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HS/S5/18/4/A
HEALTH AND SPORT COMMITTEE
AGENDA
4th Meeting, 2018 (Session 5)
Tuesday 30 January 2018
The Committee will meet at 10.00 am in the James Clerk Maxwell Room (CR4). 1. Subordinate legislation: The Committee will consider the following negative
instrument—
The National Health Service Superannuation Scheme (Scotland)(Miscellaneous Amendments) (No. 2) Regulations 2017 (SSI 2017/434).
2. Preventative Agenda: Members will provide feedback on recent visits withintheir constituencies in relation to the session on substance misuse.
3. Preventative Agenda: The Committee will take evidence on substance misuse,
in a roundtable format, from—
Lorna Holmes, Head of Services, Cyrenians; John McKenzie, Chief Superintendent, Specialist Crime Division, Head ofSafer Communities, Police Scotland; Dharmacarini Kuladharini, Chief Executive, Scottish Recovery Consortium; Fiona Moss, Glasgow City Alcohol and Drug Partnership, Head of HealthImprovement and Equalities, Glasgow City Health and Social CarePartnership; Dr Carole Hunter, Lead Pharmacist, Addiction Services, Alcohol and DrugRecovery Services, NHS Greater Glasgow and Clyde; Dr Craig Sayers, representative for Scotland, RCGP Secure EnvironmentGroup;
and then from—
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Dr Adam Brodie, Faculty of Addictions Psychiatry, Royal College ofPsychiatrists in Scotland; Teresa Medhurst, Director of Strategy and Innovation, Scottish PrisonService; Emma Crawshaw, Chief Executive Officer, Crew 2000 Scotland; Andrew Horne, Director, Addaction Scotland; David Liddell, Chief Executive Officer, Scottish Drugs Forum.
4. Preventative Agenda (in private): The Committee will consider the evidenceheard earlier in the meeting.
5. Preventative Agenda (in private): The Committee will consider a draft letter on
Type 2 diabetes. 6. Technology and Innovation in Health and Social Care (in private): The
Committee will consider a revised draft report. 7. NHS Governance (in private): The Committee will consider a draft paper on
witness selection for Corporate Governance. 8. Child Poverty Delivery Plan (in private): The Committee will consider a draft
response to a letter from Angela Constance, Cabinet Secretary forCommunities, Social Security and Equalities.
9. Scrutiny of NHS Boards - NHS Ayrshire and Arran (in private): The
Committee will consider a draft follow-up letter to NHS Ayrshire and Arran.
David CullumClerk to the Health and Sport Committee
Room T3.60The Scottish Parliament
EdinburghTel: 0131 348 5210
Email: [email protected]
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The papers for this meeting are as follows— Agenda item 1
Note by the Clerk HS/S5/18/4/1
Agenda item 3
PRIVATE PAPER HS/S5/18/4/2 (P)
Substance Misuse Written Submissions HS/S5/18/4/3
Agenda item 5
PRIVATE PAPER HS/S5/18/4/4 (P)
Agenda item 6
PRIVATE PAPER HS/S5/18/4/5 (P)
Agenda item 7
PRIVATE PAPER HS/S5/18/4/6 (P)
Agenda item 8
PRIVATE PAPER HS/S5/18/4/7 (P)
Agenda item 9
PRIVATE PAPER HS/S5/18/4/8 (P)
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Health and Sport Committee
4th Meeting, 2018 (Session 5)
Tuesday 30 January 2018
Subordinate legislation
Note by the clerk
Overview of instrument
1. There is one negative instruments for consideration at today’s meeting:
The National Health Service Superannuation Scheme (Scotland) (Miscellaneous Amendments) (No. 2) Regulations 2017 (SSI 2017/434)
The National Health Service Superannuation Scheme (Scotland) (Miscellaneous Amendments) (No. 2) Regulations 2017 (SSI 2017/434)
Background
2. The NHS Superannuation Scheme requires members to pay contributions to
the Scheme as a condition of membership. The general objective of these Regulations is to amend the Scheme to insert updated employee contribution bands for the scheme year 2018-2019. The Scheme is contained in the National Health Service Superannuation Scheme (Scotland) Regulations 2011 ("the 2011 Regulations") and the National Health Service Superannuation Scheme (2008 Section) (Scotland) Regulations 2013 ("the 2013 Regulations").
3. This instrument makes changes to the salary/earnings bands stated in various tables contained in the 2011 Regulations and the 2013 Regulations, against which the employee contribution is set. Employee members of the Scheme pay a percentage of their pensionable pay to the scheme dependent on the level of their pensionable earnings.
4. The Regulations also make miscellaneous minor changes, and provide that anyone detrimentally affected by the amendments may elect that the amendments do not apply to them.
5. The Regulations are subject to the negative procedure. They come into force on 31January 2018, but as permitted by the Superannuation Act 1972, some provisions have effect retrospectively from 1 April 2015, and another provision from 1 April 2016.
The Policy Note from the instrument is attached at Annexe A.
6. An electronic copy of the instrument is available at:
http://www.legislation.gov.uk/ssi/2017/434/contents/made
7. There has been no motion to annul this instrument.
8. The Committee needs to report by 5 February 2018.
Delegated Powers and Law Reform Committee consideration
9. The Delegated Powers and Law Reform Committee considered the instrument at its meeting on 16 January 2018. The Committee agreed to draw the attention of the Parliament to the instrument.
10. The Delegated Powers and Law Reform Committee report recommendation states:
12. “The Committee draws the Regulations to the attention of the Parliament on
reporting ground (i), as the drafting of regulation 1(2)(a) appears to be
defective, in providing that regulation 7 has effect from 1 April 2015 and it is
not intended that regulation 7 should have this retrospective effect.
13. The Committee recommends that the error is corrected by amendment as
soon as possible, given that the error concerns the date when provisions of
the instrument have effect.
Health and Sport Committee Consideration
11. The Committee considered this instrument at its meeting last week and
agreed to write to the Scottish Government seeking an update on when the errors
highlighted by the DPLR Committee would be corrected and for confirmation there would be no adverse impact on any scheme member.
12. The Cabinet Secretary for Finance and Constitution wrote to the Committee
on Thursday, 25 January to advise there was no detriment and the errors would be
corrected as soon as reasonably practicable. The full letter is available at Annexe B.
Action
13. The Committee is invited to consider whether it wishes to make a recommendation on the instrument.
Annexe A POLICY NOTE
THE NATIONAL HEALTH SERVICE SUPERANNUATION SCHEME (SCOTLAND)
(MISCELLANEOUS AMENDMENTS) (NO. 2) REGULATIONS 2017 SSI 2017/434
The above instrument was made in exercise of the powers conferred by sections 10 and 12 and schedule 3 of the Superannuation Act 1972. Functions under that Act as regards Scotland have been executively devolved to the Scottish Ministers. The instrument is subject to negative procedure. Policy Objectives Amendments to the National Health Service Superannuation Scheme (Scotland) Regulations 2011 (SSI 2011/117) and the National Health Service Superannuation Scheme (2008 Section) (Scotland) Regulations 2013 (SSI 2013/174) Employee Contributions The National Health Service Superannuation Scheme (Scotland) Regulations 2011 (1995 Section) and the National Health Service Superannuation Scheme (2008 Section) (Scotland) Regulations 2013 require members of the NHS Superannuation Scheme (NHSSS) to pay contributions to the Scheme as a condition of membership. This instrument makes changes to the salary/earnings bands of the table in these regulations against which the employee contribution is set. Employees who are members of the scheme pay a percentage of their pensionable pay to the scheme dependent on the level of their pensionable earnings. It was agreed during scheme reform discussions the employee contribution percentage rates for period 1 April 2015 to 31 March 2019 would not change however the pay/earnings bands against which the contribution is assessed would be adjusted each year in line with national NHS pay awards in Scotland. The aim is to ensure that the bandings remain in line with annual increases in members pay and that they are not penalised by having to pay a higher pension contribution because of their annual pay increase. This SSI will therefore insert into the Regulations a revised employee contribution table to reflect the pay uplift from 1 April 2017 and which will apply to majority of members from 1 April 2018. The revised table will however be applicable with retrospective effect from 1 April 2017 for officer members changing employment within the scheme year 2017/2018, new starters, practitioners and non GP partners whose contributions which are based on current year income. Other main amendments The following amendments are also made to the 1995 and 2008 sections of the scheme regulations:
References are included to the Public Service Pensions Act (Northern Ireland) 2014 to ensure that a scheme under this Act is treated as “another UK Health
Scheme” for equal treatment purposes in respect of protection of member’s rights and enabling of transfers under the transfer club rules.
A change is made to the procedure for informing joiners of their right to request a transfer
Other amendments are made only to provide clarification to or to correct existing provisions.
Consultation To comply with the requirements of section 10(4) of the Superannuation Act 1972 a formal policy consultation took place from 8 September 2016 to 19 October 2016. In particular, representatives of NHS employers and employees, other Scottish Government interests and UK Government departments were consulted. One response to the consultation was received. The comments were on technical matters and amendments have been incorporated where appropriate. Impact Assessments An equality impact statement in respect of the NHS Pension Scheme (Scotland) reforms (including contribution rates) was prepared and is available at http://www.gov.scot/Publications/2015/03/2855 Financial Effects The increase in pay bands on which contributions for members are based is beneficial to members Business and Regulatory Impact Assessment No Business and Regulatory Impact Assessment is necessary as the instrument has no financial effects on the Scottish Government, local government or business. Scottish Public Pensions Agency An Agency of the Scottish Government 12 December 2017
Cyrenians
Preventative Agenda – Substance misuse
1) To what extent do you believe the Scottish Government’s national
drugs strategy, The Road to Recovery, and the approach by
Integration Authorities & NHS Boards are preventative?
The Road to Recovery strategy, in practice, has influenced an effective approach
to integrated work and strengthened partnership working between voluntary &
statutory sector treatment providers to deliver positive outcomes to those
service users looking to address their individual substance misuse issues, whilst
accessing treatment services. It is by no means the finished article, prevention &
education work does take place but there will always be opportunities to
evaluate and further develop our approach. However in contrast to that
statement, recent figures released highlighting the increase of drugs related
deaths in Scotland, would suggest that despite the collective efforts of all parties
involved, the strategy and the principles contained within, have been anything
but preventative. Currently there appears to be a shift of focus again onto
developing more Harm Reduction/Crisis Intervention provision in light of this
report
2) Is the approach adequate or is more action needed?
Our experiences of working across several local authority areas has been that
the approach has been inconsistent. An observation on this point would be to
say, that in relation to the Essential Care aspect of the report, General Practice
has a greater role to play than it currently does, by becoming more proactive in
identifying those appropriate psycho-social interventions, community based
support service and resources, beyond a substitute prescription, that meets the
needs and aspirations of our specific client group.
3) What evaluation has been done of interventions?
Individual service providers will monitor servicer user progress against individual
assessed goals and contractually agreed targets, as well seek feedback from
their own service users which will complement or substantiate any outcomes
based evidence that they have recorded. The Care Inspectorate has carried out a
recent assessment of the local Alcohol & Drugs Partnership (ADP), where there
was some evaluation or focus on interventions, however this was linked more, in
the main to the performance of the ADP.
4) Are the service and national drugs strategy being measured and
evaluated in terms of cost and benefit?
Again this is difficult to respond to, as a service provider, who has carried out
cost & benefits analysis of certain aspects of service delivery. This exercise was
more about considering cost effective service delivery, measured against
contractually agreed service user outcomes, within the financial parameters at
that time. This is more in relation to the individual service. Given current local
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government financial constraints, there may be an argument to have as a
priority a national evaluation in terms of cost & benefits within the provision of
addiction treatment services in Scotland.
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9th January 2018 Health and Sport Committee The Scottish Parliament Edinburgh EH99 1SP
Chief Superintendent John McKenzie Specialist Crime Division
Police Scotland Scottish Crime Campus
Craignethan Drive GARTCOSH
G69 8AE
Tel: 01236 818607
Scottish Parliament Health and Sport Committee Session on Substance Misuse I refer to your email request on 27th November 2017, in which you invited Police Scotland to give evidence on drugs misuse to the Scottish Parliament Health and Sport Committee on Tuesday 30th January 2018. In my capacity as Head of Police Scotland’s Safer Communities business area, I am pleased to confirm that I will attend this event and be in a position to outline the key aspects of the preventative work which the force is currently undertaking and developing in this arena. In respect of your request for a written submission in response to the four key questions that will be posed by the Committee, I can put forward the following commentary at this juncture:
Question 1 - To what extent do you believe the Scottish Government’s National Drugs Strategy, The Road to Recovery, and the approach by Integration Authorities and NHS Boards are preventative?
The National Drugs Strategy is focussed on the recovery and wellbeing of the individual and prevention is recognised as one of a number of key priorities within Chapter 1: Making a Fresh Start. This chapter highlights ‘better prevention of drug problems, with improved life choices for children and young people, especially those at particular risk of developing a drug problem, allowing them to realise their full potential in all areas of life’ as being a priority.
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Chapter 2: Preventing Drug Use; posits that preventing drug use is more effective than treating established drug problems. This section highlights that people will always consider using drugs but it is crucial that no-one in Scotland today takes drugs out of ignorance of the consequences. The prevention approach therefore appears built around the provision of accurate and credible information to the public and effective communication with young people both within, and outwith, the school environment. Recognising that children and young people are crucial to the success of any preventative approach, the Strategy outlines that substance misuse education in schools is often the first line of prevention. Through the curriculum for excellence all those in the school community share responsibility to contribute to the Health and Wellbeing framework and teachers are not expected to deliver substance misuse education alone. It is also recognised that no single approach is effective without collaboration / coordination and that one off interventions have limited value. Chapter 2 also outlines the need to address underlying factors associated with drug use which may impact on an individual’s decision to use substances. This includes early years’ experience, family relationships and circumstances together with parental attitudes and behaviours. It is here that socio-economic disadvantage is also recognised as a clear contributory factor.
