Northern Ireland Assembly Flax Flower Logo



Sexual Health Promotion Strategy

24 April 2008

Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr John McCallister
Ms Carál Ní Chuilín
Ms Sue Ramsey

Dr Michael McBride ) Chief Medical Officer
Dr Naresh Chada ) Senior Medical Officer
Ms Janet Moore ) Department of Health, Social Services and Public Safety

The Chairperson (Mrs I Robinson):

I welcome Dr Michael McBride, the Chief Medical Officer; Dr Naresh Chada, a senior medical officer; and Janet Moore, who represents the population health directorate. I would like you to give a presentation to the Committee of up to 10 minutes, after which I will invite members to put questions.

Dr Michael McBride (Chief Medical Officer):

Thank you, Chairperson and members, for affording me the opportunity to present the Department’s draft sexual health promotion strategy and for taking the time to consider it. I will endeavour to avoid using too much jargon in the short time that I have to present to the Committee.

As some members may know, the promotion of sexual health is of particular significance to me because, before becoming Chief Medical Officer for Northern Ireland 16 months ago, I specialised in HIV and genito-urinary medicine (GUM).

Everyone knows that the primary challenge is to change attitudes to sexual behaviour. We recognise that sexual health can be a controversial subject in Northern Ireland, and we were conscious of that when drafting the strategy. In recognition of the fact that many people hold strong opinions on what constitutes the best approach, we adopted a balanced approach, founded on evidence-based practice about what works. However it is important to note that we also took into account the attitudes that are prevalent in the wider population.

Sexual health is an important part of physical and mental health, as well as emotional and social well-being. However, sexual health in Northern Ireland is poor. In June 2007, prior to the publication of my annual report, I was afforded an opportunity to give evidence to the Committee on the challenges that we face due to the poor sexual health of the population in Northern Ireland. I reiterate that Northern Ireland has a high level of teenage pregnancies and an increasing number of sexually transmitted infections.

In 2006, we dealt with 147 births in respect of teenagers under the age of 17, and more than 9,000 sexually-transmitted infections were diagnosed, of which more than 7,000 were new diagnoses. The rise in the number of newly diagnosed sexually transmitted infections is particularly worrying because of their long-term effects on people’s physical, mental and emotional health. Members are probably familiar with some of the physical complications that are associated with such infections, including infertility, ectopic pregnancies, and cervical and other genital cancers. Consequently, there are significant human and economic costs associated with those conditions.

Fortunately, compared to the rest of the UK and, indeed, internationally, we have a relatively low prevalence of HIV. However, as a result of population mobility, that is changing, and the annual number of new HIV infection cases has increased steadily each year since 2001. In 2005, 63 new diagnoses were recorded here, and that reflects the largest number of new HIV infection cases diagnosed in Northern Ireland since reporting began. It is important to note that other sexually transmitted infections are significant co-factors — in other words, they increase the risk of HIV transmission. Therefore, by addressing rising HIV infection rates through the efforts outlined in the draft sexual health promotion strategy, we will also be addressing the rising rate of new HIV infection cases.

As I said to the Health Committee in June 2007, there is strong evidence of a link between social deprivation and sexual ill health. Unplanned teenage pregnancy and early motherhood are associated with poor educational achievement, poor physical and mental health, social isolation and poverty — not only for mothers, but their children.

Nor, indeed, is sexual ill health equally distributed throughout the population. There is increasing evidence of sexually transmitted infections among young people and gay men. The highest infection rates have been diagnosed in people aged between 20 and 24.

The economic impact of poor sexual health on society should not be forgotten. Taking account of healthcare costs, lost tax revenues, social security benefits, and so on, the ongoing economic cost associated with teenage pregnancy is estimated to be approximately £28·3 million a year. In 2005, 146 young mothers were aged between 13 and 16, and that group placed additional demands on social, health and education services.

Turning briefly to HIV infection, recent evidence to the House of Common’s Health Committee estimated that between £500,000 and £1 million of individual health benefits and treatment costs are avoided as a result of preventing a single, onward HIV infection.

