3 Models of service delivery
Chapter 1 of this document discussed evidence on the effectiveness and cost-effectiveness of IEP services in general. However, the provision of injecting equipment can be undertaken using a wide range of service models. In other words, not all IEP services are alike.
One of the recommendations that will be made in the next section is that local areas should provide IEP services using a mixed-model approach. Therefore, this chapter looks in detail at the different models available, and provides information about their strengths and limitations, based on the findings of research. This information is intended to inform local decision-making about how best to structure service provision so that it meets the needs of local populations of injectors.
However, before going on to discuss the different models of IEP services, it is first necessary to describe a form of service classification that will be used at various points throughout this document.
Classification of IEP services
For the purposes of these guidelines, it is suggested that most (although not all) of the models discussed on the following pages can usefully be classified into one of three types as follows:
- General IEP service - provides a choice of needles and other injecting paraphernalia (usually through pack distribution), and basic advice and information about safer injecting practices. General services undertake a minimal assessment of clients' needs, and provide written and verbal information about other services (including other IEP services), signposting and referral. Examples of general services include: police custody and prison needle replacement schemes; and some community pharmacy and voluntary sector IEP services.
- Enhanced IEP service - provides needles and other injecting paraphernalia and access to in-depth advice and other harm reduction interventions. The latter may be delivered by staff employed within the service, or by a specialist coming into the service. It is expected that enhanced services undertake a more in-depth assessment of clients' needs, and provide consultations in relation to BBV interventions (testing, vaccination) and wound care. They should also provide written and verbal information about other services, signposting and referral. Some hospital-based services, community pharmacies and voluntary sector agencies provide enhanced services.
- Specialist IEP service - a service that provides needles and other injecting paraphernalia, in-depth advice and education, and a wide range of other interventions on-site or through outreach. Specialist services carry out in-depth assessments of clients' needs and provide access to other health and social care services either on-site and through referral. They may be delivered either within the statutory or voluntary sectors. Since specialist services may be considered to be a model of IEP service in their own right, they are described in more detail below, along with their strengths and limitations.
Models which are not covered by this classification system are those which are not delivered by professional staff - i.e., secondary needle distribution and dispensing machines. It is important to note that this classification is not intended to represent a "tiered" classification. Any injecting drug user should be able to have direct access to any of the three types of services. (In a tiered classification, higher-tiered services ordinarily require referral.)
The remainder of this chapter will now look in detail at the various models of IEP services.
Specialist IEP services
What are they?
As mentioned above, specialist IEP services may be either in the statutory or voluntary sector. These services provide injecting equipment, as well as other harm-reduction interventions, either through fixed-site or outreach services. In some cases, a specialist IEP service may be provided within a wider drug treatment or rehabilitation service. Historically, specialist services have been non-pharmacy services and much of the evidence available on specialist and pharmacy services makes a distinction between the two. However, there is now scope for community pharmacies to provide many of the interventions that have traditionally been available only through non-pharmacy specialist services. This potential development will be discussed further in the guidelines, later in this document.
The distinctive feature of a specialist IEP service is the level of interventions it provides. Many specialist services undertake in-depth assessments of their clients' needs, and offer access to a wide range of interventions, including BBV vaccination and testing, in response to those needs. In addition, the provision of needles and other injecting equipment can be tailored to suit the client's needs and preferences. Many specialist services also undertake motivational work with clients and are able to provide in-depth education and advice to reduce the risks associated with injecting.
There are examples throughout Scotland of specialist services offering BBV testing and vaccination, on-site access to primary care and dental clinics, training in overdose prevention, counselling, and other similar interventions. Specialist services are also often involved in providing training and support to other (non-specialist) service providers in their area.