In summary, the need for a collaborative, cohesive and sustained prevention based approach is recognised throughout the National Drugs Strategy, as is the value of partnership working and peer mentoring to ensure that preventative messaging is delivered to the public and to our young people. Police Scotland is not in a position to comment on the approach of NHS Boards.
Question 2 - Is the approach adequate or is more action needed?
It is suggested that more could be done to identify the drivers to problem drug use and tackle these under-lying factors collectively, rather than in isolation. This could be achieved with the assistance of Partnership for Action on Drugs in Scotland (PADS) which was recently established and includes an Executive Strategy Group and three subgroups; namely, Communities, Harm Reduction and Quality & Consistency. Each of the subgroups has been tasked to lead on areas of work designed to address drug related harms. Police Scotland has representation on the PADS Executive Strategy Group and all three subgroups. Furthermore, Police Scotland has developed a similar governance structure; the multi-agency Drug Strategy Group (or DSG) is chaired by an Assistant Chief Constable and a Tactical Subgroup – the Drug Action Group (or DAG) - which is co-chaired by me and the Detective Chief Superintendent who holds the National Drug Coordinator portfolio. This governance structure ensures that Police Scotland tackles the issues around drugs in a manner which aligns itself to the PADS programme and promotes the collaborative partnership working and information sharing needed to effectively tackle Scotland’s drug problems. More action is needed to aid understanding of social inequalities; by taking steps to address factors such as adverse childhood experiences (ACES), mental health, housing, employment and poverty, which impact on an individual’s drug use and recovery.
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Through this, we can begin to prevent problematic drug use and associated harms which contribute to the continued rise in drug related deaths. Within Police Scotland, a Harm Prevention Portfolio has been developed within Safer Communities to ensure coordination across key business areas and activities. Harm Prevention leads are already looking at the links between ACES, substance use and mental health. Police Scotland recognises the need to address these issues as one. In this regard, there is a clear requirement for existing, and any future Scottish Government strategies or frameworks, to be cross portfolio and encourage a multi-disciplinary approach to tackle these issues together - not in isolation. Work is also needed to address stigma and change the perceptions and attitudes of professionals and public around drug use, drug dependency, people in recovery or those undergoing treatment. Stigma can impact on an individual’s willingness to seek treatment and engage with support services. It can also influence the way in which we, as a society, address drug related harms. By raising awareness of stigma and the negative impacts of stigmatising attitudes we can influence behaviour and create an inclusive environment that recognises drug use as primarily a health issue. In doing so we can support individuals to address the harms they experience from their substance use and promote their engagement with services.
Question 3 - What evaluation has been done of interventions?
The National Drugs Strategy (Page 17) highlights that ‘substance misuse education in schools is often the first line of prevention against drugs use, providing opportunities to pass on accurate, up to date facts, explore attitudes and crucially foster the skills needed to make positive decisions’. ‘Choices for Life’ is a diversionary and educational initiative, funded by Scottish Government, delivered by Police Scotland and supported by YoungScot and other external partners. Its main objective is raising awareness amongst 11-18 year olds regarding the risks and dangers of substance misuse including smoking, alcohol and drugs. Police Scotland receives a grant from Scottish Government to deliver the ‘Choices for Life’ programme and the funds are utilised to ensure that key messaging is delivered effectively to the target audience. Prior to the allocation of funds, analysis is undertaken to identify / consider the underlying need and link to local / national priorities; any previous or similar programme is also reviewed in terms of cost / benefit / outcome before being presented to a Review Board which is chaired by the Head of Harm Prevention. Subsequently, proposals for the year ahead are discussed and agreed with Scottish Government. The allocated funds are divided into various events and programmes both nationally and locally. Part of the funding is specifically used to support community based events delivered in communities by Divisional personnel following an approved application process. The whole programme is continually reviewed by Police Scotland throughout the year to ensure that the on-going delivery is in line with Scottish Government expectations. This process includes a robust review of all applications for community based events to ensure that those that receive funding are those that can best deliver positive outcomes
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for young people with the focus being on programmes that are continuing or produce a legacy as opposed to one off events. The ‘Choices for Life’ programme is currently being reviewed at the request of Scottish Government to ensure it remains fit for purpose and continues to address the issues identified in Road to Recovery. Mentor UK have been funded to conduct this review and report its findings direct to Scottish Government. Police Scotland will work with Scottish Government colleagues to take forward any learning gained from the current review of ‘Choices for Life’ and utilise the findings to appropriately support the delivery of substance misuse education in schools to support informed choices and positive decision making.
Question 4 - Are the services and national drugs strategy being measured and evaluated in terms of cost and benefit?
As outlined above, a review of ‘Choices for Life’ is currently being undertaken and will include analysis of cost and benefit. With the focus being on tackling Scotland’s drug problem as a health issue, and the increased likelihood of individuals being referred to drug / physical / mental health services through the ‘seek, keep and treat’ process, there will, it would appear, be a need to examine and evaluate the delivery of such services.
Conclusion The National Drugs Strategy recognises the value of prevention based approaches and highlights those factors that impact on an individual’s use of substances. The Strategy posits that preventing drug use is more effective than treating established drug problems and a partnership approach to informing and educating our young people and to providing preventative messaging for the wider public is crucial. Police Scotland continues to support this partnership approach nationally through PADS and locally through the Harm Prevention Portfolio and engagement at Divisional level. I trust that this response will suffice and I look forward to meeting you on 30th January 2018. Yours sincerely,
John McKenzie Chief Superintendent
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Scottish Recovery Consortium, 2/1, 30 Bell Street, Glasgow, G1 1LG Charity Number: SC041181 Telephone Number: 0141 552 1355
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Health and Sport Committee
Preventative Agenda: Substance Misuse
Written Submission
1.The Road To Recovery’s (RTR) statement that it is better to prevent drug use than to
treat it is a wholly laudable desire. The document acknowledges the complex and far
reaching nature of the factors that contribute to someone becoming embroiled in
harmful substance use.
However the question isn’t whether the RTR ‘s approach is preventive, but whether
drugs problems are preventable by the means and actions outlined in this or any other
policy currently in use.
2 Is the approach adequate or is more action needed?
A. We are blind siding ourselves in our prevention approaches in a number of ways;
The reliance on information giving as the active ingredient in behavioural
transformation around substance use or intentions to use substances. This has
been shown to be ineffective. We don’t choose our means of self-soothing or
escape with our thinking or logical minds. If we did no doctors would ever smoke
and no nurses would ever have substance use problems. The research into the
effectiveness of drugs information campaigns would suggest that we ought to
consider other means of transforming substance use behaviours and intentions.
While the RTR policy does acknowledge the impact inequality and the economy
has on substance use across populations, it perpetuates the idea that we can
make an impact on drugs use separate from other substance use and health
challenging behaviours. This is a mistake.
B. Different actions, and more importantly, more connected reflection on the challenges
we face are needed now.
The roots of any rise in obesity, alcohol use, drug use, nicotine ingestion,
depression and suicide lie in the same conditions, according to both Bruce
Alexander’s Globalisation of Addiction and Phil Hanlon’s Fifth Wave of Public
Health. They come as a natural human response to the unnatural phenomena of
globalised neo liberal economies. They rise alongside values based on promoting
financial interests above human interest.
These issues arise not, as current conventional health care approaches would
suggest, as the result of individuals failing to act logically in support of their own
health. They represent a natural human response to overwhelming and
prolonged dislocation. Dislocation caused by rapid changes in the economy, war
as well as the fear and stress generated by fragile and economically dependent
employment and housing. The break-up of family, community, local economies
and indigenous cultures has been at the heart in the globalization of addictions
and the rise of mental and physical distress.
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Scottish Recovery Consortium, 2/1, 30 Bell Street, Glasgow, G1 1LG Charity Number: SC041181 Telephone Number: 0141 552 1355
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C. At the Scottish Recovery Consortium, we would suggest
that we individuals suffering from what Phil Hanlon calls “
The diseases of modernity” are in fact the canaries in the mine. We are telling you there
is something invisible but toxic in the atmosphere. The canaries are giving the whole
community in the mine the chance to save their lives.
Phil Hanlon and Bruce Alexander suggest that it is on a whole population,
cultural, legal, community and societal level that we need to operate our drug,
alcohol, obesity, smoking, depression and suicide prevention strategies. Faulty
thinking does not cause these problems and some of the current reflection on
this has been put beautifully in this talk by Johan Hari:
https://www.ted.com/talks/johann_hari_everything_you_think_you_know_about_addict
ion_is_wrong?language=en
D. A different approach to the corrosive experience of dislocation comes from Bruce
Alexander who suggests we do our best as a country to tame the neo liberal economy.
Scotland’s recovering communities in addictions and mental health are also discovering
the truth of his argument that for humans to be well, to experience psychosocial
integration we need a secure place in a real community.
Over the last 5 years, as a direct result of the RTR policy, activists in the recovery
community have built their own visible recovery support groups. There are now
over 120 of these visible recovery groups all over the country, led by people in
recovery for people trying to get into and sustain recovery in their community.
Over the last 60 years an indigenous invisible recovery community has existed in
Scotland and there are over 1,200 weekly meetings of 12 step focused self help
groups, like Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous
in Scotland. There are more such self-help meetings than there are GP surgeries
in Scotland.
Over the last 5 years Scotland has seen us take to the streets and undertake
whole city interventions in the now annual “Recovery Walk Scotland”. More than
2000 people most with lived and living experience of addiction and recovery
walk through our cities showing the faces of recovery. We know such
interventions decrease the stigma that surrounds addiction and make it more
likely that people with problems will seek help. By showing its possible to
recover – we change the hopelessness around the problem.
We believe we have learned much of the value of human connection and
compassion in preventing relapse amongst us; it is also one part of an antidote to
some of the diseases of modernity and to finding a secure place in a real
community.
E. In terms of prevention, we know that most people who die of substance use have had
prolonged and difficult substance using lives and have been known to treatment. They
have had more than one contact with helping agencies.
Shift the prevention focus from before any use to preventing relapse in those
who have recovered.
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Scottish Recovery Consortium, 2/1, 30 Bell Street, Glasgow, G1 1LG Charity Number: SC041181 Telephone Number: 0141 552 1355
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Support bright lively communities where the
conditions that support recovery from mental
distress and addictions flourish.
Links and References
Bruce K Alexander: The Globalisation of Addiction- A study in the poverty of the Spirit
http://www.brucekalexander.com/articles-speeches/healing-addiction-through-
community-a-much-longer-road-than-it-seems2
The house I live in – the results of the war on drugs
https://www.youtube.com/watch?v=MQ4VFqXVrJE
Recovery Walk Scotland 2016
http://www.youtube.com/watch?v=6-bkriUqIzM
Dharmacarini Kuladharini
Chief Executive
January 2018
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Scottish Parliament Health and Sport Committee Inquiry on Preventative Spend:
Glasgow City Alcohol and Drug Partnership Submission on Preventative Agenda for Drugs Misuse, January 2018
1. Introduction
This paper provides responses to the Health and Sport Committee on drugs prevention activities as part of its Preventative Spend inquiry. It has been prepared by Glasgow City Alcohol and Drug Partnership (ADP), representing a range of multi-partner prevention work underway in the city. This submission will be supplemented by appearance of a representative from Glasgow City ADP (Fiona Moss) at the 30th January evidence session. See Annex 1 for background on this Inquiry strand.
2. The roles of Glasgow City Alcohol and Drug Partnership (ADP) and Glasgow City Health and Social Care Partnership (HSCP)
ADPs were established under Scottish Government direction in 2010, to address alcohol and
drug issues at a strategic level within each local authority area. Glasgow City ADP
membership includes NHS, Social Work, Police, Community Safety, Prisons, Voluntary
Sector, Carers and people with lived experience. Since March 2016, the ADP has taken on
a dual function, to act as a ‘strategic planning group’ of the HSCP whilst maintaining its
original Scottish Government function.
The introduction of the Public Bodies (Joint Working) (Scotland) Act 2014 (the ‘Act’) has led to the integration authorities being established and the Glasgow City Health and Social Care Partnership since 2016.
Glasgow City Council and NHS Greater Glasgow and Clyde have integrated the planning and delivery of all community health and social care services, including those for children, adults, older people, along with homelessness and criminal justice. This work is led and directed by the Glasgow City Integration Joint Board, with the Council and Health Board delivering services under the banner of the ‘Glasgow City Health and Social Care Partnership’.
Glasgow City Alcohol and Drug Partnership (ADP) is a strategic planning group of Glasgow City Health and Social Care Partnership, and works to actively draw in the contributions of a wide range of partners to the challenge of preventing harm from drugs misuse.
3. Addressing Specific questions asked by Inquiry
Q1. To what extent do you believe the Scottish Government’s national drugs strategy, The Road to Recovery, and the approach by Integration Authorities and NHS Boards are preventative?
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Having a dedicated focus on prevention within the national ‘Road to Recovery’ strategy has been of significant benefit to Glasgow city partners since publication. Such a prevention focus has helped to reinforce our long-standing multi-partner approach, underpinned by our dedicated Prevention and Education model (see below for details) and investments. As part of this, it has also been helpful that the inter-relationship between deprivation, inequality and drugs misuse was highlighted, and thus the need to set drugs prevention strategies in a wider context of social and economic renewal and community resilience.