In Northern Ireland, we have significant problems with harassment and discrimination based on sexual orientation, and that is another important aspect of the sexual health promotion strategy. A survey carried out in 2003 indicated that a significantly higher percentage of gay men in Northern Ireland have experienced homophobic harassment and violence than in other parts of Britain and Ireland. Furthermore, research indicates that a relatively high proportion of lesbian and bisexual women have experienced discrimination at work and violent assaults.

Through the sexual health promotion strategy and action plan, we aim to address sexual health issues in several ways. At this stage, I should point out that, since 2003, funding has been available to the health and social care sector to implement action. Knowledge gained between 2004 and 2007 has also helped to shape the strategy.

The strategy focuses on five areas: prevention, training, services, research, and monitoring the implementation and achievement of the strategy’s targets. The strategy recognises that the provision of positive and accurate information about sexual-health issues is a key element in the promotion of good sexual health, and that includes the important message that everyone should treat their own and other people’s bodies with respect, and manage their sex lives with care.

Possessing the life skills necessary to enable one to make informed choices and to deter one from developing health-compromising behaviour is another important element of the strategy, and that is particularly important for young people.

The strategy recognises the central role of parents and carers and the importance of ensuring that they have the skills and knowledge to talk to their children about sexual-health issues. We recognise that the educational sector — through the school curriculum — contributes to influencing and developing young people’s attitude to sexual health and well-being.

We have limited information on the sexual behaviour of our population, and, undoubtedly, we need to conduct further research in that area to enhance our preventative strategies and services.

Significant cross-sectoral support is required to ensure effective delivery of the strategy. Successful implementation is dependent on close partnerships among the Department of Health, Social Services and Public Safety, other Departments and agencies, Churches, faith groups, community groups, schools, youth services and the health and social care sector. We propose to establish a multi-agency network to oversee the implementation of the strategy and ensure that partnerships are working.

That is an outline of the main sexual-health issues and the proposals for tackling those issues through the draft sexual health promotion strategy and action plan. As Chief Medical Officer, I strongly endorse the strategy and seek your considered views and support. I look forward to answering your questions.

The Chairperson:

I agree that the Department of Education must inform young people about life choices. Love for Life experienced difficulty in raising funds to visit schools to promote the idea that it is right for young people to say no to the pressure of engaging in sexual activity. Young people must reject peer pressure — that message might not be getting through.

Have you liaised with groups that promote abstinence? Did the Churches have any input? I did not see any reference to that, and it is important to include moral and faith-based views.

Dr McBride:

That is an important point, which you previously highlighted in June 2007. Many people believe that abstinence, or delaying the onset of sexual behaviour, is vital. The strategy reflects that, and we want it to be balanced.

One of the strategy’s targets is to, by 2013, increase the percentage of people — from 89% to 92% — between the ages of 11 and 16 who have not experienced sexual intercourse. A key component of the strategy is to equip young people with the skills and knowledge to not succumb to peer pressure and engage in sexual activity before they are ready.

Love for Life recently secured funding for its work in schools. During the process of developing the strategy, we liaised with a range of voluntary groups, Church groups and other faith groups.

Dr Naresh Chada (Senior Medical Officer):

I corroborate the Chief Medical Officer’s view on the importance of adopting a balanced approach. I am sure that the Committee is familiar with the contents of the strategy; producing such a document is a complex process because we have endeavoured to reflect the different views across Northern Ireland.

We worked closely with the Love for Life project on particular elements of the strategy. There was extensive dialogue with the head of the project, who had many opportunities to engage with us. As a member of the steering group that produced the strategy, he had the opportunity to comment on it. He also had regular access to officials.

The involvement of other interested parties was a combination of one-to-one meetings and correspondence. We also engaged with other forums, such as workshops and conferences, and a wide constituency of people had the opportunity to think about sexual-health issues and contribute to the development of the strategy. Chairperson, you make extremely valid points and, while ensuring that our approach passed muster from medical and scientific perspectives, we tried to reflect many of them in the strategy.

