5. National Mission: An outcomes focussed approach
These six outcomes articulate what is needed to reduce deaths and improve lives. They demonstrate the complexity of the challenge we face and the need for a whole systems approach. These outcomes (together with the priorities) will underpin the design and delivery of our work.
5.1 Outcome 1 – Fewer people develop problem drug use
Prevention where possible is the best intervention and is a vital part of the National Mission. Our approach to prevention sits within the government's wider commitment to address inequalities and the wider social determinants of health. Our specific approach to prevention includes work with young people, providing early access to support and addressing supply of harmful drugs.
We are partnering with Public Health Scotland to establish a national approach to substance use and harm prevention that incorporates drugs, alcohol and tobacco. This will provide an agreed, evidence based approach to preventing problem drug use. When this work is concluded, we will work with Public Health Scotland (PHS) to implement the findings across the system, recognising that effective prevention requires a whole-systems response.
In response to increasing drug harms among young people we have brought together a working group of experts from drug services and young people's services to establish a set of treatment and care standards. We are co-producing these standards with young people, putting lived experience at the heart of this work and ensuring that the needs of young people are met. The standards will ensure every young person has local access to consistent and high quality treatment services when problems start to emerge, instead of when they are in crisis.
Stopping the demand for drugs is an important element of the National Mission and supply also needs to be addressed. Many of the illicit substances found on our streets are produced using industrial pill presses. Government will continue to engage with the UK government to push for the introduction of legislation to curtail illicit usage of these presses.
Police Scotland will continue working with agencies in Scotland, the UK and internationally to take illegal substances off Scotland's streets and to dismantle the groups responsible.
5.2 Outcome 2 – Risk is reduced for people who take harmful drugs
People are entitled to support that reduces the harms associated with drug use regardless of where they are on their recovery journey. This includes promoting safer drug consumption practices, preventing overdoses as well as reducing risks when they do occur and addressing the harms caused by injecting drug use such as blood borne viruses and injection site injuries. Access to harm reduction is a core part of the Medication Assisted Treatment Standards alongside dedicated strands of work in this area.
The Scottish Government is committed to increasing the distribution and availability of naloxone: a medicine that can temporarily reverse the effects of an opioid overdose and therefore has the power to save lives. Earlier this year we agreed implementation plans with Police Scotland and Scottish Ambulance Service to equip their emergency workers with naloxone. Scottish Fire and Rescue Service (SFRS) are also rolling out the carriage of intranasal naloxone, supported by Scottish Government. In addition to emergency workers, we are also working with partners to increase peer to peer distribution of the medicine, with a greater focus on prisons.
Non-Fatal Overdose Pathways and outreach work are crucial to connect people to the right services. We will continue to ensure services across Scotland expand near-fatal overdose pathways. We know how important it is that every opportunity is taken to provide immediate support at the time of a near-fatal overdose. We also know that community-based drug outreach programmes are well placed to quickly usher patients toward treatment and we will continue our work to support them in doing so.
Safer consumption facilities are designed to prevent drug overdoses and reduce harms from drug use, and have shown strong efficacy in other jurisdictions. We will continue to work with partners, including the Crown Office and Procurator Fiscal Service (COPFS) and Police Scotland, to examine how a safer drug consumption facility could operate within the existing legal framework, focusing on how any such facility would operate and be policed.
Heroin Assisted Treatment involves the provision of a heroin substitute, diamorphine, under supervised conditions to people with longstanding problem substance use. There is a strong body of evidence that supports the effectiveness of heroin assisted treatment or "HAT" services which have been shown to reduce the use of street drugs and to increase the likelihood of individuals remaining in treatment.
Scotland's first HAT service opened in Glasgow in 2019 and while still only available to a relatively small group of people, we have committed further funding of £400,000 to scale up the provision of HAT to make it more widely available to people across Scotland.
ODART is a project aimed at developing technological solutions to reduce drug overdoses. It includes work to identify potential overdoses using technology and a function to alert first responders when it detects a possible overdose.
5.3 Outcomes 3 & 4 – People at most risk have access to treatment and recovery & people receive high quality treatment and recovery services
Evidence has shown that treatment is a protective factor against drug-related deaths and harms. There is also evidence to suggest that nearly half of people at risk of a drug death are not accessing the treatment they need. It is vital that we promote a recovery orientated system of care and get more people in to the treatment they need by making sure services are accessible and effective.
The Medication Assisted Treatment Standards (MAT) were published in May 2021 and are evidence-based standards to enable the consistent delivery of safe, accessible, high-quality drug treatment across Scotland. The ten standards reinforce a rights-based approach for people who use drugs and the treatment they should expect, regardless of their circumstances or where they are.
A significant proportion of those people who seek support for problem drug use do so through MAT. So these standards play a vital role in achieving our aims and vision – particularly around having access to treatment and recovery, receiving high-quality services, and improving quality of life.