“Drugs are therefore both a symptom and cause of the health inequalities that face Scottish society. Deprivation and chronic stress lead to a lack of resilience to cope with life events and circumstances, and to people feeling out of control and threatened. This is more likely to lead to problem drug use, which in turn has a detrimental effect on the health and well-being of individuals and societies” Source: Paragraph 39 of Road to Recovery
The significant focus in the prevention chapter of Road to Recovery on schools based prevention and education has been welcomed. However, there is a case for significant expansion of the scope of preventative approaches, priority groups and key settings (Q2 response). Evidence suggests that further harm reduction approaches with higher risk groups, expanding preventative work with adults and the opportunities for further development of secondary and tertiary prevention are required to affect population change. At the level of planning and delivery within Glasgow city, this prevention approach has been embedded in partners’ work since the ratification of the Greater Glasgow and Clyde Alcohol and Drugs Prevention and Education Model in 2008, and updated in 2012 (see Figure 1 below) which informs and inspires existing and future planning and delivery of alcohol and drug prevention and education work, in turn, providing the opportunity for partners to facilitate and deliver prevention and education structures fit for purpose that address issues of equity of provision, cost effectiveness and accountability. This model has led to having dedicated partnership business and structures focused on prevention within the ADP. These structures are responsible for considering need, holding dedicated budget for activity and monitoring and evaluating the effectiveness of prevention activity. . The model has also been used to inform service commissioning decisions regarding alcohol and drugs. There are 4 key components in the Greater Glasgow and Clyde Alcohol and Drugs Prevention and Education model as summarised in Figure 1 below:
Figure 1:
Greater Glasgow and Clyde Alcohol and Drugs Prevention and Education Model 1. Definition for prevention and education - Prevention and Education is defined as
largely concerned with encouraging and developing ways to support and empower individuals, families and communities in the acquisition of knowledge, attitudes and skills with which to avoid or reduce the development of alcohol problems, drug misuse and alcohol and drug related harm.
This definition ensures that all prevention and education planners and practitioners have a clear agreed focus regarding what prevention and education work is and it also removes the misconception that prevention and education is only about work with young people by clearly setting out the wider boundaries of prevention and education.
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2. Tiered structure diagram – Practitioners and planners can use the Tiered Model as a
visual tool to identify how their role and remit fits into the bigger picture of Prevention and
Education. This enables them to recognise existing areas of activity by their own and partner
organisations and any potential overlap, gaps or duplication in delivery within geographic
areas.
3. Core elements of activity – There are 12 evidence-based Core Elements of activity in
the model for action:
1. Resilience and Protective Factors 2. Environmental Strategies
3. Community Approaches 4. Diversionary Approaches
5. Brief Intervention Approaches 6. Education
7. Training and Support 8. Parenting
9. Social Marketing 10. Workplace alcohol and drug policies
11. Harm reduction – Alcohol 12. Harm reduction – Drugs
4. Support - The main support functions – workforce development, networking, research and evaluation and a dedicated structure. These are fundamental to maximising the successful implementation of the model. Whilst a comprehensive analysis of the full range of drugs prevention activity taken forwards in Glasgow city is beyond the scope of this paper, we provide below some programme examples, and reflections on wider issues and challenges: Preventing Drug Use – examples of partnership programmes
3.1 Providing Factual information to all users and families – early years example Partnership working has taken place with Alcohol Focus Scotland to develop and deliver the
Oh Lila nursery programme which is suitable for use with children aged 3 to 5 years and is
currently used in nurseries across Scotland. Oh Lila aims to:
Help children develop social skills Encourage children to ask for help when they are scared or worried Help children to identify trusted adults Explore emotions
For more information about Oh Lila please visit the website www.ohlila.org.uk
3.2 Schools-based prevention and education programmes Dedicated work has been undertaken by Health and Education Services to develop a range of age and stage appropriate resources and lesson plans for use by primary and secondary
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teachers and youth workers in line with Curriculum for Excellence. This is available as part of the GGC Substance Misuse Toolkit. Partnership working has also taken place with Alcohol Focus Scotland to develop and
deliver the Rory programme which is suitable for use with children aged 5 to 11 years. Rory
is a flexible resource and is used in a range of settings including schools and specialist
agencies. In using Rory we aim to:
Help children to feel less confused and guilty if they are being affected by an adult’s drinking
Encourage children to talk to someone they trust if they are worried about an adult’s drinking
Help children to feel compassion and empathy towards other children who may have a difficult home life
Help teachers and others working with children to have greater awareness of the impact of harmful parental drinking on children and of the support available
3.3 Working with vulnerable families – including involvement in justice system
One example of a partnership programme aimed at supporting families with vulnerabilities
such as being impacted by drug and alcohol misuse is Constructive Connections. Glasgow
City ADP have co-founded with community justice a Constructive Connections initiative -
aimed at the development of research, training and resources to support children affected by
parental experience of offending and prison, many for alcohol and drug related issues.
Part of this investment was to extend the rollout of the Families Outside ‘Out of the Shadows’
course to relevant staff groups working directly to support vulnerable families and young
people.
The funding also supported the development of a new resource developed by Alcohol Focus
Scotland to ensure that it meets the needs of those families. The Children Harmed by
Alcohol Toolkit (C.H.A.T.) which is an interactive resource (comprising of storybooks and
puppets) that can be used to open sensitive communication with children and families on the
impact of harmful alcohol use (more detail on the resource can be seen below).
In addition to this, Scottish Drugs Forum have been asked to develop and pilot two
advanced training courses
Working with people with substance use problems
Working with prisoners who have children affected by parental alcohol and drug use
Finally a piece of commissioned research will be taking place over the next 18 months which
is focused on building the resilience of families affected by the justice system because we
know that there are an estimated 27,000 children in Scotland affected by a family member
being imprisoned every year and when this figure is combined with the correlation between
Glasgow city’s crime statistics and drug and alcohol use this commonality strengthens the
supposition that a high percentage of Glasgow city’s children and young people who are
affected by parental imprisonment will also have an experience of parental substance
misuse.
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3.4 Connecting the mental health and alcohol / drugs prevention agendas
It has long been recognised that many mental health and substance misuse problems have common roots and therefore there is a need for joined up approaches and connected service delivery. This calls for both robust comorbidity policies, better responses to distress, shared work on issues like suicide prevention and tackling self-harm. For example there is much work now showing that issues like social isolation, loss of social role and self-worth, unaddressed previous trauma, being a victim of crime or discrimination or degraded community cohesion are all factors in driving poor mental health and possibility of substance misuse. Examples of local responses to this challenge include a focus on suicide prevention activities within alcohol and drugs services, large scale training initiatives for staff around self-harm, training for mental health staff on substance misuse – including new psychoactive substances, increasing focus on the importance of addressing social isolation across the life course, development of recovery community models that seek to recreate meaningful community connections for people in recovery, and significant use of grassroots arts and cultural methods as part of the therapeutic response. Such efforts are of course undermined by forces such as poverty, unemployment, impact of adverse effects of welfare reform and homelessness. At national policy level, a joined up approach which actively encourages joined up working, shared budget streams etc between mental health, substance misuse, economic development and community renewal strands would be highly beneficial.
Despite significant partnership commitment to a wide range of drugs prevention programmes and initiatives, and a long-standing commitment of financial investment to this field by Glasgow City ADP and allied structures, the scale and complexity of population need exceeds capacity to respond fully. There remains major scope to expand evidence-based prevention programmes and to further innovate, particularly beyond education settings in ensuring that the needs of a range of vulnerable and higher need groups are addressed. It is also the case that reductions in seemingly unrelated services – like generic youth-work services and community facilities, can have major negative effects on the substance misuse preventative agenda.
Q2. Is the approach adequate or is more action needed? As noted in responses to Q1, having a dedicated focus on Prevention within the ‘Road to Recovery’ national drugs strategy is of significant benefit. There is, however, a need to significantly strengthen and expand the scope of the overall drugs prevention effort. With this in mind, moving forward the evolving prevention and education approach should be
an innovative partnership model that takes into consideration recent changes to policy and
evidence based practice. It should have a key focus on the promotion of equalities whilst
addressing health inequalities and the impact of life stages, deprivation and vulnerability in
the most at risk groups such as vulnerable young people, looked after children, older people,
homeless population.
At a time of significant public sector budgetary constraint, one of the key challenges is to ensure that a long-term investment approach is sustained to the drugs prevention agenda. This needs to be both through dedicated ADP resource streams and by ensuring that allied
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policy areas make a sustained financial commitment to the prevention agenda. This connects strongly to the ‘spend-to-save’ and return on investment philosophy set out in publications such as the Christie Commission report - with its imperative for prevention to tackle the ‘failure demand’ issue within public services. One option for consideration might be for a national agency such as Health Scotland to investigate optimal levels of investment within ADP allocations – and allied policy areas - to the drugs prevention and education agenda, with reference to relative to levels of population need – for prevention focused recovery should we be investing 5% of ADP budgets, 10%?? Additional points for expansion, on areas where the prevention agenda should be considered for further development at national level:
Further strengthening of the ability of youth-related agencies role in drug prevention, including availability of relevant diversionary activities
Further targeted work on drugs prevention across policy areas focused on higher risk population groups, including community justice, looked after and accommodated children, vulnerable families work, closer connection to anti-poverty strategy and early years strategy
A much stronger connection to mental health strategy and care and population mental health efforts e.g. the scope to combine budgets for the provision of early intervention mental health services for young people through school and community justice would impact on mental health and future addiction services use.
A stronger recognition of adverse childhood experiences (ACES) and trauma as a predictive risk for drug use and misuse. This also relates to a more comprehensive development of trauma-sensitive care, and implementing preventative policies to reduce childhood trauma and disadvantage. Relevant in this regard is work in Glasgow city to assess trauma training needs for staff in prisons, community justice and addiction services
Strengthening parental support programmes and further expansion of work to identify and support children affected by parental substance misuse
As noted in ‘Road to Recovery’, continued focus on economic strategy initiatives – including employability programmes – that address the fundamental social exclusion that often underpins experience of drugs problems in communities
Further investigation and piloting of services is required with both young people and adults into the potential benefits of taking a multiple risk approach rather than a single topic focus
Consolidation of drugs prevention (as part of wider substance misuse prevention activity) within educational establishments to ensure consistency of approach and appropriate levels of resourcing
Glasgow City ADP Expenditure 2016-2017
The ADP commits just under 4% of its expenditure to prevention spend. See table below.
Prevention (include community focussed, early years,
educational inputs/media, young people, licensing objectives,
ABIs)
£1,872,136
Treatment & Support Services (include interventions focussed
around treatment for alcohol and drug dependence)
£34,327,214
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Recovery £10,882,829
Dealing with consequences of problem alcohol and drug use in
ADP locality
£228,427
Total £47,310,606
Source: ADP Annual report to Scottish Government: https://www.glasgow.gov.uk/index.aspx?articleid=18428
In addition to this dedicated prevention spend, committed within the ADP allocation, there is significant – but harder to quantify – investment from wider partners, including contributions in kind, such as dedicated input from teaching staff on drugs and alcohol prevention and education programmes, as well as contributions to the prevention agenda from many voluntary and community organisations.
Q3. What evaluation has been done of interventions? To date there has been investment in two commissioned pieces of independent research (2006, 2012) focused on the available international evidence base for prevention and education as part of the on-going development of the Greater Glasgow and Clyde Alcohol and Drug Prevention and Education model. This evidence base is now due to be reviewed again to ensure the baseline remains fit for purpose, and this review will be undertaken in conjunction with local partners during 2018. We will be happy to share the findings and products of this review when completed. The prevention and education activity delivered through the Glasgow City ADP Prevention Sub Group and local prevention groups is developed using the evidence base within the model and then ongoing monitoring and evaluation systems are put in place to ensure structures are accountable and activity being delivered efficiently and in a cost effective manner. Areas of dedicated spend on commissioned services which roll from one year to the next are strictly monitored and different aspects of the contracted services are reviewed on an annual basis or more as required. Although all existing approaches and work streams are based on the evidence base within the model any potential emerging prevention and education approaches are evaluated thoroughly to gauge whether there is a need for investment in them in Glasgow city and to assess the most productive way to progress the work during implementation. All new areas of prevention and education activity are also piloted and evaluated using a variety of both quantitative and qualitative methods including but not limited to pre and post questionnaires, co-production, peer review and service user satisfaction questionnaires. The feedback reports are always taken into account and changes made where required to activity or services. This collated feedback is used to inform decisions as to the next steps for rollout of new approaches and activities which are taken by the prevention and education strategic groups.
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Q4. Are the services and national drugs strategy being measured and evaluated in terms of cost and benefit?
See responses above to Q3 in terms of our Glasgow city approaches to monitoring, evaluation and evidence-based practice. Through our continual connection with the emerging international evidence base for effective practice, our local partnership approach is continually seeking to ensure that we are in tune with the best in evidence-based approaches, which includes material on cost-effectiveness.
However, we feel there is considerable scope for further development work at national level in this area, particularly where the effectiveness analyses put drug prevention activities into a wider context. To give one specific example, analysing impact of policy and practice on illicit drugs misuse needs to accommodate the many situations where alcohol misuse is closely intertwined, similarly when poor mental health may be a factor.
It should be noted as well that one of the challenges of cost-benefit analyses work is that the benefit of preventative investment often accrues over a timescale of years, and sometimes generations, and also the potential savings often accrue in settings other than where the preventative investment is made (e.g. reduced exposure to criminal justice services). Therefore, cost benefit analyses need to be comprehensive and able to track impacts over significant time periods.
It is also important that robust research work continues to progress that allows us to track and understand the changing patterns of drugs use and allied factors that may be interacting and impacting on this use. Our Greater Glasgow and Clyde Drug Trends Monitoring Group is an example of a multi-partner approach that seeks to ensure high quality intelligence about changing patterns of drug use in our Health Board and ADP areas.
Additionally there needs to be further research aimed at gaining a better understanding of the most effective ways of communicating with people in need of information, support and services in relation to drugs misuse and to more effective strategies for harm minimisation.