The Chairperson:

The media has a large part to play in determining the programmes that can be transmitted before the watershed. I watched the soaps many years ago, but I switched off when they began to deteriorate by delving into moral issues when young people were watching. Have you had any dealings with the media? Given its responsibility to ensure that children’s minds are not distorted by what they see acted out on their screens before the watershed, was there any media input?

Dr McBride:

Your point is well made, Chairperson. The media can be a positive vehicle for communicating messages. You are aware that the Department regularly uses the media to send out positive health messages. In the context of recent work on the strategy, messages were transmitted to raise awareness of sexually transmitted infections and HIV. Since March 2008, the specific message has been that it is OK to say no to engaging in early sexual behaviour — that is an example of positive engagement with the media.

I agree that young people are sometimes bombarded with information that depicts sexuality and sexual relationships in a way that none of us feels is constructive, particularly for young people who are heavily influenced by the media.

Dr Chada:

I corroborate what has been said about the media. I was closely involved with the development of the draft strategy, and I presented some of its rudimentary findings during that process. I have always made the point that the media is an important part of trying to shape the wider population’s attitudes to sexual behaviour.

I reiterate what Dr McBride said about using the media. We regard public education as an important means through which to get across our messages. At present, some of the campaigns that are running concurrently were locally produced, and others have seeped in from regions across the water.

One reason for wanting to open up the dialogue on sexual health is that young people receive a range of messages from various media — from the Internet as well as from television and radio. After the publication of the strategy, we must give more thought to how we can engage with the local and national media, although some national issues will be beyond our control.

The Chairperson:

I wanted to flag up that issue because television companies earn a good deal of money from advertising that aims to encourage children to desist from sexual activity. At the same time, they make the soap operas that are often perceived as encouraging teenagers to engage in sexual behaviour.

There are well-worn storylines such the one in ‘ Coronation Street’ about the young schoolgirl who had a baby. The soap may have handled the issue sensitively, but the storyline still gives the impression that it is OK to engage in sexual activity at such an age.

Dr McBride:

That is a vital point. The vast majority of parents and health and education experts agree that it is best for young people to delay having a sexual relationship until they are sufficiently mature to participate in a relationship that is mutually respectful.

There are examples of soaps communicating a positive message. I am not a fan of soaps, but I remember the storyline in ‘Eastenders’ about Mark Fowler living with HIV, which tried to tackle some of the stigma associated with that infection. Some soaps have communicated positive messages about STIs and chlamydia, and the need for people to go for check-ups. The media is aware of its wider corporate social responsibility to ensure that there is a balance and that positive messages are communicated to the wider population.

Mr Easton:

I support the action plan. The number of cases of sexual disease is increasing. Why were there fewer cases of sexual disease and teenage pregnancy in the past when there was less sex education? The action plan will improve the situation, but why has the number increased?

Is the number of immigrants who have sexual diseases when they arrive in Northern Ireland increasing?

Dr McBride:

There have been significant increases in sexually transmitted infections throughout the UK and Ireland — the problem is not unique to Northern Ireland. As I said, there were more than 9,000 cases last year, of which 7,000 were new cases. The economic cost associated with that, not to mention the human cost, is about £5·6 million per annum. That is significant expenditure, but does not take into account the cost to the physical and mental-health well-being of people. There has been a 21% increase in cases of chlamydia infection, which is the most common cause of pelvic inflammatory disease in women and can cause significant problems with abdominal pain, and compromise fertility. The costs associated with treating fertility are huge, which — again — do not take into account the associated human cost, distress and anguish.

There has been a change in the cultural attitude. Statistics show that young people are engaging in sexual activity at an earlier age, which is an important factor in explaining the increase in the number of cases of STIs. The level of concern among the general public about HIV is less than it was after the AIDS campaigns during the mid-1980s. Unfortunately, and tragically for some people, HIV is regarded as a treatable condition — we know that more people, irrespective of age, are having unprotected sex and exposing themselves to risks. On a positive note, as we raise awareness of sexually transmitted infections, more people who unknowingly carry those infections — unfortunately, many of them do not have symptoms — will go for a check-up.

