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Guidelines for services providing injecting equipment: Best practice recommendations for commissioners and injecting equipment provision (IEP) services in Scotland

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PART 2:
The guidelines
The Guidelines - List of recommendations

Section 1: Developing an IEP programme

Recommendation 1: Planning and developing IEP services

In planning and developing services that provide injecting equipment, NHS Boards, together with local partners, should undertake a number of tasks to ensure that services are able to meet the needs of their clients effectively. These include:

  • Needs assessment
  • Stakeholder consultation and engagement
  • Staff training
  • Advertising the service
  • Monitoring and evaluation

Recommendation 2: Choosing appropriate models of delivery

NHS Boards and other service commissioners should ensure that a range of IEP services are provided using models of delivery appropriate to their injecting populations and the geography in their locality, based on an assessment of local needs.

In addition, it is recommended that:

  • All clients should be able to access in-depth advice and information from a specialist IEP service.
  • In large towns and cities (defined by the Scottish Government's urban-rural classification as settlements of 10,000 or more), there should be a balance between the use of specialist, enhanced and general services.
  • Fixed-site services should be located in areas where there are clusters of injecting drug users.
  • All NHS Board areas should have at least one fixed-site service.
  • Fixed-site services should be located on, or within five minutes walk of, a public transportation route.
  • When injectors live in areas where they cannot easily access a fixed-site service on foot or by public transportation, other models of distribution (for example, through outreach) should be used in preference.

Recommendation 3: Meeting the needs of sub-populations of injectors

In deciding which models of service provision to use, service commissioners and service providers should give special consideration to the specific needs of the following sub-populations of injectors, where these populations exist in their area:

  • New injectors
  • Women
  • Sex workers
  • Homeless injectors
  • Users of performance and image-enhancing drugs ( PIEDs)
  • Minority ethnic groups
  • People receiving opiate substitution therapy, or who have recently relapsed following treatment
  • People in custody (both prison and police custody) or recently released from custody or court.

Recommendation 4: Opening times

IEP services should operate at times when injecting drug users are likely to need access to injecting equipment. There should be out-of-hours and weekend access within each NHS Board area corresponding to the needs of local injecting populations.

Section 2: Increasing distribution of injecting equipment

Recommendation 5: Provide one needle per injection

IEP services should provide, free of charge, as many needles as an individual client requires.

Services should continue to encourage clients to return used needles, and individual safe disposal bins should be provided for this purpose. However, the provision of sterile needles should not be dependent on the return of used needles. Services should aim at all times to ensure that all clients have a sterile needle for every injection.

NHS Boards should ensure that all IEP services in their area are actively encouraging their clients to take sufficient numbers of needles.

Recommendation 6: Provide other (non-needle) drug injecting equipment

IEP services should provide, free of charge:

  • Acidifiers
  • Cookers
  • Filters
  • Water for injections
  • Pre-injection swabs

These items should be supplied in sufficient quantities to enable the use of one item each per injection.

Recommendation 7: Secondary distribution

Secondary distribution should not be discouraged. If a client states that he / she is supplying injecting equipment to others, it is acceptable to provide supplies for the purpose of secondary distribution.

However, those clients who supply equipment to others should be encouraged to bring the other injectors into the IEP service so that they can benefit from advice and information.

Recommendation 8: Provide methods for syringe identification

Injectors should always be encouraged to use a sterile needle and related paraphernalia for every injection. However, the reality is that some injectors may continue to reuse needles. Therefore, a method of equipment identification should be made available to clients who inject in the company of other injectors in order that they can identify their own equipment and avoid accidental sharing.

Section 3: Improving the effectiveness and consistency of IEP services

Recommendation 9: Training of IEP service staff

As a minimum, all individuals involved in the distribution of injecting equipment should receive appropriate training prior to providing a service or during induction in relation to:

  • Understanding drug use
  • How to engage with drug users
  • Injecting risk behaviour
  • Correct, single person use of injecting equipment
  • Needs of different sub-populations of injectors, including those who are in treatment
  • Prevention of HCV and other blood-borne viruses
  • Overdose prevention and management
  • Procedures regarding safe disposal of used injecting equipment
  • Procedures for managing needle stick injury
  • Contact details of other local relevant services

All staff involved in the provision of injecting equipment should have read and understood these guidelines. They should also be familiar with the Lord Advocate's Guidelines (issued in March 2010), and have basic training in child protection awareness. Pharmacists involved in the delivery of IEP services should complete the NHS Education Scotland ( NES) distance learning package on "Pharmaceutical Care of the Substance User."