4. Summary and Policy / Development Considerations
We have provided a number of examples of partnership programme activity and investment areas in Glasgow city, but by no means a comprehensive overview of a complex landscape, involving multiple partners – from statutory, voluntary and private sectors. We have been guided for approximately the last decade by a locally created drug and alcohol prevention and education model, underpinned by regularly reviewed evidence base for good practice While Glasgow city partners have sustained dedicated drugs (and alcohol) prevention investments over a significant period of time, additional investment in the prevention agenda would allow for expanding scope and scale of this body of work, in order to more comprehensively address population needs.
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Policy and development considerations Additionally, we have offered a number of policy considerations, particularly at the national level, that could help to provide further focus and impetus to the vital challenge of preventing harm to our communities from the misuse of drugs, particularly material in response to Q2 Examples of such policy considerations include:
Need to ensure that drugs prevention policy is closely connected with wider efforts to tackle social disadvantage, poverty, exclusion and inequality
Need to ensure close connection in terms of both policy and practice in relation to vulnerable groups who are much more likely to be impacted by drugs misuse – including homelessness, unemployment, criminal justice, vulnerable families and children affected by adverse childhood experiences, looked after children, and more generally any social group at risk of or affected by social isolation (local and wider analyses repeatedly show social isolation as a risk factor for deaths by drugs, alcohol and suicide). Ensuring close linkage with neighbourhood renewal and safer communities agenda is also vital.
Need to ensure that there is sufficient resource capacity available to the voluntary and community sectors for innovation and grassroots development, as a vital complement to the work coordinated via statutory sector structures for this wider work to receive the recognition that it deserves
There is a need for more robust policies that set out multi-partner approaches to harm reduction as one key element of the wider prevention agenda
Annex 1
Background Material Supplied by Committee Inquiry:
As part of an inquiry into Preventative Agenda, the Committee has agreed to carry out a
one-off evidence session on drugs misuse. This evidence session will take place on
Tuesday 30th January at 10:00am for approximately 75 minutes and the Committee has
invited Glasgow City Alcohol and Drug Partnership to contribute evidence. Questions
were issued in Dec 2017 and written responses are expected by Wednesday 10th
January.
In addition to Glasgow City ADP, a representative from the following organisations have
been invited to appear:
Police Scotland
Professor David Nutt, Imperial College London
Scottish Recovery Consortium
Cyrenians
Pharmacist with addiction specialism (to be identified by the Royal Pharmaceutical Society of Scotland)
Alcoholics Anonymous
Royal College of Psychiatrists
Scottish Prison Service
Crew
Addaction
Scottish Drugs Forum
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Preventative Agenda - Substance Misuse
The Royal Pharmaceutical Society in Scotland (RPS) welcomes the opportunity to respond to the Health & Sport Committee’s inquiry into: ‘Preventative Agenda – Substance Misuse’. Our submission, noted below and written jointly with Dr Carole Hunter who will be giving evidence at the session on 30 January, focuses on the role of the pharmacy profession and how pharmacists and their staff teams can continue to support and enhance the pharmacy role in supporting people who use drugs in Scotland to minimise harm to individuals and local communities.
1. To what extent do you believe the Scottish Government’s national drugs strategy, The Road to Recovery, and the approach by Integration Authorities and NHS Boards are preventative?
We fully support the principles of the Road to Recovery (RtR) where each person using drugs should be treated “on their own terms” and care centred around “the person, not the addiction”. We also strongly support the principle that prevention is better than cure. Further work is required to continue to address the problem of drug use as it is clear that this problem continues to have adverse effects on individuals and communities. It is acknowledged that there are many underlying health and wider social causes of drug use and it is therefore inevitable that prevention will be more effective when approached in an integrated way.
Moving forward, greater emphasis is required around preventing the harms associated with drug use. Harm reduction strategies serve to protect the health of the individual and thereby enable people to proceed on a recovery journey with maximum potential health capital.
The pharmacy profession has a significant role to play in delivering harm reduction strategies and we strongly support an enhanced role for the pharmacy profession in this aspect of prevention. The International Pharmaceutical Federation, of which we are members, published their “Reducing harm associated with drugs of abuse – the role of pharmacists”1 in 2017 and this report may be of particular interest also to the committee as part of this inquiry. In it they advocate a human rights approach to drug policy and summarise the benefits of a harm reduction approach as follows:
Individual benefits o Prevention of infection by HIV, hepatitis C and other blood-borne pathogens o Increased capacity for self-care
1 International Pharmaceutical Federation (2017): “Reducing harm associated with drugs of abuse – the role of pharmacists”, accessed 10 January 2018.
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o Reduced chaos associated with drug use through a methadone maintenance programme
o Fewer overdoses o Increased sense of control o Options to a person who may not have perceived any choices o Opportunities to link with sources of support
Community benefits
o Decreased incidence of HIV, hepatitis C and other blood-borne pathogens in the whole community
o Decreased number of discarded used needles in the community o Reduced negative consequences of drug use, such as drug-related criminal
activity, and reduced prostitution o Fewer overdoses and deaths o Reduced strain on social, health income and employment services o Increased number of people who use drugs and feel less marginalised o Cost savings.
2. Is the approach adequate or is more action needed?
There is no specific mention of the pharmacy profession in Chapter 2 on “Preventing Drug Misuse” but we believe that the profession could play a wider role and contribute positively in this area, particularly in the “provision of factual information on drugs to the public, including families”.
The pharmacy profession has a strong history of disseminating public health messages and participating in public health initiatives, including:
Smoking cessation Sexual health Preventing antibiotic resistance; and Supporting national campaigns on priority areas such as, cancer, coronary heart
disease, diabetes, meningitis, mental health and physical activity amongst others.
In our 2016 Manifesto “Right Medicine, Better Health, Fitter Future”2, we advocated “Promoting health literacy from an early age as part of general education within Curriculum for Excellence to gain an understanding of our healthcare system, to encourage self-care and to know where to go for help when required.” In this context, we would recommend utilising the pharmacy profession’s expertise to support delivery of Curriculum for Excellence in relation to controlled drugs, safe use of medicines, alcohol and tobacco.
It is important that a refreshed national Drug Strategy also reflects and incorporates the current aims for the development of the pharmacy profession in Scotland. This is particularly relevant when considering the ageing population of people who use drugs, which will inevitably require a more co-ordinated approach with general health services to impact on morbidity and mortality. Clearly, pharmacy clearly has an increasing role to play here and this should be recognised in the national drug strategy, mirroring the Scottish Government’s aims in “Achieving Excellence in Pharmaceutical Care: A Strategy for Scotland” to transform
2 Royal Pharmaceutical Society in Scotland (2016): “Right Medicine, Better Health, Fitter Future”, accessed 09/01/18.
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the “role of pharmacy across all areas of pharmacy practice, increase capacity and offer best person centred care”3. “Achieving Excellence in Pharmaceutical Care” describes how pharmaceutical care will evolve in Scotland and the crucial contribution of pharmacists and pharmacy technicians, working together with other health and social care practitioners, to improve the health of the population and impact on health outcomes, especially for those with multiple long term and complex conditions. The strategy has been aligned with the Scottish Government’s strategic approach for pharmacy set out in the Health and Social Care Delivery Plan, the National Clinical Strategy, Pulling Together, the Modern Outpatient Collaborative, Realistic Medicine, the Mental Health Strategy and the six essential actions to improve unscheduled care. It is essential that any refresh of the RtR drug strategy also aligns with the national pharmacy strategy to ensure that services and service users can benefit from advances in pharmaceutical care. "Pharmaceutical care focuses the knowledge, responsibilities and skills of the pharmacist on the provision of drug therapy with the goal of achieving definite therapeutic outcomes toward patient health and quality of life” (p, 1). There is a very brief one sentence mention of the role of pharmacist prescribers in the RtR (p.45). Although there are local examples of excellent practice where this is working well, developing this role further is one where more action is needed. In 2016 the RPS published a “Competency Framework for All Prescribers”4. This was published in collaboration with NICE and all of the prescribing professions and regulators in the UK. We recommend this should form the basis of all non-medical prescribing developments within a national drug strategy and enable Drug Treatment Services in Scotland to develop local operational policies. In order to incorporate and achieve full benefit from pharmacist prescribers within drug treatment services it is urgent that the issue of access to patient records is addressed. We have addressed the Health & Sport Committee on this point in a previous submission to its Technology in the NHS Inquiry5. In addition we have also, through our Primary Care Clinical Professions Group Collaboration, responded collectively to the same inquiry; between us representing more than 60,000 front line primary care clinicians working across the length and breadth of Scotland6. We would promote a four way shared care approach (GP, client, Alcohol and Drug Action Team and pharmacy), enabling the pharmacist to feed into a review on someone on opioid replacement therapy. Sharing of information and coordination of care is key to supporting someone recovering from substance misuse. The community pharmacy network in Scotland plays a key role in Harm Reduction Services, including Injecting Equipment Provision, naloxone supply and in new initiatives including Blood Borne Virus testing. Pharmacists are often the only health care professional that homeless or chaotic drug users may have contact with. This contact can serve as a key entry point into treatment and recovery services. The RtR recognised that “Pharmacists have the highest number of contacts with people with problem drug use, often seeing them and their families on a daily basis” (p29). Despite this level of contact and service provision
3 Scottish Government (2017): “Achieving Excellence in Pharmaceutical Care: A Strategy for Scotland”, accessed 09/01/18. 4 Royal Pharmaceutical Society (2016): “A Competency Framework for All Prescribers”, accessed 09/01/18. 5 Royal Pharmaceutical Society in Scotland (2016): Response to Health & Sport Committee Inquiry into Technology and Innovation in the NHS, accessed 09/01/18. 6 Primary Care Clinical Professions Group (2016): Response to Health & Sport Committee Inquiry into Technology and Innovation in the NHS, accessed 09/01/18.
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there is no formal role for the pharmacy profession within the Alcohol and Drug Partnership (ADP) structures. The RPS would recommend the inclusion of local specialist pharmacists as core members of ADPs to help to fully involve the profession in an integrated approach.
3. What evaluation has been done of interventions?
The Action Plan in RtR has no national evaluation framework although we understand that individual developments, including the naloxone programme, have been subject to a formal evaluation with agreed local individual improvement targets.
In 2012, the then Chief Medical Officer for Scotland, Sir Harry Burns, commissioned a review of Opioid Replacement Therapies (ORT) to “Ensure that these interventions are being used appropriately and in line with the international evidence base as part of a person-centred recovery focused approach” and to “Consider where further improvement may be made to contribute to the quality emphasis of Phase Three of RtR strategy delivery Programme”7. The Review concluded, amongst other recommendations, that the role of pharmacists in the community is “central to the delivery of high quality ORT” and highlighted areas where the pharmacy role should be extended to impact positively on the care received by an individual (p 45). It referred to the increase in range and quality of pharmacy services and premises and the benefits of contribution that is increasingly being incorporated into wider NHS developments to contribute to better health outcomes (p46). The Review stated that there was a “need to endorse further the notion of pharmacists as an integral part of the care team” and to “look at joint training and better integration within the broader addiction services in a locality” (p 46). The RPS recommends further involvement and development of the pharmacy role. It is important that the national strategy documents mentioned above promote the role that pharmacists can play in community based multidisciplinary drug treatment services. As the Review stated, it is important to recognise and make maximum use of the fact that “Pharmacies are much more likely to be present in areas of high deprivation than any other health care provider” (p 46). This is in line with research in England which demonstrated that 99.8% of the population in areas of highest deprivation had access to a community pharmacy within a 20 minute walk8. 4. Are the services and national drugs strategy being measured and evaluated in
terms of cost and benefit? The RPS is not aware of any recent cost benefit evaluation but this is something that we would strongly support. In 2009, the report on “Assessing the scale and impact of illicit drug markets in Scotland” was published9. Although published in 2009 this report provided estimates of the size and value of the illicit drugs market and estimates of the economic and social cost of illicit drug use in Scotland based on data from 2006. The report illustrates the
7 Scottish Drug Strategy Delivery Commission (2013), “Independent Expert Review of Opioid Replacement Therapies in Scotland. Delivering Recovery”, accessed 09/01/18. 8 Todd, Copeland et al, (2014): “The Positive Pharmacy Care Law: An Area-level Analysis of the Relationship Between Community Pharmacy Distribution, Urbanity and Social Deprivation in England”, BMJ Open 2014, Vol 4, Issue 8, accessed 09/01/18. 9 Casey, Hay et al, (2009), Scottish Government Social Research, “Assessing the scale and impact of illicit drug markets in Scotland”, accessed 09/01/18.
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costs associated with health care, criminal justice, social care, economic costs and wider societal costs. This analysis clearly demonstrates the significant savings that accrue to the public purse as a result of the provision of drug treatment and recovery services. Updated figures would now also need to reflect new developments in preventative treatments and additional significant taxpayer costs in treating recent outbreaks linked to illicit drug use such as Anthrax, Botulism and HIV. Summary Since the introduction of the RtR in 2008 there have been significant advances in the Scottish Pharmacy contract and development of a new Scottish pharmacy strategy to maximise the contribution of pharmacists and pharmacy technicians to provide evidence based patient centred care. It is important that these advances are also reflected in drug treatment services to enable all patients, including those with drug and alcohol problems to benefit from improved pharmaceutical care. It should be recognised that these services are often delivered against a background of stigma which needs to be addressed. This was illustrated by the recent enforced closure of the pharmacy based Injecting Equipment Provision in Glasgow Central rail station despite this being an essential professional service delivered in an exemplary fashion by the pharmacy staff.
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Health and Sport Committee
Preventative Agenda
Submission Regarding Substance Misuse Evidence Session – Prison
From a prison perspective there has been little impact in the total population following the
introduction of the Road to Recovery strategy. Scottish prison population numbers were 7376 in
2007/8, rising to 8179 (2011/12) and then falling to 7552 (2016/17).
