and whether it provides an equitable service to those from more

socially deprived areas.

The earlier report discussed the perceived need for better signposting within the

Initiative and, whilst this is an issue that has been tackled by the service as a whole,

there is still a view that signposting is unclear. At the same time there would appear

101

to be a tension between those wishing clear unambiguous signposting of clinics and

those grateful for the lack of banners announcing the purpose of other services. The

main area where clarity would appear to be particularly appreciated is in

distinguishing between general Family Planning Clinics and The Place. The wish for

a front of house person was expressed again.

A final issue related to access is that of waiting times. Across the services there was

a degree of dissatisfaction either with the length of time spent on a waiting list before

being allocated a counsellor or with the time spent in waiting areas on the day of an

appointment. These voices of dissatisfaction were, however, tempered with an

acceptance of waiting as being part and parcel of receiving a good service.

Shaping expectations

As with the interim report, users’ expectations of receiving a social model of care and

perceptions of it having been delivered were variable. Those receiving counselling

services were far more likely to see their social world as being a legitimate domain

for health care and were generally happy that their needs were being addressed.

For those receiving more traditional types of service there was a greater likelihood of

users expressing uncertainty about the appropriateness of seeking advice about

social issues from medical and nursing staff. This is important from a number of

angles. Firstly, there was a view expressed that social problems are best disclosed

with a practitioner with whom one has an ongoing relationship and ensuring this type

of continuity of care is problematic with some of the Sandyford services. Secondly,

some participants appeared to view the discussion of personal social issues and

receiving professional care as being inimical to one another.

This relates to a final issue that should be strongly underlined in relation to the

findings on users’ expectations, namely, the role of services in shaping espectations.

Most users clearly expressed a view that they had previous negative experiences

with health services and that they were attracted either to the expertise and

professionalism or the holistic care offered by the Sandyford services. However, a

number of participants reflected that, whilst they felt that they had the opportunity to

ask questions and raise social issues, they didn’t know what to ask. This implies that

a service that operates a social model of care requires not only to provide space for

issues to emerge but to structure consultations in such a way that social issues are

102

seen by users to be integral components of the process of diagnosis and treatment.

The findings from the GUM clinic provide a good example of a user who, initially

surprised by a question concerning relationship issues, reflects on the legitimacy of

the question (p 61 of this report). Ways of supporting those services that provide

more traditional health care to positively shape users’ expectations should be

considered.

A holistic service (‘a huge big hypermarket of health’)

The interim evaluation found that, on the whole, users perceived the Sandyford

Initiative to be made up of disparate clinics with only those using the Centre for

Women’s Health tending to use more than one service. There was some evidence of

more users within the current group of participants moving between services. In the

last year a number of changes to the Initiative have been made that may in the future

lead to a greater sense of identity for the Initiative – the creation of a single Director

and the merging of counselling services. These may allow the development of a

range of joint service initiatives such as courses in self-esteem, aromatherapy and

other alternative treatments requested by some participants. Such integration should

also be encouraged as a means of providing support and a critical mass to the

shaping of users’ expectations as discussed above.

Accessing users’ views

An initial aim of this component of the evaluation was to use a longitudinal

methodology to assess changing perceptions of the delivery of a social model of

health within the Sandyford Initiative. This has proved to be problematic for two

reasons: firstly, the number of participants in the first round who gave consent to

being invited to take part in a second round of interviews was small; and, secondly,

none of those who gave consent were willing or available to be re-interviewed when

invited to do so.

It is perhaps unsurprising that, whilst many users are happy to give of their time on

one occasion when on the premises, they are less likely to make time for a repeat

interview when it might require more effort and planning. Initial consenters may also

have ceased contact with the Initiative.

We would argue, however, that the value of the second round of interviews is not

diminished by the fact that repeat participants were not available. Instead, the vast

103

majority of the interviewees were repeat users of the service and were, therefore,

able to reflect to a certain extent on changing expectations and experiences.

We would also argue that the approach of taking an annual snap-shot of users’ views

of the extent to which care conforms to a social model is a worthwhile exercise for

the Initiative as a whole. The interviews conducted as part of the current study have

allowed rich and detailed views to emerge and accessing the voices of a small

number of users in this manner (incorporating both repeat and new appointments)

may serve as a complement to other means of assessing views. This method need

not require the resources of external evaluation but might be incorporated within the

remit of the user involvement strategy.

In the initial round of interviews we struggled with three issues in accessing users’

views. In round two we have offered some means of resolving these. Firstly, in

services where there is a greater likelihood of stigmatisation it is helpful if the initial

contact with potential participants is by staff members. Secondly, in deconstructing

the language of the social model of health the notion of users’ expectations was a

helpful one. Finally, we suggest that the difficulty of encouraging younger people to

engage in discussions in this area may also be aided by conducting the interview in

the presence of a confidante.

104

References

Advanced searches were undertaken using BIDS databases (International

bibliography of social sciences) and Psychinfo dating from 1995 to 2001 (English

language)

Initially the words sexual and health and social were used. After the initial search,

sexual was replaced with reproductive and women. Many of the same articles were

identified but new ones also emerged. Using a range of these core articles as a

basis for the literature review, some key themes emerged and further searches were

undertaken using more specific terms, for example, youth and sexual health, ethnicity

and sexual health, empowerment and sexual health.

