Section 3: Improving the effectiveness and consistency of IEP services
A review of international research carried out for NICE found that there was a lack of evidence about the optimal provision of IEP services. 6 The review therefore suggested that it was difficult to draw conclusions on 'what works best' within the range of harm reduction services available to injecting drugs users. Nevertheless, it was apparent from the literature that the distribution of sterile needles and syringes alone is not sufficient to reduce the transmission of blood-borne viruses among IDUs, especially the transmission of HCV.
This suggests that the effectiveness of an IEP service is likely to depend not only on what the service offers, but how it is offered.
The National Needle Exchange Survey found a lack of consistency between services in almost all aspects of service delivery in Scotland. Focus groups with service commissioners, service providers and pharmacy co-ordinators also identified a lack of consistent training among staff as one of the most significant barriers to good practice in IEP services. 19
Therefore, this section makes recommendations that aim to improve the quality and consistency of IEP services. The focus is very much on improving the way services interact with their clients. To some extent, this requires improvements in staff training - so that staff can feel more knowledgeable and confident in speaking to clients. However, there is also a need, even after staff are trained, to find better ways of engaging with clients - not only to find out what the client's needs are, but also to ensure that important messages are repeated to clients frequently and consistently across 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.
There is currently no standard training for people involved in the delivery of IEP services. Work is on-going by the Scottish Government to agree a national drug and alcohol workforce development strategy, and separate work is also being undertaken through the Hepatitis C Action Plan, Phase I, to create a national HCV Learning and Workforce Development Framework, which will ensure that Scotland's HCV workforce is knowledgeable, skilled and confident in working with people who have, or who may be affected by, the HCV virus (Action 3, see page 41). 1
In the longer term, both these strands of work will lead to greater consistency and standardisation in training for staff involved in the delivery of IEP services. However, in the short term, NHS Boards still have a responsibility to ensure that IEP staff are adequately trained and skilled to be able to provide a high-quality service. In relation to this, it is worth noting that the National Quality Standards for Substance Misuse Services in Scotland require that:
Workers (paid and unpaid) will be appropriately trained and supervised (Quality Standard 8, point 3).
Services should employ and train their staff to treat clients with respect and dignity. (Quality Standard 3, point 2)69
Recommendation 9, above, specifically focuses on the knowledge and skills required by staff who are involved in face-to-face contact with clients. Experts are of the opinion that training in these areas is important to ensure that staff are delivering consistent messages and providing a consistent service.
Staff training is not a one-off action. On-going training is necessary to ensure that staff are able to learn about innovations and new approaches to working with clients. Staff also need remain up-to-date with new information on HCV and other blood-borne viruses - treatment, prevention and vaccination procedures.
It is often the case that staff employed in specialist harm reduction services have previous experience of working directly with injectors prior to starting work in the IEP service. However, this may not be the case for service providers in other types of services. 35 It is suggested, therefore, that training for all IEP staff should be multi-disciplinary (that is, pharmacists, custody suite officers and specialist IEP providers should ideally receive training together, rather than separately), and training might usefully include brief work experience within a well-run IEP service.
Having the right knowledge and skills is important in providing an IEP service. However, the personal qualities of staff are also important in maintaining the quality of IEP services. In focus groups with service commissioners, service providers and pharmacists undertaken as part of the National Needle Exchange Survey, it was reported that negative staff attitudes - perceived to be linked to inadequate staff training and support - were identified as two of the biggest barriers to good practice in IEP services. 19 And indeed, there is evidence from qualitative research among injectors in the UK to indicate that negative and judgemental staff can act as a barrier to clients accessing services. 70 In contrast, friendly, approachable staff can encourage the use of the service. 58
Finally, it is not enough to simply make training available to IEP service staff. The training must be offered in a way that allows staff to attend. This may have implications particularly, for example, for pharmacists, and may require the employment of locums or that training be delivered in the evenings. Local commissioners should ensure that services are given support to enable staff to attend training. In any case, while it is the responsibility of local service commissioners and planners to make relevant training available, it is the responsibility of service providers to ensure that all staff involved in the provision of injecting equipment are trained prior to delivering a service.
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.
Many clients value speed and convenience in an IEP service. However, to meet a client's injecting needs appropriately, services will need to take some time, at least initially, to find out what those needs are. The National Quality Standards for Substance Misuse Services (Standard 4) requires that services undertake an assessment of the client's needs, and that the client should be involved in this process. 69
In the context of an IEP service, the term "assessment" simply refers to a very basic discussion which should take place with all clients the first time they attend the service. The questions listed above should form the basis for this discussion. (Service providers should also ask these questions of all their existing clients if they have not previously done so.) The main purpose of this discussion is to ensure that clients receive sufficient injecting equipment (needles, filters, cookers, etc.) for their injecting needs - i.e., to enable the use of one set of injecting equipment per injection. The responses to these questions do not need to be recorded by the service, but it is recognised that if they are not recorded, services may find it easier to ask the questions each time a client attends the service.