There has been a decrease in the remand population from 1561 (2007/8) to 1370 (2016/17)
One of the greatest risks of incarceration is the loss of tolerance to illicit substances during a period
in custody with a significantly increased risk of overdose following liberation:
All cause mortality - 50 x greater than general population in first two weeks following
liberation
All cause mortality - 11 x greater than general population in first four weeks following
liberation
All cause mortality - 4 x greater in first four weeks following liberation if not on opiate
substitution treatment (Methadone/Buprenorphine) compared to individuals liberated on
OST
Drug-Related Deaths- 8 x greater in first four weeks following liberation if not on OST
Brief remand periods and very short sentences put patients at risk of overdose due to the loss of
tolerance as above but do not allow adequate time for meaningful assessments and interventions by
addictions teams within the prison.
National strategies to try and use alternatives to custody for drug-related offences (for example,
DTTO) are welcomed as are the sentencing policies which have reduced very short-term sentences.
Individuals admitted to custody for longer periods are able to engage in a meaningful way with
prison addictions services to address their addictions issues and commence substitute treatments if
appropriate.
Whilst the introduction of voluntary throughcare services are welcomed, the uptake (particularly by
male prisoners) is low. This may be exacerbated in National facilities (i.e. Glenochil – Sex Offender
population) as patients may be liberated to an area located a considerable distance from the prison
facility resulting in difficulty arranging appointments. One of the key factors leading to relapse
following liberation is the difficulty in arranging housing as prisoners are usually told to present as
homeless on release – even after long sentences. This clearly impacts on the ability to arrange
appointments and contact patients following release.
It is hoped that the introduction of community facing units (for female population initially) will allow
prisoners to engage with a multidisciplinary team from their locality whilst housed in these facilities.
These same individuals will then be able to continue working with the prisoner-patient following
liberation.
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An area requiring monitoring/intervention is the abuse of prescription medication and the ease with
which this is obtained both in the community (GPs, psychiatrists, pain clinics, addictions teams) and
also within prisons (prison GPs, psychiatrists). Prison consultations are dominated by requests for
desirable commodity medications (particularly Gabapentinoids – Pregabalin/Gabapentin).
There are no reports by police services of Gabapentinoid medication being illicitly generated
indicating that the supply is being accessed from prescriptions generated by the medical profession:
2006 – 1 Million Gabapentinoid prescriptions generated (UK)
2015 – 11 Million Gabapentinoid prescriptions generated (UK)
Studies have shown that Gabapentinoid medications have the direct effect of suppressing
respiration which is significantly enhanced when combined with opiates.
Contribution of Gabapentinoids to DRDs in Scotland (ONS Toxicology):
2012 – Gabapentinoids present in 29 DRDs
2016 – Gabapentinoids present in 225 DRDs
Given the increasing numbers of DRDs in Scotland following the introduction of the Road to
Recovery Strategy it would suggest that further action and intervention is required.
It is the writer’s opinion that one area worthy of addressing should include the monitoring of abused
prescription items
Dr Craig Sayers
Clinical Lead Prison Healthcare – Forth Valley
RCGP Secure Environments Group – Scotland Represntative
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DATE: 10 January 2018
RESPONSE OF: The Royal College of Psychiatrists in Scotland
RESPONSE TO: Scottish Parliament Health and Sport Committee
Evidence Session on Substance Misuse This response was prepared by the Royal College of Psychiatrists in Scotland. For
further information please contact: Elena Slodecki on 0131 344 4964 or at [email protected].
The Royal College of Psychiatrists is the leading medical authority on mental health in the United Kingdom and is the professional and educational
organisation for doctors specialising in psychiatry.
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It is important to note this process is set up to look at drugs policy and practice. If alcohol is to be considered, a separate inquiry would be required.
1. To what extent do you believe the Scottish Government’s national
drugs strategy, The Road to Recovery, and the approach by Integration Authorities and NHS Boards are preventative?
The Road to Recovery stresses a preventative agenda and emphasises recovery. The focus on recovery, and emphasis on person-led and holistic care is
important and still relevant. It is important for people to be aware that recovery is possible for them, however, there is concern that too much of an emphasis on recovery is unrealistic for the most vulnerable and sets them up to fail. Whilst
prevention is an important element in reducing future substance misuse, it is important to remember there are those who will still require treatment for their
addiction issues. Those attending treatment are often the most vulnerable in society, with multiple social, physical and mental health problems in addition to their addiction issues. We cannot ignore the social determinants of substance
misuse and the impact they have in preventing people with a drug problem moving towards recovery. If the Scottish Government want to take the issue of
health inequalities seriously, services must be adequately funded.
Members tell us there has been inconsistent prioritisation of substance misuse services within Integrated Joint Boards (IJB), with spending in this field often only occurring when resources are ring-fenced. It would be helpful to have
spending data for each IJB to get a clearer picture of funding and service provision in each area, alongside data on recovery. There has been a reduction
in allocated funding for Alcohol and Drug Partnerships over the past few years1 which is also a concern. This is not consistent with prevention or intervention approaches and risks creating a postcode lottery for patients who should have
access to services in their local area. IJBs have an important role to play in substance misuse services, as they can address local priorities and have both a
commissioning and delivery role. However, it is imperative they are mandated to prioritise substance misuse services.
2. Is the approach adequate or is more action needed?
More action is needed. If prevention and intervention for substance misuse is not prioritised then it will not be supported or promoted within stretched systems of care delivery. The number of drug related deaths doubled between 2006 and
20162. Whilst we recognise this may be in part due to population growth, it is still a major concern and more work needs to be done in this area.
We need more ‘seek, treat and keep.’ There is a need for outreach work from treatment services to reach the most vulnerable people in our society and retain
them in services. By engaging with opiate replacement therapy and stabilising their chaotic lives, services can help engage them in treatment, not only for their
addictions but for their physical and mental health problems too. Seek, keep and
1 Scottish Government, Alcohol and Drug Partnerships (ADPs) Funding Allocation 2014-15 to 2017-
18 2 National Records of Scotland, Drug-related Deaths in Scotland 2016, Table HB1: Drug-related deaths by NHS Board area, 2006-2016 (with averages for 2002-2006 and 2012-2016)
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treat is only possible with adequate resources to seek out individuals in the community who could benefit from treatment, bring individuals into services and
keep them there. To do this, an appropriately sized and sufficiently trained workforce is needed. Harm reduction work must also be a priority and should
include prevention of drug related deaths, education about safer injecting, detection and treatment of blood-borne virus infections, sexual health and crime reduction.
3. What evaluation has been done of interventions?
We are not aware of any evaluation of primary prevention. Secondary prevention is well-evidenced in the area of harm reduction. The National Institute for Health
and Care Excellence (NICE) have clear guidance and pathways on prevention and on targeted interventions for alcohol and substance misuse, with an
established evidence base and health economic analysis. Qualitative Outcome Tools (such as the Scottish Government’s Recovery Outcome Web and others) can be used to evidence the impact of interventions, but need to be interpreted
with care due to other factors which may influence apparent deterioration or improvement.
4. Are the services and national drugs strategy being measured and
evaluated in terms of cost and benefit?
The Scottish Drug Misuse Database (SDMD), provides information in support of
monitoring targets set by the Scottish Government. The new Drug and Alcohol Information System (DAIsy) is still in development. It is proposed the new
system will collect Scottish Drug and Alcohol Treatment, Outcomes and Waiting Times data from staff delivering specialist drug and alcohol interventions. It is essential the new database includes outcome measures on recovery if it is to be
used to evaluate services and the national drugs strategy. This means follow-up data will need to be collected and routine data submitted on an IJB level, since
this is where services are being provided. There is a need for joined-up data and strategies to understand and monitor a
national drugs strategy. For example, community substance use services are provided by IJBs, but substance use services in prison and police cells are
provided by Health Boards. Any future national drugs strategy must take into account that we are now in an era of integration. To improve outcomes for those with addiction problems, services must be adequately funded and evaluated.
This submission was prepared by the Royal College of Psychiatrists in
Scotland Faculty of Addictions Psychiatry.
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Response from the Scottish Prison Service
Drug Misuse – Targeted Call for Views
1. To what extent do you believe the Scottish Government’s national drugs strategy, The Road
to Recovery, and the approach by Integration Authorities and NHS Boards are preventative?
The Scottish Prison Service (SPS) was involved in the development of The Road to Recovery. The
national drugs strategy contains several references to drug problems in prisons. Actions for SPS,
and outcomes, are described in Annex 1.
In 2011 responsibility and accountability for healthcare in prison transferred from SPS to local NHS
Health Boards. This included substance misuse services, associated management information
records and their administration. All clinical staff also transferred from SPS to local NHS Boards.
The Road to Recovery was published in 2008, 3 years before the transfer of prison healthcare to
the NHS. This means that the majority of actions relating to prisons in The Road to Recovery do
not reflect how services are delivered in 2018, nor the organisations now responsible for their
delivery.
Since transfer in 2011 NHS Health Boards have reconfigured the substance misuse services they
deliver in prison to better reflect community recovery models of care. The role of Integrated
Authorities in the delivery of substance misuse services in prisons is ambiguous, prisons are not
mentioned in the Public Bodies (Joint Working) Act 2014. Some NHS Health Boards have
delegated responsibility for prison healthcare to an Integrated Authority while others have
retained responsibility centrally in the Health Board.
The SPS Strategy Framework for the Management of Substance Misuse in Custody1 was
introduced in 2010 and reflects the aims and objectives of the Scottish Government's National
Drug and Alcohol Strategies. The SPS Strategy Framework aims to contribute to a reduction in
re-offending by adopting the principles of recovery to reduce the supply and demand of illegal
substances and the harm caused by problematic drug and alcohol use. This framework reflects
The Road to Recovery and the public sector landscape in 2010. As above the transfer of prison
healthcare in 2011 means that addiction services transferred to NHS Health Boards and are
provided in line with local NHS Board strategies.
SPS is responsible for security, drug testing for prisoner management purposes, programmes and
the voluntary Throughcare Support Service (established in 2015). Information is given on
1 SPS Strategy Framework for the Management of Substance Misuse in Custody http://www.sps.gov.uk/Corporate/Publications/Healthcare5.aspx accessed 18/12/2017
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programmes in the response to question three and on the Throughcare Support Service in the
response to question four. The SPS Throughcare Support Service provides coordinated support
to people serving short-term prison sentences who choose to participate, it should not be
confused with Local Authority throughcare addiction services, statutory throughcare or clinical
continuity of care between NHS services.
Drug Testing
As discussed in The Road to Recovery, SPS has moved from a more punitive approach of
mandatory drug testing to a set of testing arrangements with clear purpose. Punitive responses
to drug use, as happened under mandatory drug testing, have been found not to be a deterrent
to drug users, had limited success as a trends and prevalence measure and did little to encourage
problem users into treatment.
SPS now carry out drug testing in prison to support progression through a sentence, risk
management and to identify incidence and prevalence of drug use. A therapeutic approach can
be a support mechanism to encourage people on their recovery journey and to support their
drug free status. Prisoner management drug testing is conducted by prison staff, however all
clinical drug testing is the responsibility of addiction services provided by NHS Health Boards.
Addiction Prevalence Testing
Addiction Prevalence Testing (APT) is conducted across all Scottish prisons annually. During one
month of the year, people arriving in custody are tested for the presence of a range of illegal
substances. Similarly, those leaving custody during the month are tested to assess progress
towards the ‘reduced or stabilised’ offender outcome. The results of SPS’ APT are used to inform
Scottish Government and NHS policy and practice.
In 2016-2017 76% of those tested on admission as part of the APT tested positive for illegal drugs
while 30% of those tested on liberation tested positive for illegal drugs.
Security and Prevention
SPS has built on the actions in The Road to Recovery by developing a comprehensive range of
security measures in order to reduce the supply of illegal drugs entering Scotland’s prisons. This
includes:
Significant investment in new technology (e.g. BOSS Chairs and portable detection units)
to combat the growing threat of illegal commodity entering the prison estate. This
includes preventing and detecting mobile phone use and attempts to introduce drug
paraphernalia.
Staff have ongoing training and development in this area in order to detect, disrupt and
deter those individuals attempting to introduce drugs into the prison environment
SPS has significantly increased our canine complement to 14 Officer Dog Handlers and 30
dogs, capable of detecting drugs and other contraband.
SPS has an established search plan for each establishment which ensures that all key
areas are searched within agreed timescales (outlined in The Prisons and Young Offenders
Institutions (Scotland) Rules 2011). Intelligence-led searches, together with extensive use
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of the Tactical Dog Unit, are central to combating the threat of illegal commodity to the
prison environment and the wider community.
2. Is the approach adequate or is more action needed?
The concerning year on year increase in drug related deaths across Scotland, the changed and
changing public sector landscape and changes in drugs culture indicate that a refresh of The Road
to Recovery would be appropriate.
The growth of Psychoactive Substances (PS) is an emerging issue for SPS and for services
provided by NHS Health teams in Scottish Prisons. This topic has attracted considerable media
interest and parliamentary scrutiny.
The Psychoactive Substances Act 2016 made the possession of a psychoactive substance in prison
a criminal offence. At the time of the Act SPS took the decision not to seek to amend the
mandatory drug testing policy to test for PS due to the fact that the compounds that make up
this group of substances are continually changing. This position was supported by Scottish
Government.
Intelligence reporting around the use of PS has risen across SPS establishments. In order to
gather evidence to corroborate the intelligence picture, SPS have recently trialled the training of
two drug detection dogs - trained to identify the current most common components within
psychoactive substances. This trial is ongoing and any recoveries made will be tested by
colleagues in Police Scotland in order to confirm the identity of substances recovered.