One of the important strengths of specialist services in Scotland is that they appear to be very successful in getting large numbers of needles out to their clients. The National Needle Exchange Survey found that, in the one year period between April 2004 and 2005, there were three times as many pharmacy services as specialist services in Scotland, and pharmacy services had twice as many transactions as specialist services. Nevertheless, in that year, the combined number of needles given out by all specialist services across Scotland substantially exceeded the combined total given out by all pharmacy services. 19
A further strength is the quality of advice and information provided by specialist services. A review of qualitative evidence undertaken for NICE found that injecting drug users rated specialist IEP services based in drug agencies more highly than those in pharmacies for advice and information. 32
One of the limitations of specialist services is the lack of consistency in staff training and qualifications. The National Needle Exchange Survey found that there is currently no standard training for specialist IEP service staff across Scotland. 19 Some services are delivered by highly-qualified staff with formal training in nursing or drug misuse. Others are delivered by unqualified staff who have only received in-house training.
Pharmacy IEP services
What are they?
Pharmacy IEP services are delivered within the premises of community pharmacies. They may be either general or enhanced, and as mentioned above, there is scope for some to become specialist services as well. There are many benefits to basing an IEP service within a pharmacy.
First, the use of community pharmacies can make IEP services more accessible to injecting drug users - both in large cities and in small towns - as the infrastructure is already in place. Providing injecting equipment within a community pharmacy also gives injectors on-site access to a qualified health care practitioner and a full range of NHS pharmaceutical services. The new Scottish pharmacy contract provides considerable opportunities for developing the care of drug users in a community pharmacy context. For example, the electronic Minor Ailments Service (e MAS) allows all patients who are exempt from prescription charges, to access a range of medications and dressings free of charge, directly from the pharmacist.
There are also other practical and cost benefits. The provision of injecting equipment within an existing pharmacy precludes the need to find and fit out new premises and hire staff, with all the expense that would entail. Furthermore, there is no need to obtain planning permission in order to deliver an IEP service within a pharmacy. At the same time, funding from the Scottish Government has allowed many pharmacies to construct consultation rooms that allow for greater confidentiality and privacy when speaking to customers.
In practice, however, community pharmacies are busy places which are used by members of the general public. There is often not the time, and in some pharmacies, there is not the space, to provide in-depth advice and education to injectors. Finally, in most pharmacy services, injecting equipment is provided in pre-packed bundles, and so the extent to which the service can be tailored to client needs and preferences is somewhat limited.
A review undertaken for NICE found evidence that pharmacy-based programmes are popular with injectors and are generally rated more highly than drug-agency-based IEP services for accessibility (both location and opening hours). 32 However, perceptions about staff attitudes and fear of exposure have led to negative feelings about pharmacy IEP services, particularly among women. This same review found evidence that injectors would like greater privacy when collecting needles from pharmacy services.
Some studies in Scotland have found significantly more positive attitudes towards drug users among pharmacists providing an IEP service than among those who do not. 33, 34 However, others have found a wide range of attitudes (both positive and negative) among pharmacy IEP service providers. 31
The National Needle Exchange Survey found that, in some areas of Scotland, IEP service provision is almost exclusively through community pharmacies. 19 However, there can be barriers to pharmacy provision of injecting equipment services. Some of the difficulties include the size and suitability of the premises, a lack of separate consulting areas and a shortage of storage space. 35 In addition, pharmacists themselves may fear that the presence of drug users in the pharmacy will deter other customers - although there is evidence to show that these fears can be in contradiction to the views of customers who are often unaware that the pharmacy is providing drug services.
There are currently more than 1,000 community pharmacies in Scotland; however, only a small proportion (12%) are currently funded to provide injecting equipment services. Therefore, there is considerable potential to make greater use of the pharmacy network for injecting equipment provision, and there is evidence from primary research carried out in Scotland that active local recruitment can increase the participation of pharmacies in IEP service provision. 34 At the same time, consultation with service providers undertaken as part of the National Needle Exchange Survey suggested that it is essential to give on-going training and support to pharmacists and support staff involved in delivering an IEP service. 19
What are they?