Therefore, I fully anticipate, for instance, that if indeed the draft strategy is approved, and the action plan is implemented, we might, paradoxically, witness an initial increase in the numbers of people diagnosed with sexually-transmitted infections as they come forward for screening. That is actually a good thing. It will be difficult to communicate to the media that we want people to come in so that we can ultimately reduce the burden of infection and the risk of complications. Mr Easton’s point is very well made, but we are seeing a general change in cultural attitudes.

Mr Easton:

My second question was about the number of immigrants arriving in Northern Ireland who had been diagnosed with sexually transmitted diseases.

Dr McBride:

I do not have the specific figures on that. However, population mobility is an important factor, particularly with regard to HIV infection. We know that a significant proportion of the new diagnoses of individuals last year in Northern Ireland had had non-UK contact. We live in an increasingly shrinking world in which there is greater population mobility. Certain infections are undoubtedly more prevalent in other parts of the world, and population mobility will create trends and changes in the local prevalence of those infections.

Ms S Ramsey:

Thank you for your presentation. I support the strategy, and I have a couple of questions that I hope will tease out some of the issues. We often criticise the media, but it has a positive role to play, and we should regard it as a useful resource.

It is also important to put the message out that it is wise to form a long-term relationship before engaging in sexual activity. However, we must be careful not to isolate or write off the small percentage of people that engage in early sexual activity. Teenage parenthood is an important issue. In your presentation, you mentioned that the cost of teenage pregnancy, in unemployment benefits administration and lost tax revenue, stands at £20,000 per mother. That tells me that there is a need to continue to support community and voluntary-sector programmes for school-age mothers and fathers who are not being supported.

That brings me on to a number of other questions. You said that it was important that everyone, including education professionals, communities and the Churches had a role to play in advising young people about their sexual health and well-being, and I agree with you. There is a crisis in the community and voluntary sector, but of the 25 action points that you outlined, 10 of them highlight the need to involve the community and voluntary sector. There is a clear message that none of the strategy can be implemented unless the community and voluntary sectors are involved. Not only is there a crisis in health funding, but social-development measures, such as the children and young people’s fund, are also affected.

We must get real. Although it is important that the strategy has been created and is down on paper, will we come back next year to complain that no funding has been made available by other Departments? You also mentioned that £640,000 is available in 2008-09 to implement the action plan, with support over five years. You may not have the figures to hand, but can you give us a breakdown of where that money will go? Can you provide the Committee with an indication of the projected figures for the next four or five years?

There is an issue about the border areas. Young people nowadays feel freer to go into areas that straddle their home area. Has there been any discussion with the Department of Health and Children in Dublin? It has an important role to play, even if it is not supporting the community and voluntary sector’s involvement in the action plan. The multi-agency network that will oversee the framework is important, but we need to know who will form its membership.

Dr McBride:

I will try to answer as many of those questions as I can. You are absolutely right about the need for ongoing support for young mothers and fathers. The aim of the presentation was to highlight the cost to society, but also the loss of life opportunities for those individuals as a result of teenage pregnancy in areas such as educational achievement and employment.

The cost to society, never mind to the individual, is significant. Therefore, there is a case for continuing investment in the strategy to ensure that we fully implement all the actions and targets that we have set ourselves.

You raised an important point about services. An important aspect of the strategy is for people to have equitable access to services and support. Community-based initiatives will be vital in relation to the implementation of the strategy. The strategy stemmed from a commitment given in the Investing for Health strategy, and its approach is entirely consistent with that which is outlined in the strategy. That can be delivered only through a partnership approach, working in a cross-sectoral way with the community. We see that as part of a wider opportunity.

There are also exciting opportunities in the context of the review of public administration, such as the proposed establishment of a new regional public health agency, which will bring together the critical mass. That is subject to the outcome of a consultation process, which will end on 12 May. We also have interesting proposals and exciting opportunities to form linkages with local government and to work with local communities on proposals such as a duty of well-being on local government. We have an exciting opportunity to realise the targets and objectives in the Investing for Health strategy. That can only be achieved by working in partnership.

Genito-urinary medicine services here are more comprehensive than similar services in the Republic of Ireland. We recently commissioned the four boards to carry out an assessment of services across Northern Ireland. The report was completed at the end of October 2006. On the back of that, we have developed an implementation plan to enhance access to GUM services, with investment of more than £250,000. Undoubtedly, many of those services are in border areas.