Further papers were located using references cited in papers during the primary

search. A range of relevant articles and books were also located by the researchers

using libraries at the Sandyford Initiative and the University of Glasgow, and again by

following up references cited in these.

Adam, R and Guthrie, B (2001) The death of the personal doctor, Journal of Health

Service Research and Policy, 6, 129-130

Annandale, E and Hunt, K (2000) Gender inequalities in health. Buckingham: Open

University Press

Balint, E (1969) The possibilities of patient centred medicine. Journal of the Royal

College of Practitioners 17, 269-276

Blaxter, M (1983) Causes of disease: women talking. Social Science and Medicine,

17, 59-69

Blaxter, M (1990) Health and Lifestyles. London: Routledge

Broom, D (1997) The best medicine: women using community health centres.

Australian and New Zealand Journal of Public Health 21, 275-280

105

Broom, D (1998) By women, for women: the continuing appeal of women’s health

centres. Women and Health 28 (1) 5-22

Busfield, J (1996) Men, women and madness: understanding gender and mental

disorder. London: Macmillan

Campbell, S., Rowland, M and Buetow, S (2000) Defining quality of care. Social

Science and Medicine 51, 1611-1625

Calnan, M (1987) Health and Illness: the lay perspective. London: Tavistock

publications

Coulter, A (1999) Paternalism or partnership?, British Medical Journal 319 (7212)

719-720

Craddock, C and Reid, M (1993) Structure and Struggle: implementing a social

model of a well woman clinic in Glasgow, Social Science and Medicine 36 (1) 67-76

Doyal, L (2000) Gender equity in health: debates and dilemmas, Social Science and

Medicine 51, 931-939

Elwyn, G., Edwards, A., Gwyn, R and Grol, R (1999) Towards a feasible model for

shared decision making: focus group study with general practice registrars. British

Medical Journal 319, 753-756

Evans, RG and Stoddart, GL (1994) Producing health, consuming health care. In RG

Evans, ML Barer and TR Marmor (eds) Why are some people healthy and others not.

New York: Walter de Gruyter

Graham, H (1998) Health at risk: poverty and national health strategies. In L Doyal

(ed) Women and health services (22-38), Open University Press

Greater Glasgow Primary Care Trust. Sandyford Initiative – Review of service

integration and management, April 2001.

Guadagnoli, E and Ward, P (1998) Patient participation in decision-making. Social

Science and Medicine 47 (3) 329-339

106

Hills, M and Mullett, J (2002) Women-centred care : working collaboratively to

develop gender inclusive health policy, Health Care for Women International 23: 84-

97

Hughes, W (2000) Medicalised Bodies in The Body, Culture and Society: an

introduction. Open University Press

Hurley, M (2002) Effect of patient-centredness and positive approach, BMJ 324,:543

Janzen, B (1998) Women, gender and health: a review of the recent literature.

Winnipeg: Prairie Women’s Health Centre of Excellence

Labonte, R (1998) A community development approach to health promotion: a

background paper on practice tensions, strategic models and accountability

requirements for health authority work on the broad determinants of health.

Edinburgh: Health Education Board for Scotland and the Research Unit in Health and

Behavioural Change, University of Edinburgh

Lupton, D (1996) Your life in their hands: trust in the medical encounter. In Health

and the sociology of emotions by V James and J Gabe (Eds), Blackwell Publishers

Laughlin, S, Nandwani, R, Ilett, R, Bigrigg, A (2001) The Sandyford Initiative: creating

added value to health and health care, Health Bulletin 59 (4) 238-243

Little, P., Everitt, H., Williamson, I., Warner, G et al (2001) Preferences of patients for

patient centred approach to consultation in primary care: observational study. British

Medical Journal 322, 468-472

Little, P., Everitt, H., Williamson, I., Warner, G et al (2001) Observational study of

effect of patient centredness and positive approach on outcomes of general practice

consultations, British Medical Journal 323, 908-911

Mackenzie, M, Lawson, L and Mackinnon, J (2001) Evaluation of the Sandyford

Initiaitve: having your voice heard – Interim Report

107

O’Flynn, N and Britten (2000) Menorrhagia in general practice – disease or illness,

Social Science and Medicine 50 (2000) 651-661

Ogden, J, Baig, S, Earnshaw, G, Elkington, H et al (2001) What is health? Where

GPs and patients’ worlds collide, Patient Education and Counselling 45 (2001) 265-

269

Peberdy, A (1997) Communicating across cultural boundaries, in M Sidell., L Jones,

J Katz and A Peberdy Eds (1997) Debates and Dilemmas in Promoting Health, Open

University

Stewart, M (1995) Effective physician-patient communication and health outcomes: a

review. Canadian Medical Association 152, 1423-1433

West, J (1999) (Not) talking about sex: youth, identity and sexuality. The

Sociological Review, 525-547

Whitehead, M (1995) Tackling health Inequalities: review of policy initiatives. In:

Benzeval, M., Judge, K, Whitehead, M (eds) Tackling Inequalities in Health, an

agenda for action. London: Kings Fund