This initial discussion should also be used to educate the client about safer injecting practices and safe disposal procedures, and to provide information about other (types of) IEP services in the area. This is particularly important for young, or new injectors, who may have had little or no previous accurate advice or information. Some service providers may find it helpful to use a leaflet or other written resources to guide this discussion. However, it is not recommended that services give clients a leaflet without going through the leaflet with them first. (The reason for this will be discussed in relation to Recommendation 11 which addresses service user education in more detail.)
As has been mentioned earlier in this document, injecting drug users place great value on confidentiality and privacy in using IEP services, and some may avoid attending services for fear of being exposed. 32 Therefore, wherever possible, services should find ways to conduct IEP service transactions and have discussions with clients in a private space, away from other customers. In a community pharmacy setting, a consultation room can be used for this purpose.
To allay any fears or concerns that clients may have in relation to being asked about their injecting practices, service providers should clearly explain to clients that this is being done only so that they can be provided with a better service, and the information will be kept confidential.
Once IEP service staff have established a relationship with a client, it is suggested that these questions should be repeated from time to time, to ensure that the client's injecting needs are still being met. In addition, service providers should ask their clients at frequent intervals if they are having any difficulties with the use of their injecting equipment, or if they have any questions about its use. Services should at all times put the client at the centre of the service, and treat clients with respect and dignity as required by the National Quality Standards (Standard 3). 69
The recommendation above relates to a basic assessment which should be undertaken by all IEP services. However, it is recognised that specialist and enhanced IEP services may be able to undertake a fuller assessment of a client's needs. Where this is possible, the assessment should additionally include questions about:
- Where clients are injecting (ie, what part of the body)
- BBV status
- Current or previous experience of treatment for drug misuse
When responding to clients' needs, IEP services should also take into account that different clients may have different preferences, for example, in relation to the size of needles and syringes they use. Services, including those that distribute needles / syringes through pre-packed bundles, should offer clients a choice of needles / syringes.
Recommendation 11: Service user education
As a minimum, when providing needles and injecting equipment, IEP services should educate clients about:
- 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 10 touched on the importance of IEP services providing information to their clients on safer injecting practices. This recommendation considers this issue in more depth.
As discussed in Chapter 1 of this document, there is evidence to show that the sharing of needles among injecting drug users in Scotland is declining. 14,15 However, the reuse of needles and the sharing of other injecting paraphernalia (cookers, filters and water) continues to be highly prevalent. 14,16,16,18 The practices of frontloading (drawing up a drug solution into a 'donor' syringe and then measuring out appropriate amounts into one or more other syringes) and backloading (removing the plunger from a recipient syringe and squirting the drug solution into the syringe through the back opening) are also common. 17, 71 In addition, some studies have found that injectors often do not understand how sharing cookers, filters and water can result in HCV transmission. 18,16, 72 This evidence suggests that IEP services may need to take a more active role in educating injectors, and / or to find new ways of providing advice and information about safer injecting practices.
As mentioned in Chapter 3 of this document, the level of information and advice available through IEP services will depend to some extent on the knowledge and expertise of the staff. It is expected that staff in specialist IEP services will be able to provide in-depth information and take on more of an educational role with clients than staff in general IEP services. However, staff in all services should be able to give clients basic information (both verbal and written) about how to reduce the risks associated with injecting.
The content of this information should include, as a minimum, the points listed above. The first three points are recommended on the basis of research which examined the theoretical benefits and risks associated with different items of injecting paraphernalia (eg, acidifiers, cookers, filters, sterile water) and different injection preparation methods. 18
The distribution of injecting paraphernalia should initially be accompanied by a discussion about the correct single-person use of each item of paraphernalia. In relation to the use of acidifiers, it should be explained to clients that although the use of a sterile acidifier is safer than using non-sterile alternatives (e.g., lemon juice or vinegar), 30 the use of a sterile acidifier is not entirely without risk. An acidifier can irritate or cause acid burns during injection. Unfortunately, it is not possible to recommend precisely how much acidifier should be used during the injection process without knowing the purity and thus the concentration of diamorphine in street heroin. 18 Therefore, when supplying acidifiers, IEP services should advise service users to add acidifier in small amounts, a little at a time until all the drug has been dissolved. In some cases, an entire sachet of citric acid or ascorbic acid will not be needed, and the remaining acidifier should be disposed of safely.
Services should discuss these issues with all clients attending the IEP service for the first time or after a period of absence, even if the client may have been attending another IEP service. As mentioned in relation to Recommendation 10, this discussion should take place in a private space or separate room to ensure client confidentiality. In addition, every time a client attends an IEP service, staff should remind him / her of the following key messages:
- Clients should wash their hands before injecting
- Clients should always use a sterile needle for every injection - do not reuse needles.