You flagged up an issue that was highlighted in the review, which was the need to consider opportunities that will create a win-win situation regarding access to services for all communities. We have established similar models in relation to radiotherapy services, and, undoubtedly, further models will be established if they benefit the population, North and South of the border. Dr Chada will comment on some other specific issues.

Dr Chada:

Most of the points have been addressed. However, presenting figures on the health and economic issues surrounding teenage pregnancy was not an attempt to stigmatise people who happen to look after young children and who happen to be in that age group. That was purely a means of highlighting the point that we must invest in services in that area. In fact, I was involved heavily in the teenage pregnancy and parenthood strategy. “Parenthood” is an important word in the title of that strategy, and we will ensure that we continue to support young mothers, so that they can access education and training and receive all the support that they need to raise their children in a healthy environment. I simply wanted to underline the importance of that issue. The teenage pregnancy and parenthood strategy is being reviewed because it reached the end of its natural life in 2007. We want to take a fresh look at what we can do in that area in the latter part of this decade.

The other point that you made about voluntary groups is extremely important and will be taken on board. The importance of voluntary groups in implementing the strategy and in the planned sexual health promotion network has been stressed. Membership must reflect all of the agencies involved.

Ms S Ramsey:

Where will the initial money go, and who will be on the multi-agency network?

Dr McBride:

I will supply that information to the Committee in writing, if that is acceptable.

The Chairperson:

Thank you very much.

Dr Deeny:

The strategy interests me, as a GP. A few years ago, just off the Strand Road in Derry, I remember seeing a girl, no older than 16, with a baby. A young fellow, presumably the child’s father, ran to meet them, still wearing his schoolbag. I thought, “My goodness — parents at 16.”

A change of mindset is required. I support the strategy and the action plan, but have some questions on practical issues.

The approach appears subjective, because it relies on young people’s admitting that they have had sexual intercourse before the age of 16. What happens if they say that they did it out of bravado and because of peer pressure? Figures show that, by 2013, 92% of people aged 11 to 16 will not be having sexual intercourse, so can you rely on individuals’ providing accurate information?

Schools have for years shouldered a lot of responsibility for children’s conduct, which is fair enough, but they cannot be expected to sort out the behaviour, sexual or otherwise, of all of our young people. More emphasis must be placed on parents. Therefore, bearing in mind what you say in your prevention plan, how are you going to involve parents?

Nowadays, parents seem to let their children do whatever the hell they want and leave it to teachers, doctors and other people to sort them out. Not enough responsibility is placed on parents’ shoulders for their children’s behaviour in all areas of life, but particularly sexual behaviour. However, advising young people in a negative way and instilling fear into them often fails. Rather than saying that misbehaving and having sexual intercourse too young will lead to suffering, will the positives be accentuated — such as being healthy, free, able to travel, and looking forward to their entire, potentially wonderful life?

That deals with measurement, parents’ involvement and the message. Lastly, what is the current situation regarding the human papilloma virus (HPV) vaccine programme?

Dr McBride:

I agree with what the Committee has said today. I believe that, at the same time as promoting good sexual health, it is also important to get the right messages across to young people in Northern Ireland.

I will ask Dr Chada to update you in relation to the survey that we carried out. That survey formed the basis of the baseline number of young people in Northern Ireland who are currently engaging in sexual activity. I will also ask Dr Chada to tell the Committee how we propose to reanalyse that information to ensure that we are meeting our targets.

First, I would like to discuss the HPV vaccine. The Committee will be aware that — as a result of the moneys that were secured following the comprehensive spending review — the Department is now in a position to implement the HPV vaccine programme, in line with the rest of the UK. That programme will commence in September 2008 with children aged 12-13, with a catch-up programme for older girls beginning in 2009.

The programme is an important initiative. Its implementation in Northern Ireland is likely to prevent upwards of 705 cases of cervical cancers and, long term, the vaccination programme will save upwards of 30 lives each year.