SPS is a member of the Psychoactive Substances Centre for Excellence Working Group alongside
representatives from Scottish Government, Police Scotland, Scottish Ambulance Service, NHS
and subject matter experts in the field of illegal drug use. SPS is also working with CREW to
develop a PS strategy to enable us to respond effectively in the management of those under the
influence of PS.
SPS would welcome any opportunity to work alongside Scottish Government and national
partners to refresh national drug policy. Working alongside partners, SPS have been leaders in a
number of Recovery orientated initiatives and would be happy to share our experiences and
lessons learned in this field. Including:
The development of a national multiorganisation protocol for the management of people
in prison experiencing excited delirium while under the influence of psychoactive
substances.
Working in partnership with CREW and the Scottish Drugs Forum to deliver estate wide
staff training and awareness in psychoactive substances and Naloxone (Naloxone is used
to treat a narcotic overdose in an emergency situation).
The establishment of the first prison based Recovery College in the UK, in HMP Perth,
which now leads a prison based recovery network across Scotland.
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In September 2017 14 prisons across Scotland took part in a ‘Recovery Walk’. In total over
580 people in custody, staff and ambassadors took part in the SPS Recovery Walks. The
theme was ‘Recovery comes from within’ highlighting how the prison community can
sow the seeds of Recovery.
In 2016-2017 the drugs portfolio was transferred from the Scottish Government Justice
directorate to the Health directorate.
3. What evaluation has been done of interventions?
SPS do not carry out evaluation of clinical interventions delivered by NHS Health Boards. Some of
SPS’ programmes and interventions have been evaluated internationally and SPS uses a number
of methods to collect feedback from users of services in prisons.
Programmes
As well as a wide range of local activities and initiatives SPS run national programmes – two of
which target those for whom there is a clear link between their substance misuse and offending.
SPS Offending Behaviour Programmes (OBP) have either been developed in-house or sourced
externally for delivery in prison. OBPs go through an accreditation process and are supported by
SPS Psychological Services. These are more likely to be delivered to people serving longer
sentences.
There have been two substance-related OBPs developed and delivered by SPS over recent
years: the Substance Related Offending Behaviour Programme (SROBP) and the new substance-
related programme, Pathways: Routes to Recovery and Desistance, which is replacing SROBP
across the estate. Pathways was accredited by the Scottish Advisory Panel on Offender
Rehabilitation (SAPOR) in early 2017. Evaluation is a compulsory part of accreditation. As a newly
accredited programme, Pathways will not be evaluated until it is more fully embedded into the
organisation. It is likely that an independent process evaluation will be commissioned during
2018. Pathways has been designed to help participants lead a meaningful life free from substance
misuse and offending. It has not been designed to address an addiction per se; that is the remit
of other specialist supports.
Prisoner Survey
The 2017 SPS Prisoner Survey (unpublished) shows a decline to 39% of respondents reporting
illegal drug use in prison, this is reflective of a general downward trend that has been evidenced
over a number of years.
Preliminary results also suggest that:
One fifth of respondents (20%) reported being prescribed methadone.
Of these, just under half were on a maintenance dose (48%), almost a third were on a
stabilising dose (32%) and a fifth on a reducing dose (21%).
Approximately one in five (18%) reported using Naloxone at some point.
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Of those who were supplied Naloxone in the last year 63% were supplied it in prison and
67% in the community.
Around one quarter of respondents said they have been given the chance to receive
treatment for drug use (28%) or that they have received help/treatment for drug use
during their sentence (25%).
Of the 25% who have received help or treatment for their drug use during their sentence a
majority (82%) found it useful.
User Voice
Several establishments hold, or are planning, Recovery Cafés where attendees take the lead on
deciding which recovery-related topics should be discussed and how to implement these. This
model reflects the services available which already exist in the community and empowers the
people to choose the best method of managing their own addictions issues in a supportive
environment.
4. Are the services and national drugs strategy being measured and evaluated in terms of cost
and benefit?
As substance misuse services are provided by local NHS Health Boards, any information relating
to the cost and/or clinical outcomes of health and addiction services in prisons should be
requested from each local Health Board.
A national HEAT target (Health Improvement, Efficiency, Access, Treatment) introduced by the
Scottish Government, required that 90 per cent of people would wait no longer than three weeks
from referral to treatment for drug or alcohol problems. This target was achieved in June 2013
and has now become a Local Delivery Plan (LDP) standard to support sustained performance
across Scotland. The LDP standard applies to NHS services and NHS Boards are accountable to
the Scottish Government for achieving LDP standards.
Drug and alcohol treatment waiting times data is collated by NHS Prison Healthcare Teams who
then submit the data to NHS Health Scotland's Information Service Division (ISD). Drug and
alcohol treatment waiting times data for people accessing services in prison have been published
since 1st April 2013; the first quarterly publication to feature prison waiting times data was
published in September 2013.
The most recently published National Drug and Alcohol waiting times report from ISD2 shows
that in April-June 2017, of the 1,282 people who started their first drug or alcohol treatment,
94.5% waited three weeks or less and 69.4% waited one week or less.
Between April-June 2017 all NHS Boards delivering drug or alcohol treatment services in prison,
except NHS Lothian, met the LDP standard that at least 90% of people who started drug or
alcohol treatment waited three weeks or less.
2 National Drug and Alcohol Treatment Waiting Times Report - https://www.isdscotland.org/Health-
Topics/Drugs-and-Alcohol-Misuse/Publications/2017-09-26/2017-09-26-DATWT-Report.pdf accessed 18/12/2017
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National Naloxone Programme
The National Naloxone programme was introduced in Scottish prisons in 2010/2011 when SPS
nursing staff were trained to administer Naloxone in emergency opiate overdose incidents in
prison. This responsibility was transferred to local NHS Health Boards in 2011. This is continuously
monitored to inform ongoing evaluation by Scottish Government.
SPS Throughcare Support Service
SPS has provided a dedicated, voluntary, Throughcare Support Service, with Throughcare
Support Officers (TSOs) in 11 prisons, since 2015. Throughcare takes a coordinated approach to
the provision of support to people who serve short-term prison sentences (less than four years),
from their imprisonment, throughout their sentence, and during their transition back to the
community and initial settling-in period.
The role of TSOs in supporting those released from prison has recently been positively
evaluated3. Among the strengths identified by the evaluation was that ‘gate pickup’ could help
service users avoid exposure to risks which might lead to reoffending (e.g. alcohol, drugs, lack of
accommodation).
Self-assessment data shows that the proportion of service users (approximately 25% of the short
term prison population) who stated that they had no problems with alcohol or drugs rose from
13% on assessment to 25% at the end of service (an 89% increase in the actual number). The
proportion who stated that they had serious issues with alcohol and / or drug use which caused
them problems in their daily lives fell from 34% to 14%.
Among the reasons given for a positive impact were that:
Links between TSOs and addictions services in prison helped identify and access support
in prison and the community.
Liberation day support helped avoid a high risk of drug and alcohol misuse, and the
associated health and reoffending risks.
Support from TSOs helped keep people focused on recovery and provided a point of
contact if there was a risk of relapse.
Support from TSOs helped prevent other problems causing relapse.
SPS throughcare support service data indicates that 93% of those who return to prison after receiving TSO support do so for new offences. Of those who gave a reason for their return 92% described the role of substance misuse.
Through the Throughcare Support Service SPS will continue to work with partners to improve
collaborative working and ensure that people leaving our care are able to access the services
they need - including drug misuse services.
While SPS provides the voluntary Throughcare Support Service to people in prison on a short
term sentence there are a number of other throughcare social work and associated services
3 http://www.sps.gov.uk/Corporate/Publications/Publication-5246.aspx accessed 18/12/2017
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available to people in prison and their families from the point of sentence or remand, during the
period of imprisonment and following release into the community that are the responsibility of
local authorities. Those serving more than four years are released under statutory supervision.
Those serving less than four years who are short-term sex offenders under Section 15 of the
Management of Offenders Etc. (Scotland) Act 2005, or who are subject to an extended sentence
or supervised release order, are also supervised on release. The objective of local authority
throughcare services is public protection, as well as assisting individuals to prepare for release
and supporting community reintegration and rehabilitation. SPS works in partnership with the
local authorities that provide these services.
Conclusion
While SPS is no longer responsible for the delivery of clinical substance misuse services it is
committed to working with partners to support people in prison with substance misuse
problems. From investing in security and rolling out new training to staff across Scottish prisons,
to Recovery cafés and colleges, SPS is working to ensure that its services better meet the needs
of those in our care in the face of an ever changing social, cultural and public sector landscape.
The Road to Recovery is 10 years old. SPS would welcome an opportunity to contribute to a
refreshed national drugs strategy as eagerly as it did the opportunity to contribute to The Road to
Recovery over 10 years ago.
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Annex 1
Key Actions Outcome Responsibility Timescale Update - 2018
Review a 'pilot' project in HMP Edinburgh to improve the integration of medical treatment with wider 'wraparound' therapeutic support and consider rolling it out across all prison establishments.
To see more people recovering from problem drug use and reduce future drug-related crime and drug-related deaths.
Scottish Prison Service
Autumn 2008 Completed prior to transfer of healthcare in 2011.
This pilot resulted in an integrated addictions process and was central to the 2010 SPS Substance misuse strategy. In 2011 responsibility for healthcare (including addictions services) transferred from SPS to NHS boards. While SPS aspires to an integrated model of care across all prisons and health boards local NHS health boards have their own substance misuse strategies and responsibility for delivering addiction services locally – these vary across the prison estate.
Develop and implement an information sharing protocol between Throughcare Addiction Services (TAS) and Enhanced Addiction Casework Service (EACS).
Improved continuity of care on admission, during a sentence and on release into the community.
Scottish Prison Service
Autumn 2008 Completed.
EACS’ were transferred to NHS Health Boards as part of the 2011 transfer of prison health care. NHS Health Boards are now responsible for continuity of care and connecting with throughcare services.
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Review the issue of chaotic drug users who stay for short periods in custody following the report from the Independent Prisons Commission.
Improved continuity of care on admission, during a sentence and on release to the community to reduce the risk of drug-related death soon after release.
Scottish Prison Service
June 2008 NHS Health Boards are now responsible for continuity of care and connecting with throughcare services.
The Scottish Prison Service has established the Throughcare Support Service for people in prison with short sentences. Further details on pg. 6.
The Criminal Justice and Licensing (Scotland) Act 20104 commenced in February 2011 and included a presumption against short sentences (3 months or less).
Publish a new Substance Misuse Strategy, which fits with the Government's drugs strategy.
To see more people recovering from problem drug use and reduce future drug-related crime and drug-related deaths.
Scottish Prison Service
Autumn 2008 Completed
This strategy was published in 2010.
In 2011 responsibility for the delivery of healthcare to people in prison transferred from the SPS to the NHS. This included addictions services. Specific roles and responsibilities are now described by the NHS/SPS Memorandum of Understanding (MOU) and Information Sharing Protocol (ISP).
Table 1 The Road to Recovery – Annex A Action Plan5
4 http://www.legislation.gov.uk/asp/2010/13/contents accessed 19/12/2017
5 http://www.gov.scot/Publications/2008/05/22161610/9 accessed 18/12/2017
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Crew Submission for the Scottish Parliament Health and Sport Committee Inquiry on
Preventative Spend 2018: Substance Use
Introduction: Crew is an award-winning public health charity based in
Edinburgh. Our aim is to reduce the harm and stigma associated with
psychostimulant drug use by providing a range of services for young
people and adults, their families, friends and communities, using a
‘stepped care’ approach which includes primary, secondary and
tertiary harm reduction and prevention.
Crew’s primary prevention work includes drug education training for
teachers, social, prison, NHS and youth workers and developing peer-
produced, non-judgemental risk and harm reduction information and
dialogue (step 1). Secondary harm reduction and prevention includes
outreach, welfare peer support and specialist crisis intervention at music festivals and night clubs, delivered in
partnership with paramedics (step 2). Tertiary harm reduction and prevention includes person-centred
counselling for adults wishing to reduce, stabilise or stop stimulant drug use, developing on-going tier 3
support for young with problematic drug use in our Drop-in shop (step 3) as well as National Acupuncture
Detox Association ear acupuncture to support people to manage cravings, sleep and anxiety, contributing to
sustaining recovery; and mindfulness-based relapse prevention (step 4).
1. To what extent do you believe the Scottish Government’s national drugs strategy, The Road to
Recovery (R2R), and the approach by Integration Authorities and NHS Boards are preventative?
The commitment to prevention in the strategy is clear (1) and the strong recognition of the links between
social, economic, educational and health inequalities and problem drug use (2, 3) embedded in this chapter is
still pertinent.
Key point 32 identifies the need for an integrated, cross-sector approach to address these links. Part of the
Program of Action is to prioritise: “cross-cutting work, involving all arms of SG and public services, to prevent
drug use by tackling factors associated with drug use, as well as improving education and information”. This
encompasses economic strategy, early years/early intervention, health inequalities and organised crime in
communities.
NHS Health Scotland’s 2017 paper ‘Tackling the Attainment Gap by Preventing and Responding to Adverse
Childhood Experiences’ (ACEs) (4) highlights the association between trauma or stressful events with young
people’s health and wellbeing outcomes. One key finding from the ACEs study showed that if children and
young people experienced four or more adverse events in early life they were more likely to smoke, be a high-
risk drinker and use heroin or crack cocaine.
Recommendation 1: Ensure economic, health, education, welfare and justice policy development,
construction and review is indeed “cross-cutting”, including impact assessment on problematic drug
use and related harms in its development as well as evaluation stages, and that policy is developed
with and for the people and communities it seeks to serve.