"Outreach" is a generic term which may cover a wide variety of IEP services. An outreach service may take the form of a mobile unit (van, bus, etc.), or a backpacking service on the street. Outreach may also be provided through home deliveries or a peripatetic service offered on the premises of another agency such as a health centre on certain days of the week for a few hours each day. Finally, the term outreach may also apply to an IEP service that is delivered out-of-hours to a particular target population, such as a night-time drop-in service for sex workers or a service for users of performance and image-enhancing drugs.
Outreach services are generally delivered by a specialist IEP service provider, and are often targeted at populations of injecting drug users that are difficult to reach through ordinary fixed-site services delivered during day-time working hours.
An Australian review of evidence on effective harm reduction interventions reported that outreach programmes have been shown in that country to promote treatment entry and encourage some degree of change in levels of risk behaviour. 36 In addition, some US studies have indicated that outreach-based education programs were effective in reducing risk behaviours in injectors, including needle sharing and unsafe sex. 37
A review of research on mobile vans found that, compared to fixed site services, mobile vans can provide greater accessibility to injecting equipment over large geographical areas, and at times and in places where coverage is poor. 38 A roving site can also keep staff and clients relatively inconspicuous to neighbours, local businesses and the police. A review of the evidence carried out for NICE reported that mobile vans may attract younger injectors and injectors with higher risk profiles than pharmacy-based services. 6 However, this evidence is based on studies that were all conducted in countries where injecting equipment was usually provided through the pharmacy sale of needles, rather than through free distribution. A review of qualitative evidence carried out for NICE found that mobile services were thought to increase accessibility for clients, but that they could not offer the full range of services available at some fixed site services. 32
There is a lack of published review-level evidence on the cost-effectiveness of outreach in preventing HCV transmission, as compared with other models of IEP services. However, a substantial programme of research on community-based outreach carried out by the US-based National Institute on Drug Abuse ( NIDA) over 15 years, and involving more than 60,000 drug users in 52 communities, concluded that community-based outreach is an effective and cost-effective method for preventing transmission of HIV among out-of-treatment IDUs. 39 In Scotland, focus group participants who took part in the National Needle Exchange Survey suggested that outreach services were more successful than either community pharmacy or fixed-site specialist services in reaching hard-to-reach groups including women, sex workers and homeless injectors. 19
Police custody suite / prison needle replacement schemes
What are they?
When taken into police custody, injecting drug users are required to dispose of any used injecting equipment found on their person. Needle replacement schemes involve providing replacement packs of sterile needles, and returning any sterile equipment to the injector when he / she leaves custody. At the same time, injectors are informed of IEP services and drug treatment services available to them in the area.
Tayside Police in Dundee were the first to pilot needle replacement in Scotland in 2001-02. Following formal evaluation, it was recommended that the scheme be expanded to the whole of the Tayside region. The perceived success of the scheme resulted in similar schemes being rolled out to police forces across Scotland.
Following a successful pilot, the Scottish Prison Service also now provides a needle replacement scheme at reception in several prisons to support the schemes that exist in many police custody suites. This involves offering sterile needles to known injectors when they leave prison.
There is some tentative evidence from Scotland to indicate that police custody suites may be able to reach a group of injectors who are not in contact with other services. An evaluation by Central Scotland police undertaken during the pilot of their own needle replacement scheme in 2003 showed that, within the first 10 months of the scheme, there were 127 needle replacement transactions. One quarter of arrestees who received sterile needles upon release from custody, had never used an IEP service before. 40
In-prison IEP services
What are they?
There are currently no prison-based IEP schemes in Scotland. However, under the Hepatitis C Action Plan, Phase II, there are plans to pilot an in-prison injecting equipment initiative in the Scottish Prison Service as one of a range of harm reduction measures to reduce the transmission of HCV. This initiative is due to be evaluated as part of the Action Plan and is currently in discussion between Government Ministers and prison unions. (See Action 17 of the Hepatitis C Action Plan, Phase II.) 1
The provision of injecting equipment to injectors in prison may be done through a dispensing machine or through a hand-to-hand exchange delivered by a doctor / nurse, a prison official or a harm reduction specialist.