In preparation for that work, we have been conducting some research among parents and carers on their views of the vaccination programme. Parental attitudes are vitally important in the successful implementation of the vaccination programme, and the preliminary findings from our research suggest significant parental support. The Department will be conducting further research, and a phase of that research will concentrate on the acceptability of the local implementation of the programme. Work is progressing on that issue, and I wish to assure the Committee that I am confident that we will be introducing the vaccination in line with rest of the UK.

The strategy clearly identifies that parents and carers have an important role to play. Part of aim of the strategy is to ensure that we are equipping parents and carers with the skills and competencies to help them communicate in an open way about sexual matters, and to help them provide such information to their children.

Regrettably, in a survey carried out in, I believe, 2001, 53% of adult respondents in Northern Ireland stated that they had gleaned knowledge and information about sexual relationships from their friends. That is absolutely unacceptable, and it goes back to the point that the Chairperson made about having healthy and responsible attitudes to sex and sexuality.

The strategy aims are to equip parents and carers with the necessary skills, knowledge and confidence to engage in sexual-health-related conversations with their children. The Committee is absolute right in that the primary responsibility for sexual education resides with parents and carers. The role of education is to support children and parents in the further development of those children and to equip them with the necessary life skills to make informed choices later in life.

I ask Dr Chada to advise the Committee on how we established the previously mentioned baseline and how we propose to track that.

Dr Chada:

In conducting our research, we wanted to get some particular information and detail about the numbers of teenagers who had not experienced sexual intercourse. That became an important target in the strategy; not only from the point of view of measuring abstinence, but by ensuring that we had a cohort of people who were able to make an informed and healthy choice as to when they wished to participate in or begin sexual activity.

I totally agree with the Committee about the data. Ultimately, we have to rely on surveys and, as the Committee may have garnered from the strategy itself, we have used the young person’s behaviour and attitude survey.

We are able to get information about groups of people on a regular basis to make comparisons. Such surveys have strengths and limitations, which I am sure everyone around the table, as well as professionals and officials at the Department, would recognise.

We spend a lot of time designing those surveys using the best scientific and statistical methods to achieve a degree of validity of which we can be confident. I hope that applies to the tangible measurement of the targets.

Another issue that arose was how to involve parents, which has already been mentioned. The sexual health promotion network will have to examine innovative ways of ensuring that it devises programmes to achieve that particular goal. Although that remains a challenge, it is vital to the success of the strategy.

Dr McBride:

Strategies such as Investing for Health, Sure Start, Healthy Schools, health action zones and healthy living centres already possess the basis for strong working partnerships within those overall frameworks. We should be able to use that, but that is dependent on the maintenance of those existing mechanisms.

Ms Ní Chuilín:

Have any results been returned from the reviews, undertaken since 2006, of the National Institute for Health and Clinical Excellence (NICE) guidelines?

The introduction of chlamydia testing must be fully considered. What will that mean and what will it involve? Alex Easton raised the issue of increasing numbers; if the aim is to promote better health and well-being by including chlamydia testing, the demand for that service will increase. The report states that, because of the current increase, there can be up to a six-week wait for an appointment at a GUM clinic.

On the one hand, the Department is trying to promote its strategy, vis-à-vis promoting awareness of services, but on the other, there are questions about whether the existing infrastructure can support a potentially large increase in numbers, particularly if chlamydia testing is fully considered. What impact will that have on services?

Dr McBride:

It is about maintaining balance; one of the key aspects of the strategy concerns how to monitor the implementation of those targets to ensure that we have a range of services — including GUM, sexual-health and educational services — available to meet people’s needs. I anticipate an increase in demand for services as we raise awareness about the importance of good sexual health among the population.

I refer to my earlier answer to Sue’s question, when I talked about the work that we commissioned — completed by the four boards in October 2006 — to examine the capacity of GUM services and how we asked the boards and trusts to develop proposals to ensure that we were able to realise the target that people with cases regarded as clinically urgent could access services within two working days. On the basis of that analysis, an implementation plan was developed to ensure that capacity and funding in the region of £250,000 was made available to enhance services.