Funding cuts in real terms, whether reductions in funding, stand-still budgets for Alcohol and Drug Partnerships
(ADPs) (5) or inconsistencies in funding across Integrated Joint Boards (IJBs) (6) create the risk of geographical
inequality in access to services and, it could be argued, of preventive spend losing out to the demands of the
‘front-line’ or tertiary services. Fighting to keep a service open is not conducive to rigorous quality improvement
or embedded prevention. Full cost recovery for voluntary sector drug services is of crucial importance within
commissioning.
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Protective factors supporting young people’s resilience (including strong family bonds; strong parental
engagement and boundaries, successful school experiences, strong bonds with local community activities; a
caring relationship with at least one adult) interact in complex ways and do not guarantee to prevent early or
problematic drug use in themselves, however sustaining the conditions where these factors can thrive is key to
a preventive approach (7).
Recommendation 2: Funding for drug, education and community services needs to be consistent and
sustained.
2. Is the approach adequate or is more action needed?
To be effective, or even ‘adequate’ the approach needs to consider recent developments and changes to the
drug market. For example:
Technology: Access to illegal drugs is no longer restricted to “highly concentrated pockets of intense
deprivation with multiple social problems” (1) in Scottish communities. The development of online technology
has resulted in significantly increased access to a greater number and variety of legal and illegal drugs since
2008 (8) many of which test higher for purity and UK purchase of drugs from the dark web has more than
doubled from 12.4% in 2014 to 25.3% in 2017 (9).
In 2017, Afghanistan’s total area under opium poppy cultivation increased by 63% from the previous year as
farming methods and technology have improved, in addition to many other factors such as increased political
instability and lessening engagement with the international aid community. This is despite opium poppy
destruction having increased by 111% (10).
Advances in technology have not only expanded the online market and improved mass manufacturing
methods but have also allowed for the development and synthesis of hundreds of new drugs. Improved
transport infrastructure and connectivity means we are working within an international drugs market, not a
Scottish one.
Trends and legislation: When invited by the Home Office in 2015 to give evidence of potential risks and harm
foreseen as a result of the introduction of the Psychoactive Substances Act 2016 (PSA) and the removal of
Novel Psychoactive Substances (NPS) from open sale, Crew identified serious potential impacts for people
who had previously been taking NPS returning to traditional controlled drugs including heroin and other opioids
(likely to have reduced tolerance thus at increased risk of overdose) and an increase in non-prescription use of
medicines such as benzodiazepines, gabapentin and pregabalin. We also noted the risk that people having
developed a taste for stimulant drug effects while using NPS might lead to an increase in people using
stimulants like cocaine (11). Our counselling clients between 2016 and 2017, after the lead up and
implementation of the PSA, reported higher use of cannabis, cocaine, MDMA and heroin than in previous
years.
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Cannabis, MDMA and cocaine were the drugs most reported as being used in the last 12 months in Scotland
by participants in the Global Drugs Survey 2017 (12) and Scottish participants also reported being more likely
to access emergency treatment with cocaine, MDMA and alcohol use compared to the rest of the UK.
Recommendation 3: There is little reference to stimulant drugs or emerging, harmful drugs within the
R2R. To ensure our future drug strategy is effective, the needs of people who take these drugs and a
response to changing technologies must be included.
The emergence of chemsex (sex intentionally involving primarily stimulant drugs) in recent years demonstrates
a need for quality harm reduction information and dialogue, and bespoke services for a cohort whose use may
indeed be problematic but who may be unlikely to access mainstream treatment and are perhaps more likely
to utilise emergency services once in crisis.
Recommendation 4: Drug services should continue to develop a more consistently joined up approach
with sexual health services.
Education and prevention: The Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS)
provides national level data on secondary school-aged students’ self-reported use of alcohol, tobacco and
illegal drugs as well as ‘lifestyle trends’ and forms part of the evidence base for drug and health policy.
Limitations of this approach include the fact that the survey is self-selecting: schools are not obliged to take
part and students must complete the survey in 45 minutes under exam conditions in order to contribute.
We need to hear from the young people who aren’t likely to sit down and write about highly sensitive,
potentially criminalised topics for 45 minutes under exam conditions because they are truanting, excluded,
experiencing conflict at home or struggling with Attention Deficit Hyperactivity Disorder or ACEs – all risk
factors for higher than average likelihood of early onset drug use and greater harm as a result (2; 3; 4; 7).
Recommendation 5: Conduct additional research to enhance SALSUS and Scottish Drug Policy. This
should be conducted by, with and for young people most at risk of using drugs harmfully and should
build on existing relationships between targeted young people and their trusted peer and youth
workers.
Evidence-based approaches to education and assets exist in Scotland, but aren’t as ‘joined up’ as they could
be (13). Approaches with stronger evidence of effectiveness include:
interventions based on social influence approaches and/or on learning social and life skills
interactive and/ or peer-led interventions
targeted interventions for young people at highest risk of developing problematic use
school-based programmes that help to reduce bullying and victimisation, both behaviours that can be
associated with substance use
interventions which take cognisance of the local context
and approaches with weaker/no evidence of effectiveness or evidence of adverse outcomes include:
knowledge-focussed/information provision alone
fear arousal approaches or shock tactics
using testimonials from people who used to take drugs in the classroom
one-off sessions (14)
There is a legislative duty on Ministers and local authorities to ensure schools are health-promoting Schools
and the new Curriculum for Excellence Health and Wellbeing Outcomes rightly place drugs education in the
context of mental, emotional, social and physical wellbeing.
Recommendation 6: Develop a national strategy for consistent drug education which is evidence-
based, up to date, starts with the person and builds on the good intentions of R2R. Key factors for
effective, evidence-based drugs education include:
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promoting inclusion of young people and local services in its development and delivery
promoting support, recognising the impacts on students affected by parental/carer drug use, or
their own, including tobacco
drawing on further research into effective targeted interventions for young people at risk
interactive, multi-modal approaches including media, parental and community as well as
classroom components
promoting collaboration between ADPs, NHS, local authorities, schools and wider community
mental health/wellbeing and youth organisations
steering group to develop more effective drug education in schools, consistently across
Scotland, providing advice, guidance and proposals aimed at helping schools/authorities
achieve the outcomes sought through Curriculum for Excellence. This was a key action in
prevention strand of R2R.
producing short-form guidance on ‘what works’
training and guidance equipping teachers to develop and evaluate evidence-based, student-
centred, student-involving, on-going programmes integrated within health and wellbeing and
centred on local context
support and sufficient resourcing over time to evaluate longer term impacts and effectiveness
of interventions and methodologies: “a nation’s social context, drug policies and the need for
high quality supporting structures are all important in determining the success of a
programme” (7)
Recovery and harm reduction: The ministerial foreword of R2R defines recovery as “the desire of people
who use drugs to become drug-free” and the strategy describes supporting individuals to move toward a “drug
free” life to become an active and contributing member of society. If we are to truly “treat each person using
drugs on their own terms, and centre care around the person, not the addiction” (1) then a wider definition of
the principle of recovery in our ‘refreshed’ strategy, recognising that people may wish to reduce or stabilise
their use, rather than only seeking strict abstinence may be more inclusive and fruitful as part of the Scottish
Government’s ‘seek, keep and treat’ treatment concept. It’s encouraging that the Quality Principles: Standard
Expectations of Care and Support in Drug and Alcohol Services 2014 (15) do not include the words “drug-free”
but emphasise approaches being responsive to peoples individual needs and beliefs and keeping them “safe
and free from harm”. Ian Paylor (16) argues that England’s new drug strategy’s emphasis on abstinent
recovery or becoming “drug free”, and a lack of focus on harm reduction can, in practice, hinder engagement
by more vulnerable people seeking to reduce their use or use more safely; and unintentionally reinforce
stigmatising approaches which suggest that only those willing or ready to “get clean” deserve support.
Harm reduction dialogue and practical support: This offers a ‘way in’ for people who would otherwise not
access a ‘mainstream’ or opiate-focussed, abstinence-focussed drug service, because abstinence might not
feel achievable at that point in their lives. This is especially important for those who are taking non-opiates as
there are few recognised current substitution therapies available. Reducing the barriers on the ‘way in’ offers
our best chance of reaching those people most at risk: those who are not engaged and retained in specialist
addiction treatment.
Scottish Drug Related Deaths 2016
Drug 2015 2016
Etizolam 43 225
Pregabalin 42 71
Gabapentin 102 145
Xanax 2006-15: 2016
5 for entire period 24
In 2016, 176 people died as a direct result of psychostimulant drugs, 20% of the highest annual total of drug-
related deaths (DRDs) since records began (16).
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Deaths by Drug 2000 2004 2008 2012 2016 Percentage increase
between 2000 and 2016
Total DRDS 292 356 574 581 867 197%
Heroin 196 225 324 221 473 141%
Methadone 55 80 169 237 362 558%
Heroin, Methadone or
Buprenorphine
232 275 445 399 650 180%
Benzodiazepines 164 140 149 196 426 160%
Cocaine 4 38 36 31 123 2,975%
Ecstasy-type 3 10 11 18 28 83%
Deaths from psychostimulant drugs may result from occasional recreational use, but also from routine
and prolonged use. Psychostimulant drug use, however, is not included in the current official
definition of problematic drug use used by the Information Services Division/NHS National Services
Scotland.
People who use non-opiate/opioid drugs may not find ‘mainstream’ or opiate-focussed drug services relevant
to their needs. The Global Drug Survey 2017 found that 30% of people using cannabis and 36% of people
using cocaine reported wishing to reduce their use with a smaller proportion indicating they would like
treatment to support this. The 2008 strategy noted the need for a more fundamental change in response
should cocaine use continue to increase, and the rapid increase in deaths over time shows that this need has
increased.
Recommendation 7: We propose that some of the £20m additional funding announced to address
drug-related harm in Scotland should be used to develop needs-based and evidence-based harm
reduction and treatment interventions for people using psychostimulant and other drugs across ADP
areas.
3. What evaluation has been done of interventions?
The Novel Psychoactive Substances Treatment UK Network’s guidance includes a summary of the substantial
evidence for the effectiveness of psychosocial interventions including harm reduction for problematic
psychostimulant drug use, including National Centre for Clinical Excellence (NICE) guidelines. These are the
primary form of treatment for problematic stimulant drug use or dependence as few new or psychostimulant
drugs have recognised pharmacological interventions (17).
The 2012 Report of the Special Working Group on Prevention and 2015 National Research Framework for
Problem Drug Use and Recovery identified a need to develop a clear picture of current prevention activity in
Scotland.
John Davies’ 2017 review into drug education work in schools (13) drew the following conclusions:
local authorities/ADPs had a rounded understanding of components and effectiveness of drug
education and prevention interventions: knowledge as a precursor to skills development, social norms
and peer-led approaches
there is an opportunity for collaborative development of resources between local authority, ADPs, NHS
and community partners in order to develop quality assurance
embedded, multi-modal programmes focusing on social norms and social competences are more
effective than one-off interventions – teachers may need to build confidence in developing these
resources may have diminished for targeted interventions in recent years (ADP funding)
time, guidance and financial support are needed for developing rigorous evaluation methodologies.
School’s work is currently subject to school’s internal self-evaluation and Her Majesty’s Inspectorate of
Education inspections.
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4. Are the services and national drugs strategy being measured and evaluated in terms of cost and
benefit?
Offering effective, acceptable harm reduction and support before people’s use becomes problematic, among
people using cocaine and MDMA in particular, could prevent and save the significant financial, health and
community costs of people using psychostimulants accessing emergency treatment at the point of crisis (12).
Robust evaluation and measurement of costs and benefits will require significant additional investment and
more co-operation across the voluntary, health, education and social justice sectors.
Recommendation 2: Funding for drug, education and community services needs to be consistent and
sustained.
Notes:
1. Scottish Government 2008: ‘The Road to Recovery: A New Approach to Tackling Scotland's Drug
Problem’
2. Advisory Council on the Misuse of Drugs 2006: ‘Pathways to Problems’
3. Leyland, A H; Dundas, R; McLoone, P and Boddy, FA 2007: ‘Inequalities in Mortality in Scotland, 1981-
2001’, Medical Research Council (MRC) Social and Public Health Sciences Unit Occasional Paper no
16 Glasgow: MRC Social and Public Health Services Unit
4. NHS Health Scotland 2017: ‘Tackling the Attainment Gap by Preventing and Responding to Adverse
Childhood Experiences (ACEs)’ accessed December 2017
http://www.healthscotland.scot/publications/tackling-the-attainment-gap-by-preventing-and-responding-
to-adverse-childhood-experiences
5. Scottish Government 2017: Alcohol and Drug Partnerships (ADPs) Funding Allocation 2014-15 to
2017-18 http://www.gov.scot/Topics/Health/Services/Alcohol/treatment/ADPsFundingallocation2017-18
6. Smith, A 2017: ‘Drug and Alcohol Services Funding Timeline 2015–17’ accessed December 2017
http://www.sdf.org.uk/wp-content/uploads/2017/09/CPG-ADP-Funding-Timeline-2.pdf
7. Mentor ADEPIS accessed 2017: Risk and Protective Factors accessed December 2017 http://mentor-adepis.org/risk-protective-factors/
8. Power, M 2013: ‘Drugs 2.0: The web revolution that’s changing how the world gets high’
9. United Nations Office on Drugs and Crime (UNODC) 2017: ‘World Drug Report: pre-briefing to the
member states’ accessed December 2017
https://www.unodc.org/wdr2017/field/WDR_2017_presentation_lauch_version.pdf
10. UNODC 2017: ‘Afghanistan Opium Survey 2017: Cultivation and Production’ accessed January 2018
https://www.unodc.org/documents/crop-
monitoring/Afghanistan/Afghan_opium_survey_2017_cult_prod_web.pdf
11. Craik, V 2017: ‘Crew NPS Annual Report 2015-16’ accessed December 2017
http://www.mindaltering.co.uk/
12. Winstock, A; Barratt, M; Ferris, J and Maier, L 2017: ‘Global Drug Survey 2017’
13. Davis, John 2017: ‘Substance Misuse Education and Prevention Interventions in Scotland: Rapid
Review Mapping Exercise’
14. http://www.emcdda.europa.eu/best-practice/prevention/school-children accessed December 2017 in
City of Edinburgh Council 2018: ‘Delivering Substance Use Education and Prevention Work in Schools’
15. Scottish Government 2014: ‘The Quality Principles: Standard Expectations of Care and Support in
Drug and Alcohol Services’ accessed December 2017’ http://www.gov.scot/Publications/2014/08/1726
16. National Records of Scotland 2016: ‘Drug-related Deaths in Scotland in 2016’ accessed January 2018
https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/drug-
related-deaths-in-scotland
17. Novel Psychoactive Treatment UK Network 2015 (NEPTUNE): ‘Guidance on the Clinical Management
of Acute and Chronic Harms of Club Drugs and Novel Psychoactive Substances’ accessed December
2017 http://neptune-clinical-guidance.co.uk/wp-content/uploads/2015/03/NEPTUNE-Guidance-March-
2015.pdf
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Health and Sport Committee
Preventative Agenda: sexual health, blood borne viruses and HIV
Addaction Scotland
Addaction is the largest charity provider of drug and alcohol services across Scotland. We have had a
significant presence in Scotland since 2004 and across the UK since 1967. We deliver whole
population and specialist services in the following:
Scottish Borders
Dumfries and Galloway
Argyll and Bute
South Lanarkshire
South Ayrshire
East Ayrshire
Glasgow
Dundee
East Dunbartonshire
Fife
Lanarkshire (BBV)
1. To what extent do you believe the Scottish Government’s national drugs strategy, The Road to
Recovery, and the approach by Integration Authorities and NHS Boards are preventative?