Staff training should include information about the importance of sensitivity and confidentiality in delivering an IEP service, and information about how best to liaise with other local services in relation to the needs of their clients.

On-going supervision should be provided and training should be updated at least annually.

NHS Boards should ensure that relevant training is made available to staff involved in the distribution of injecting equipment, including counter staff in community pharmacy services, and that these individuals are given all necessary support to attend the training.

Recommendation 10: Identifying and responding to the individual client's needs

All clients attending a service for the first time should be welcomed to the service and asked some basic information about their injecting practices in order that services are able to meet their needs. This initial discussion should be carried out in a private area, separate from the public, to ensure client confidentiality, and it should include the provision of both verbal and written information about safer injecting practices and about safe disposal of used injecting equipment.

As a minimum, IEP services should ask clients:

  • How often they inject
  • What they are injecting
  • How often they (usually, or intend to) visit the IEP service, and
  • Whether they are collecting supplies for anyone else.

This is to ensure that clients' equipment needs are addressed and that they leave the service with sufficient supplies to enable the use of one set of equipment per injection.

Recommendation 11: Service user education

When providing needles and injecting equipment, IEP services should educate clients about - as a minimum:

  • Washing their hands with soap and water before injecting
  • The correct use of each item of injecting equipment
  • The risks of sharing injecting equipment
  • The correct methods of disposing of used injecting equipment.

Recommendation 12: Getting client feedback

All IEP service providers should put in place mechanisms for identifying and responding to client feedback at regular intervals - at least annually.

NHS Boards should ensure that client feedback informs the on-going planning and development of local IEP services in their area.

Recommendation 13: Monitoring, evaluation and audit

IEP services should have systems for monitoring, evaluation and audit to enable on-going needs assessment at a local level.

In terms of monitoring, services should report to their local NHS Boards, and NHS Boards should participate in national data collection requirements. As a minimum, monitoring systems should allow NHS Boards to report on:

  • The number of general, enhanced and specialist IEP services available in the area
  • The number of needles distributed
  • The number of items of other injecting paraphernalia distributed
  • An estimate of the number of needles returned
  • The number of transactions
  • An estimate of the number of clients
  • The proportion of male and female transactions / clients.

Section 4: Integrating IEP services with other services

Recommendation 14: BBV testing and vaccination for IEP clients

IEP services should encourage clients to be tested annually for HCV. In addition, wherever possible, all IEP services should make available vaccination (for HAV, HBV and tetanus), and testing (for HCV, HBV and HIV) on-site in a suitable private space.

Testing - including pre- and post-test discussion, sample collection, result-giving and onward referral - should always be delivered by appropriately trained staff. Where IEP services do not offer testing and vaccination facilities on-site, they should develop referral pathways that are user-friendly and accessible to injecting drug users.

Recommendation 15: Improving integration between IEP services and other services

All IEP services should be able to signpost or formally refer clients to treatment for drug misuse.

In addition, IEP services should be able to signpost or formally refer clients to other broader health and social support services, including:

  • Well women, sexual health services and family planning advice
  • Benefits advice
  • Legal aid
  • Social and mental health services
  • Homelessness services
  • Primary healthcare, including dressings, wound care and antibiotic prescribing
  • Dental care
  • Counselling
  • Emergency department care

Wherever possible, IEP services should make any one or more of these broader support services (excepting emergency department care) available on-site. Where this is not possible, user-friendly and accessible referral pathways should be developed.

Section 5: Health and safety of staff, clients and the community

Recommendation 16: Ensuring the safe disposal of used injecting equipment

As part of wider risk assessment procedures, NHS Boards should ensure that all services in their area have robust policies and procedures in place in relation to the safe disposal of used injecting equipment.

To prevent the transmission of BBVs through improperly discarded injecting equipment, IEP services should:

  • Educate staff and clients to safely handle and dispose of used injecting equipment
  • Provide multiple options and locations for safe disposal of used injecting equipment
  • Inform staff and clients that they could be prosecuted if they are found disposing of used injecting equipment in a way that could put members of the public at risk.

Recommendation 17: Hepatitis B vaccination for staff

NHS Boards should work together with employers to facilitate vaccination for Hepatitis B, free of charge, for all staff who are responsible for delivering an IEP service.