A pilot study of injecting paraphernalia distribution (where prisoners had access to cookers and filters, but not needles and syringes) was carried out in HMP Aberdeen. Following the success of this pilot, it became Scottish Prison Service policy in 2007 to allow the provision of injecting paraphernalia throughout the prison estate, although some prisons have been slow to implement this policy.
Addiction Prevalence Testing carried out by Scottish Prison Service in 2008 found that 64% of people entering prison in Scotland tested positive for illicit drugs, with 34% testing positive for opiate use. 41 Annual prison surveys show that a small proportion (national average = 3%) continue to inject drugs while in prison. 42 However, because of the lack of availability of sterile injecting equipment, the sharing and reuse of injecting equipment is common among this group.
A review undertaken on behalf of NICE found evidence that prison-based IEP programmes in six prisons all had positive results. These included no new cases of HIV, HCV or HBV; and stable or reduced drug use. The authors of this review concluded that prison-based injecting equipment provision was likely to be feasible in small prisons, but there was insufficient evidence to determine the effectiveness of these programmes in larger prisons. 6
A review of qualitative research carried out for NICE found evidence that prison-based IEP services may find support, but also opposition, among both injectors and non-injectors. 32 This review also found that anonymity was seen to be important by injectors in relation to prison-based IEP services.
The Scottish Prison Service carried out its own review of the literature on prison-based IEP services in 2005, and found that there have been 46 prisons in four European countries with IEP schemes in operation for around 10 years. 43 Evaluation of these schemes showed that they resulted in lower transmission rates of HIV and HCV, and no increase in drug use or injecting among prisoners. They also had not interfered with drug prevention strategies within the prison context, and there had been no attacks on staff or other prisoners with injecting equipment since the introduction of the schemes. Five of the schemes identified were no longer in operation at the time of the review. However, those that were discontinued had stopped, not because of problems or lack of success in implementation of the scheme, but rather due to the intervention of politicians. The discontinuation was universally opposed by the staff in those prisons - 85% of whom had initially opposed the introduction of the scheme.
Secondary needle distribution
What is it?
Secondary needle distribution involves the distribution of sterile injecting equipment to one service user, who then redistributes it to others in his / her social network.
The advantage of secondary distribution is that it increases the reach of the IEP service to injectors who might not otherwise access sterile injecting equipment. Services may use the opportunity of secondary exchange to provide in-depth advice and education to the secondary distributor. However, in practice, services have little control over the nature of the secondary transaction, or the advice given out by secondary distributors to others. Furthermore, the distributor may sell the equipment on to others, rather than distributing for free. Where the sale of equipment takes place, it is principally an indication of a lack of adequate service coverage, and the response of services should be to increase equipment availability and supply.
The practice of secondary distribution is highly prevalent among injecting populations. 18,44 Indeed, some injectors prefer secondary distribution. A review of qualitative research carried out for NICE, found that many injectors fear being caught and publicly exposed as drug users (to the police, neighbours or family) and that this can impact upon the use of IEP and other services. 32 Anonymity, confidentiality and convenience are all very important to injectors, and some prefer secondary distribution for this reason - even if it means having to buy needles from another injector.
Women, in particular, can be reluctant to attend IEP services (particularly community pharmacy services) because of concerns about confidentiality and the perceived negative attitudes of staff. 32 As a result, women are more likely than men to obtain injecting equipment through secondary distribution. Younger, or new injectors, also often obtain needles through peers, rather than through an IEP service.
As mentioned above, there are some disadvantages to secondary distribution. In particular, there is little control by IEP services over the advice and information given out by secondary distributors. This can lead to high-risk injecting practices among those taking part in secondary distribution. Some evidence for this comes from a study carried out in California ( USA) which found that injecting risk behaviours were significantly more common among injectors who took part in secondary distribution (either as recipients or as distributors) than non-participants. 44
What are they?