When providing information to clients, service providers should try as much as possible to avoid the use of jargon. For example, the word, "paraphernalia," may not be understood. 18 In addition, there is evidence suggesting that leaflets are not the most effective method of communicating important messages to injecting drug users since some may have literacy problems. 31 Therefore, verbal communication is an important method for educating service users. Where printed materials are used, it is suggested that they use visual / graphic methods of communicating messages, rather than relying heavily on written text.
In planning IEP services, local NHS Boards should be aware that, for a variety of reasons, some injectors may prefer not to attend fixed-site services to obtain their injecting equipment. These individuals need to receive educational input through other means, and it is suggested that outreach or peer-led services may be suitable for this purpose.
Recommendation 12: Getting client feedback
All IEP service providers should put in place mechanisms for obtaining 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.
Any attempt to improve the quality of IEP services in Scotland must take into account the views and preferences of the people who use those services. The National Quality Standards for Substance Misuse Services in Scotland state that the perspectives of service users must play a central role in service delivery and development, and that service users should be asked at least once a year for their views and ideas on the service. (See Quality Standard 11.) 69
However, the findings of the National Needle Exchange Survey suggested that service users views currently appear to play little part in IEP service provision. 19 This recommendation seeks to change this situation.
Client satisfaction is an important aspect of service effectiveness, and it is suggested that services could benefit by asking their clients for their views more often. The process of finding out the views of clients needs not be time-consuming or expensive. However, a little time will be needed to analyse and report the results.
There may be some benefits in having client feedback collected consistently across services within a local area and it is suggested that NHS Boards assist with this. Agreeing a consistent method is more likely to result in services collecting the information - whereas if it is left to each service to decide what information to collect and when to collect it, the task may not be prioritised. In addition, some services may require assistance in deciding what to ask clients and how to record and analyse the information.
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 and clients.
This guideline introduces a requirement by NHS Boards to participate in the national monitoring of IEP service activity through collection of a minimum data set. The development of a national minimum data set is an action under the Hepatitis C Action Plan for Scotland, Phase II (see Action 21). 1 The purpose of national monitoring is to allow the Scottish Government to determine whether NHS Boards are distributing sufficient injecting equipment to meet the needs of their local injecting populations.
However, the data items listed above are recommended not only to facilitate monitoring at a national level, but also at a local level. Data collected through monitoring provides the basis for on-going needs assessment and future service development. In relation to this point, it is suggested that local areas may also find it useful to collect additional data on:
- Drugs injected
- Frequency of injecting
- Client BBV status
- Postcode sector of residence (this is the first half of the postcode plus the first digit of the second half, eg, EH12 6 or DD3 7)
These latter four items will not be included in the national minimum data set, but they are nevertheless very important for planning services at a local level.
To provide an estimate of the number of clients attending IEP services, it will be necessary for services to assign a unique identifier to each of their individual clients. Examples of a unique identifier could include, for example, a combination of the client's initials and date of birth. Clients may also be asked to provide their own unique identifier, for example, a nickname, or a number which has significance for them. Services are not required to record their clients' names.
In some cases, clients will be collecting injecting equipment for other injectors. If possible, services should attempt to capture information about the number of other injectors for whom the client is collecting supplies. It is recognised that this will not provide a precise estimate of the number of injectors in a particular area.
Traditionally, IEP services have been completely anonymous. However, with an increasing emphasis on evidence-based practice and measurable outcomes, IEP services need to move away from complete anonymity for the sake of improving the quality and accessibility of services.
As discussed in relation to Recommendation 10, some clients may feel worried or suspicious about the shift away from a fully anonymous IEP service. Service providers should anticipate these fears, and explain to clients that new guidelines have been introduced across Scotland to improve services, and that to be able to provide a good quality service, local areas need better information about the number of injectors living in their area. IEP services should continue to operate on a confidential basis.
The national minimum data set will also require an estimate of the number of needles returned. The inclusion of this data is not for the purposes of determining whether sufficient injecting equipment is being distributed, but rather for evaluating the effectiveness of educating clients about safe disposal. It is accepted that data on returns is significantly flawed and can only be based on a rough estimate: IEP service staff should never open returned disposal bins to count the contents. Furthermore, clients might dispose of equipment safely through a variety of IEP outlets or through public sharps disposal bins.
However, NHS Boards should work together with local authority Environmental Health Departments to monitor sharps and injecting paraphernalia discarded in public places. The routine collection and analysis of this data can be used to good effect in planning the locations of sharps disposal bins (discussed further in relation to Recommendation 16).
Finally, although service monitoring is very important, monitoring of the data outlined above does not provide information about service outcomes or adherence to these guidelines. Therefore, NHS Boards should undertake service evaluation, and ensure that robust audit procedures are in place at a local level, to assess whether local IEP services are implementing these guidelines. Obtaining and acting upon client feedback (as discussed in Recommendation 12) should form an integral part of this process.