Prevention and Integration
Needless to say this is both a broad and complex question. Prevention can mean many things from
information and education where young people have the knowledge and resilience to never develop
drug and alcohol problems through to preventing sustained and progressive difficulties to those
who have long term drug and alcohol use.
With regards to primary prevention there has been significant changes in drug and alcohol use in
Scotland, the UK and across Europe. It is extremely rare for services to see young people under the
age of 25 with heroin problems and this has been the case for some time.
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2
Substance use prevalence has remained largely stable since 2013, but it remains the case that prevalence has
declined considerably over the last couple of decades. (SALSUS)
A large majority of pupils do not take any substances regularly, 80% of 15 year olds and 95% of 13 year olds.
(SALSUS)
In 2014, 8% of children aged 11-15 in England drank alcohol in the last week; this was the lowest level
recorded since a peak of 27% in 1996. Most pupils who drank in the last week had done so on one or
two days (63% and 25% respectively). On the days they did drink, 45% drank more than four units of
alcohol on average. (Briefing Paper: House of Commons)
This is not to say that there are no young people with significant drug and alcohol problems – just
that the numbers are much smaller than they were 10/20 years ago. There is still substantial drug
and alcohol use among young people that can be both harmful and hazardous but less likely to be
dependent. This is partly due to changes in drugs of choice. Young people and Young Adults are
much more likely to be attracted to stimulant type substances which in general are less harmful.
Heroin in Europe is, at the moment, out of fashion.
Why? Changes in housing, economic growth, demolition of sink estates, employment, and social
media are all associate factors to declining drug/alcohol use.
However and unwittingly the decline in dependent drug and alcohol use among young people has
been mirrored by a dearth in services for YP. In our opinion this is a folly and such short termism
hampers us from preventing that small group of YP developing more serious long term drug and
alcohol problems and all their associated consequences and costs (personal, familial and
monetary). Across the country there is a postcode lottery regarding young people’s specific drug and
alcohol services. As an adviser to Corra, Partnership Drug Initiative for the past 20 years there is a
lack of statutory match funding for work with at risk YP.
With regard to people with established long term drug and alcohol problems much can still be
achieved from a preventative approach. There has been a steady decline in specialist fixed site
needle exchanges across the country. Provision has largely been provided by pharmacy and while
this is to be welcomed in terms of clean paraphernalia, it misses the opportunities for assertive
health and social care interventions.
Additionally, drug consumption rooms and supervised heroin facilities could be seen as part of a
preventative campaign in terms of health and wellbeing. (over dose, fatality, HIV/Aids, HEP C)
A note of caution: dependent drug use (Heroin, Valium) is seen by young people to be completely
unfashionable. Paradoxically, there is a theory that the very visible supervised daily consumption of
methadone from pharmacies across the country may have a deterrent/preventative effect on young
people. However, we are continuously aware of the burgeoning opiate and opioid problems rife
across the USA.
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3
Addaction has a UK wide webchat which has had nearly 4000 interventions in the last 6 months.
The number one presenting issue is alcohol followed by cocaine and then cannabinoids.
2. Is the approach adequate or is more action needed?
In the opinion of Addaction Scotland we need to see a shift in service delivery, resource and design.
In particular we need to concentrate on the following areas:
Whole population approach – Brief Interventions and enhanced Brief Interventions for
harmful and hazardous drug and alcohol users.
Young peoples services for those coming to the attention of schools, A&E, and police
because of their alcohol/drug use.
Emphasis on Recovery – the greatest thing to come out of the road to recovery has been the
fantastic growth of the organic recovery communities across the country. This needs to be
further supported and championed in any new strategy. Addaction supports these
communities using staff to help with accounts, leases, secondments, mediation and room
availability.
A note of caution: If we had another heroin “epidemic” would we be ready? Would we take
the same approach? Are we fit for purpose?
We also need to look at the disconnect between mental health services and addiction.
People are still failing to get appropriate treatment because of their dual diagnosis.
3. What evaluation has been done of interventions?
Evaluation of primary whole population prevention is notoriously difficult. There are far too many
variables to attribute a national/local intervention to future positive outcomes. However where
there is direct service delivery (static needle exchange, drug consumption rooms, YP service for
people at risk – these can all be evaluated).
4. Are the services and national drugs strategy being measured and evaluated in terms of cost and
benefit?
No.
In fact there are no outcome targets set for treatment and recovery services. At present we
measure waiting times, presentations and outputs but there are no targets for successful outcomes
and planned discharges. We fear that “seek, treat and keep” will continue to increase churn with
little movement in the system. We are already seeing unambitious practice that hampers people in
their recovery journeys.
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4
As a third sector provider we continuously ask to be given outcome targets to no avail. In response
we have set up internal targets/bench mark across our own services. We are not advocating
Payment By Results but we need to instil the people who use our services with hope and realistic
expectations. In deed we need to strive more for individual tailored recovery plans that are asset
based and aspirational in approach. Recovery happens every day if it is allowed. We have set a
target of 40% planned discharge, that is drug free (opiate, benzo and cocaine) and alcohol problem
free (within recommended units).
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Scottish Drugs Forum
Preventative Agenda – Substance misuse Prevention ___________________________________________________________________ In Scotland, we define problem drug use as the use of opiates (heroin) and benzodiazepines (valium-type drugs). Latest estimates are that there are 61,500 people with a drug problem in Scotland (1). The UK has the highest estimated prevalence of high-risk opioid use, per head of population, in Europe. In the context of the UK, the prevalence of problem drug use in Scotland is far higher than the other UK nations. (2)
Prevention must be based on an understanding of the root cause and drivers of problem drug use. A focus on personal health behaviours and so-called lifestyle choices offers limited insight and misses the most obvious causes and drivers of much of the problem drug use in Scotland – poverty and inequality (3); the experience of trauma, abuse, neglect and other adverse experiences in childhood and early adulthood are also significant; and a lack of opportunity to access education, training and employment both drive the development of, and prevent people from moving on from, problem use.
In terms of primary prevention of problem drug use, the issues are –
How the total assets and resources in Scotland are distributed across Scottish society.
How inequalities in education and opportunities for housing, education and employment, as well as access to services, for example mental health services, are reduced.
These are wider policy perspectives than lie within the remit of the Committee, the drugs strategy itself or the expertise of Scottish Drugs Forum but they are crucial to prevention. In terms of a cost benefit analysis, a reduction in problem drug use should be included in consideration of policies that reduce inequalities and relative poverty.
We might also look at how children and young people are protected from trauma – a common factor in many people with drug problems is a history that includes some or all of the following – bereavement, abuse, neglect, being in care, poor experience of education, police contact, offending, imprisonment, homelessness, unemployment.
We could define problem drug use as drug use that causes harms. In this light, eliminating or reducing harms can be viewed as prevention – secondary prevention.
It is hard to separate the human and financial costs, but in terms of total years lost due to premature death and years lived with disability – drug use is 8th in the league table of causes. By comparison, dementias are ranked 7th; alcohol dependence is 12th and diabetes is14th(5)
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In Scotland we had an early start and success in terms of harm reduction with the response to the outbreak and rapid spread of HIV in Edinburgh and, on a smaller scale, Dundee, in the 1980s. This involved the introduction of services providing sterile injecting equipment and methadone to people injecting heroin. This contained the HIV outbreak. The success of this work is internationally recognised.
There is a huge body of evidence regarding the impact of Opioid Replacement Therapy (ORT) (4) and needle exchanges in reducing harm. But these must be delivered according to agreed good practice standards.(6)
Injecting equipment provision and substitution treatment are both available across Scotland now. But we are failing in preventing considerable drug-related harms – so, for example, we had 867 overdose deaths in 2016 (7); we have an ongoing uncontained outbreak of HIV in Glasgow involving 115 new cases… why?
There is both a failure to invest adequately and to deliver models of care which are person centred and able to adapt to individual need, rather than requiring the person with the problem to fit the available service. With regard to ORT in particular, it is estimated that 24,000 people of the 61,500 are on ORT at any one time. However, what is clear from our research among those aged 35 and over with a drug problem is that many of the most vulnerable are not in ORT for a long enough period of time for the provision to impact positively on their lives. (8)
Countries with lower fatal overdose death figures are those who have higher numbers of people on ORT and where people remain long enough in the service for it to make an impact.
Large scale specialist treatment services led by the NHS have frontline staff who have large caseloads. As a result, staff are focussed narrowly on prescribing and monitoring and dealing with health and other crises rather than addressing the wider health and social issues facing their service users. Medication is often prescribed in sub-optimal doses and there is little opportunity to develop a therapeutic relationship between staff members and service users.
Yet there are significant opportunities to save money by spending money more wisely. Investment in the treatment services that prevent further health and other harms could be funded from savings available if, for example, we could prevent these same NHS patients presenting at A&E and being admitted to hospitals. This group is hugely over-represented in statistics for both. Why? Because their health problems reach crisis point and because they have little other option as they are not engaged by primary care services.
Statistical modeling work undertaking by the Information Services Division produced estimates for the number of hospital bed stays for people with a drug problem over the next ten years, showing that there would be nearly 200,000 hospital bed days annually by 2028, if current responses remained broadly the same. (9)
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Projected annual number of hospital bed days (PDPs, by age group 2012/13-2017/28)
Source: ISD OPDP cohort 2012/13 & population projections with 20% non-replase rate
It is estimated that the following hospital usage figures were associated with People with a Drug Problem (PDPs) in 2012/13:
168,200 hospital bed days (estimated to cost £88.8 million)
26,800 hospital stays; of which,
20,700 were emergency hospital stays (9)
The following hospital usage figures associated with PDPs are projected in 2027/28:
192,600 hospital bed days (estimated cost: £101.8 million (based on 2012/13)
30,100 hospital stays; of which,
21,800 were emergency hospital stays (9)
Influenced strongly by the increase in the vulnerability of those aged 35 and over who have had drug problems for many years, the Government is proposing a treatment strategy around the concept of Seek, Keep and Treat. This is our understanding of what the different elements will contain:
Seek The aim is to decrease the number of people who have a drug problem but are not in specialist addiction treatment.
Means to do this include:
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Arrest referral
Assertive outreach
Prison and hospital throughcare
Ending additional barriers to accessing treatment
Having easy and rapid access to treatment
The need to invest in these elements will be reduced the more attractive and effective treatment is. The quality of treatment is key.
Keep
Ensure that people remain in medical treatment so long as they can benefit from it.
This can be achieved through the provision of high quality medical treatment services which:
are acceptable to this group of patients
deliver to national standards and guidelines of good practice
offer a person-specific approach
can prescribe a full range of medications
allow informed patient choice
Treat
The model rightly makes clear that medical treatment is a narrow focus and that people with a drug problem have a wider set of issues and needs. In this respect, many of their needs will be similar to other members of their community; however, they often lack access to services around advocacy, housing, housing support, education, training, volunteering and employment.
This model and approach, if successfully implemented, does have potential in delivering real savings to non-drug services in secondary and tertiary care and to police and prison services.
Notes
1) Estimating the National and Local Prevalence of Problem Drug Use in Scotland 2012/13 (ISD 28 October, 2014) (Updated - 4th March 2016)
2) European Drug Report 2017 (EMCDDA , 2017) 3) Shaw, A et al Drugs and Poverty A Literature Review (Scottish Drugs Forum
and SAADAT, 2007) 4) Independent Expert Review of Opioid Replacement Therapy 2013 (Scottish
Drug Strategy Delivery Commission, 2013) 5) The Scottish Burden of Disease Overview Report (NHS Health Scotland, 2015) 6) Drug Misuse and Dependence UK Guidelines on Clinical Management (UK
DoH, Scottish Government, 2017) 7) Drug-related Deaths In Scotland 2016 (National Records of Scotland, 2017) 8) Older People With Drug Problems in Scotland: a Mixed Methods Study
Exploring Heath and Social Needs (Scottish Drugs Forum, 2017) 9) Older People With A Drug Problem in Scotland: Addressing The Needs of An
Ageing Population (Scottish Drugs Forum, 2017)
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