By tracking and monitoring progress, we can estimate the potential increase in demand; if we are not meeting our objectives, we will need to enhance capacity in those services. However, I can assure you that we have been assessing the current capacity and building additional capacity and responsiveness into the service.

Dr Chada:

The point about the NICE guidelines is extremely important, and I am glad that it was included under action 6 of the sexual health promotion strategy and action plan, which considers how those guidelines will be reviewed and implemented.

It is extremely useful and helpful if we ensure that evidence-based practice lies at the heart of everything that we attempt to do, not only in relation to the strategy, but in our attempts to improve services generally.

For some time, the Department has provided a facility whereby we are able to access the evidence-based guidelines issued by NICE in order to ensure that they are reviewed by local experts. Subsequently, we are able to cross-match those guidelines with practices in Northern Ireland and recommend how they might best be issued and implemented here.

Considering the strategy’s detail, it was important to ensure that any pertinent guidelines be issued in tandem with it. I can provide you with details; however, as far as I am aware, the guidelines are being peer-reviewed prior to issue. Our aim is to issue them at the same time that we eventually issue the strategy document, so that both documents work in tandem with and corroborate each other.

Dr McBride:

It is worth adding that, in May 2006, we established a service-level agreement with NICE, and we completed a review of its procedure, whereby, as Dr Chada outlined, we asked local reviewers to comment on the applicability of NICE’s guidance to Northern Ireland by considering whether there were any demographic differences — in other words, whether the population differs to such an extent that guidance and technology appraisals did not apply and, indeed, whether there were implementation issues in relation to, for example, infrastructure and staff training. In that time, we found that all of NICE’s documentation and guidance does apply and we have not substantively altered it. We are now reviewing the necessity of having that second-stage process in Northern Ireland.

Mr Gallagher:

Thank you for your presentation. Members referred to the fact that this is an uncomfortable topic, particularly when dealing parental issues. At the end of the day, people prefer to pass the problem along in the hope that someone else will pick it up.

Given that figures demonstrate a worrying increase in STIs, how closely do you work with, for example, the Department of Education? Relationship and sexuality education is an important means by which more effective work could be done to get to grips with the problem. How much time is spent on that in schools? Good teachers and principals work to deliver the best programmes that they can; however, circumstances are difficult for schools, and, given that mandatory curriculum choices must be delivered, they will become more difficult. What contact do you have with educationalists, and, given that such programmes are worthwhile, does someone monitor what it is possible to deliver in schools?

Paragraph 2.22 of the draft strategy states that:

“The prevention of unplanned pregnancies by contraception has estimated savings of approximately £85 million in Northern Ireland per annum (based on research by the Department of Health in England).”

That research was carried out by the Department of Health in England. For clarification, did I understand Dr McBride to say that savings of £28 million were made in Northern Ireland?

That paragraph does not sit properly with the foreword by the Minister, in which he refers to the religious, cultural and moral dimensions of the issue. I am not moralising, but, in view of the Minister’s words, the paragraph is not well worded. Its conclusion is almost that savings will be made by teenagers’ resorting to contraception. A significant number of parents would simply not agree that that is the way solve the problem. That paragraph should be rewritten.

Dr McBride:

To eliminate any confusion about the two amounts, the figure that I quoted from paragraph 2.20 on page 10 is the cost of £28·3 million per annum that is associated with teenage pregnancies. The figure of £85 million that you correctly quoted from paragraph 2.22 is the estimated saving per annum from the prevention of unplanned pregnancies. The figures relate to the same issue, but from different perspectives: one is the current cost of teenage pregnancies, and the other is the estimated potential saving from their prevention.

I want to stress that it is not about creating a stigma, which was another valid point that was made earlier. As with many health issues, the aim is to invest in order to save. By investing in the health of the population, we aim to ensure that society benefits from a return on that investment. The benefit of that return will be felt by individuals, the community and wider society.

Naresh will comment on the working relationship with the Department of Education, both in developing the strategy and in determining how we intend to ensure its implementation.