Peer-led distribution of injecting equipment is similar in some ways to secondary distribution, in that it involves one injector (or sometimes, a former injector) distributing sterile injecting equipment to other injectors. The difference is that the peer distributor has been formally trained (and may be formally employed) by an official IEP service provider, to provide accurate advice and information to other injectors.
The advantage of peer-led services is that they increase the reach of the IEP service to injectors not in contact with services, and they provide greater control over the nature of the secondary transactions. The disadvantage is that the training and supervision of peer distributors can be time intensive, and there may be a high turnover of personnel.
A review of qualitative research carried out for NICE found that the use of peers as staff in IEP services increased engagement of clients with the service. 32 However, the recruitment and training of peer staff was said to be time-consuming. Peer-led (and even peer-run) services have been widely used in Australia, particularly among the indigenous population, and are reported to be effective in reaching people who may not be reached by other means. 45,46 An evaluation of an HIV peer-led education intervention in Maryland ( USA) reported positive benefits for peer educators. 47
A review of the literature on educational interventions to prevent HCV found examples from around the world of highly effective incentive-based "peer-driven" schemes, where injectors are given rewards for passing on a specific body of information to members of their social network, and then recruiting those individuals to attend an IEP service where they are given further educational information. 48 A comparison of this intervention with a traditional outreach intervention in Connecticut ( USA) found that both interventions produced significant reductions in self-reported HIV risk behaviours. 49 However, the peer-driven intervention outperformed the traditional intervention with respect to the number of injectors recruited, the ethnic and geographic representativeness of recruits, and the effectiveness of the HIV prevention education. In addition, the costs of recruiting injectors into the intervention and educating them about HIV in the community was only one-thirtieth as much in the peer-driven intervention as in the traditional intervention.
However, an evaluation of a peer-led HIV prevention intervention among gay men (steroid injectors) in London found that there was high turnover among peer educators (only 1 in 5 remained with the project throughout). 50 The intervention also required substantial input from the professional health promotion team - equivalent to one team member devoting 2.5 days a week to recruit, train and support peer educators over 18 months. The conclusion of this study was that peer education should not be viewed as a low-cost approach to prevention.
Needle dispensing machines
What are they?
Needle dispensing machines provide sterile needles and other injecting equipment through an automated machine. The machine may be operated free-of-charge or with a coin or token. If the machine is token-operated, the client is required to obtain tokens in advance from an IEP service.
The machine can be used to exchange new for used equipment, or it can be used to dispense equipment only, with a disposal bin located beside the machine. Dispensing machines can provide greater accessibility at times and places where coverage is poor.
Dispensing machines may be located near to, or on the premises of an existing IEP service to provide access to sterile injecting equipment when the staffed service is closed. Alternatively, they can be located in other areas. In Australia, for example, machines are located outside hospitals, community or sexual health centres and alcohol and drug services, in both urban and rural areas. 36
There are currently no needle dispensing machines available in Scotland. However, dispensing machines have been used in Denmark, Norway, Switzerland, Germany, France, The Netherlands, Austria, Australia and New Zealand. 38
An international review of evidence on dispensing machines found no evidence to indicate that the availability of injecting equipment through dispensing machines led to an increase in drug use or injection frequency, and moreover, the sharing of needles was reduced significantly among individuals who used the machines. 38 This same review found that dispensing machines in France tended to attract younger injectors, those not in treatment and those who inject less frequently, and similarly, dispensing machine users in Berlin were more likely to report a shorter history of injection.
A more recent international review of qualitative research carried out by the same authors, found that dispensing machines increased access to sterile injecting equipment, reduced needle and syringe sharing, and were likely to be cost-efficient. 51 They also complemented other modes of service delivery as they were used by injectors who were less likely to attend staffed IEPs.