Dr Chada:

The Chief Medical Officer, colleagues in DHSSPS and I appreciate the value of working with the Department of Education on a range of health-improvement issues. For example, the Department of Education has been integral to the development of our childhood obesity programme, Fit Futures. If anyone asked me to name another Department that is crucial to the delivery of the strategy, the Department of Education would be first on the list.

I will outline the practicalities of working with the Department of Education, and highlight how we plan to progress the issues. In the development of the strategy thus far, a relatively senior member of staff represented the Department of Education and was able to steer and guide us both on what is required and what is possible.

I am sure that all members know that the curriculum is becoming increasingly crowded. It puts children under lot of pressure by expecting them to acquire a wide range of knowledge and skills within fixed timescales.

All that I can say is that we are working very closely with the Department of Education. We are aware that the curriculum is very crowded, but that Department is working very hard to ensure that that matter is represented in key parts of it. I cannot provide the exact details at the minute, but I can certainly send the Committee a written response, if it would find that useful.

As for the implementation of the strategy, the Department of Education is listed under quite a number of headings in the action plan, and it is expected to deliver on those actions with us. I see that Department as a key delivery partner. That is all that I can say at the moment.

The Chairperson:

Before we conclude, I want to raise two pertinent points. First, are there any statistics to suggest that the morning-after pill has added to the problems of young women who present with STIs?

Secondly, are there figures to show the numbers of young people who had a mental-health problem before they contracted an STI or became pregnant, and the numbers who presented with a mental-health problem after becoming pregnant or being diagnosed with an STI?

Dr McBride:

Those are very pertinent questions. I am not aware of any statistics or research that demonstrate a connection between the use of the morning-after pill and incidences of sexually transmitted infections. I will check that and write to the Committee with any research or evidence that I find that suggests that such a link exists. I am not aware of any research that would suggest that there is a causal relationship.

The Chairperson:

Do you not consider it important to have such before-and-after figures? At Westminster, I tried to get statistics for the incidence of STIs before the introduction of the morning-after pill. I want to know whether its introduction has led to a more marked increase in the incidence of STIs. As far as I can see, on the mainland, there seems to be a greater incidence of STIs and more pregnancies. Can you comment on that?

Dr McBride:

There will always be limitations with historical controls. We are comparing two different populations at two different time periods, and other multiple factors may also be relevant. I have already mentioned the significant increase in incidences of sexually transmitted infections, which may or may not be related to the introduction of post-coital contraception. Any comparison would involve two very different time frames and populations and different incidences of sexually transmitted infections. Such studies — if any have been conducted — would be very difficult to interpret. However, I will certainly try to uncover any that have specifically sought to answer that question, and I am happy to communicate my findings to the Committee.

The Chairperson:

What about mental-health problems?

Dr McBride:

I will defer to Dr Chada on that matter. However, I have worked in that field for many years, and my experience — both anecdotal and professional — has been that the psychological, emotional and mental-health impacts of sexually transmitted infections and unplanned pregnancies on young people of either sex are extremely significant. I cannot quote any figures from research publications today.

Dr Chada:

I am not able to quote from any specific studies on that area, but I can corroborate that mental-health issues impinge greatly on many different aspects of health.

That illustrates an earlier point. Chairperson, you have drawn to our attention some of the limitations of existing research and information, and to the importance of ensuring that some of those gaps are bridged.

The Chairperson:

It is important that we understand whether improvements have been made. We must face facts. When a mechanism is introduced, it can have the effect of encouraging the very behaviour that it is intended to remedy. For example, a person can take the morning-after pill and carry on with irresponsible sexual activity. A balance should be struck. Are there plans for statistical research comparing the situation before and after the introduction of the morning-after pill?

Dr Chada:

That is an important point. Policy-making is a complex process: we have always to second-guess the ramifications of what we plan to do.

Dr McBride:

There is a much wider issue — that of evidence-based policy. Policy should be informed by the evidence of the success or failure of its implementation; and the policy refined as a result. When we introduce new policies, an important element must be identifying gaps in knowledge; and, in order to inform that policy, we must commission research and close the gaps in knowledge. I agree that this is an important part of that.

The Chairperson:

I thank you all for attending the meeting and for answering the Committee’s questions.