Other evaluations of dispensing machines report similarly positive results. An evaluation of a 12-month trial of dispensing machines in one Australian city reported that the machines appeared to be serving both the clients of other IEP services and clients who were reluctant to use other IEP services or who find them inconvenient. 52 A trial in Southampton (England) found that the installation of a dispensing machine outside the main IEP service in that city accounted for an increase of 7% in client transactions during the first four months of its operation. 53
Hospital-based IEP services
What are they?
Hospital-based IEP services are provided within a hospital building and are one way of providing 24-hour access to sterile injecting equipment.
There was little evidence available on the use of hospital-based IEP services. The National Needle Exchange Survey found IEP services were delivered in the Emergency Departments of three hospitals in Scotland, 19 and the use of hospital-based IEP services is common in some areas of Australia. 25
A review carried out for NICE found evidence to show that hospital-based IEP services may increase the accessibility to outpatient services among injectors attending these services. 6
Table 1 below briefly summarises some of the key strengths and limitations of different IEP service models.
Table 1: Key strengths and limitations of different models of IEP services
Specialist IEP services
- In-depth education and advice
- Provision of injecting equipment can be tailored to individual client need
- Able to provide a wide range of interventions
- Option for locating other services on-site
- Lack of consistent training among staff
Community pharmacy IEP services
- Longer (including weekend) hours of operation
- Multiple locations
- Less stigmatising / more anonymous
- Relatively inexpensive
- No planning permission required
- Access to a full range of NHS pharmaceutical services
- Access to qualified health care professional for general health advice
- Generally does not provide a full range of harm reduction interventions, in-depth advice and education (although these may be provided in enhanced services)
- Needles / syringes generally given out in pre-packed bundles rather than tailored to client need
- Can be difficulties with staff attitudes and lack of training / support
Outreach IEP services, including:
Mobile services (eg, bus or van)
- Increases accessibility (ie, the service goes to where the clients are) - particularly useful for covering a large geographic area
- More attractive than fixed-site services for certain hard-to-reach and high-risk groups of injectors
- Potential for in-depth education and advice to be made available
- Relatively inconspicuous to the public
- Depending on the size of the vehicle, may have insufficient space for counselling sessions; arranging referrals; BBV testing; etc.
- If they operate for only a short time at each location, there is a high chance that they will be missed
- Cost and maintenance of the vehicle
- Able to reach hard-to-reach injectors (eg, women in particular)
- Better returns of used injecting equipment
- Safety for staff
- Potentially intrusive for clients
Peripatetic IEP services (provided as part of a wider service,
for example, within a health centre or social work service)
- May attract different groups of injectors
- Improves accessibility in terms of location, time, culture and age group
- Peripatetic services delivered in health centres may improve injectors' access to other primary care services
- Relatively inexpensive
- If they operate for only a short time in a particular location, there is a chance that they will be missed.
Prison / custody suite needle replacement
- Ensures that known injectors have access to sterile injecting equipment and information about local IEP services upon release from custody
- May reach some injectors who are not otherwise in contact with IEP services
- Little or no harm reduction advice given
Prison injecting equipment provision
- Reduces sharing of needles, and other high-risk injecting practices among prisoners
- Can be opposition from politicians, prison staff and prisoners
- Concerns among injectors about anonymity
- Improves reach to groups of injectors who will not (or cannot) use other forms of IEP services
- Lack of control over provision of, or accuracy of, harm reduction advice and information to recipients
- Continued high-risk injecting behaviour
- Peer knowledge of drugs and drug use
- Improves reach to groups of injectors who will not (or cannot) use other forms of IEP services
- May provide education, employment skills and income for peer distributors
- Convenient / accessible for clients
- Peers have credibility and can be important role models
- Training / supervising of peers can be costly
- Conflicting identities as peer worker and injector
- High turnover of peer workers
- 24-hour access
- Location can be wherever the need requires
- Convenient and easy to use
- Limited staffing required
- No face-to-face education or advice can be provided
- No way to regulate access to the machine (by under-16s for example), unless a token system is used
- Difficult to maintain anonymity when located in a public place
- Potential for public opposition
Hospital-based IEP services
- Can be opposition from hospital staff