Alongside an additional £10 million per year for local services to roll out these standards, the Government has set up a multi-disciplinary implementation support team lead by PHS, which provides direct help to local services to deliver change and continuous improvement. The support team is helping local areas implement these standards as quickly as possible, focusing initially on getting a consistent level of care across standards 1 – 5 in particular.
Ministers set areas an ambitious target to embed the standards by April 2022 and continue to set high ambitions to implement at pace. This is the beginning of a continuous improvement process which aims to achieve sustainable, ongoing quality of care for those most at risk of drug harms and drug death.
Figure 3: Medication Assisted Treatment Standards
The MAT Standards are ten evidence based standards to enable the consistent delivery of safe, accessible, high-quality drug treatment across Scotland. They focus on how treatment is offered and take a person centred approach contributing to a number of our outcomes (2, 3, 4 and 5)
1. All people accessing services have the option to start MAT from the same day of presentation.
2. All people are supported to make an informed choice on what medication to use for MAT, and the appropriate dose.
3. All people at high risk of drug-related harm are proactively identified and offered support to commence or continue MAT.
4. All people are offered evidence based harm reduction at the point of MAT delivery.
5. All people will receive support to remain in treatment for as long as requested.
6. The system that provides MAT is psychologically informed (tier 1); routinely delivers evidence-based low intensity psychosocial interventions (tier 2); and supports individuals to grow social networks.
7. All people have the option of MAT shared with Primary Care.
8. All people have access to independent advocacy and support for housing, welfare and income needs.
9. All people with co-occurring drug use and mental health difficulties can receive mental health care at the point of MAT delivery.
10. All people receive trauma informed care.
In parallel to MAT, we are undertaking a programme of work to develop models of care at a national level to deliver drug treatment within primary care. The models of care will support the implementation of Medication Assisted Treatment (MAT) Standard 7 – all people have the option of MAT shared with Primary Care. This will be support by work to increase the number of GP practices that deliver integrated drug treatment services.
By 2024, we aim to increase the number of people who are prescribed community-based Opioid Substitution Therapy or "OST" treatment to 32,000. An increase of approximately 9%. All people accessing services have the option to start MAT from the same day of presentation.
We have also announced a treatment target for opioid substitution therapy (OST). By 2024, we aim to increase the number of people who are prescribed community-based Opioid Substitution Therapy or "OST" treatment to 32,000 an increase of approximately 9% (2,500). This will be delivered by local authorities. We also intend to expand and stretch this target to include all people with problem drug and alcohol use from 2024.
In 2021 we set a target to increase the number of statutory funded residential rehab placements by 300% so that by 2026 at least 1,000 people every year would be publicly funded for their placement.
The government is committed to improving access to a range of evidence-based prevention, treatment and recovery services across the country. A key part of this commitment is increasing the provision of residential rehabilitation. Government has committed £100 million over the life of the National Mission to expand access to this service. Through this work we aim to increase the number of statutory funded residential rehab placements by 300% over the next five years. This means that in 2026 at least 1,000 people every year would be publicly funded for their placement.
This extensive programme of work includes capital funding for new rehabilitation facilities (£18 million over five years), funding to ADPs to support placements and pathways (£5 million per year), supporting commissioning of services, grassroots funding and working in partnership with Health Improvement Scotland (HIS) to improve pathways in, through and out of residential rehabilitation.
More generally, we will increase the number of people in treatment by working with prisons to ensure inmates have access to treatment and supporting the Digital Lifelines Scotland initiative that aims to design better ways for people to access the support they need. The digital lifelines group involves members of the Drug Deaths Taskforce, Drugs Research Network Scotland and ODART. The group has already launched initiatives to make mobile devices available to people leaving hospitals and prisons, for example. This helps people in key times of transition to remain in touch with services (such as web-chat services which provide advice brief interventions and sign-posting), and in touch with peers. Social contact is a vital part of treatment and recovery. This service will be expanded over the life of the National Mission.
This is also closely linked to a new initiative being run through the Scottish Health in Partnership group, led by and funded through the Chief Scientist's Office which brings together academics and industry in Scotland to develop new technologies to help support people at risk of drugs harm. Work on this began in late 2021 and there will be technological innovations introduced during the life of the National Mission as a result.
5.4 Outcome 5 – Quality of life is improved to address multiple disadvantages
We know that many people with drug problems have complex needs or comorbidities, and therefore require support from a wide range of services. In too many instances people with drug problems are confronted by services that do not communicate with each other. The MAT Standards emphasise the importance of allowing people to make informed choices about the type of medication and help available to them. This includes access to independent advocacy and support for housing, welfare and income needs (MAT Standard 8) and work is going on across government to ensure we get it right for everyone.
Many people who use drugs may also have difficulties in securing long-term housing. The Scottish Government will continue to encourage a Housing First approach for those with problem drug use and support those leaving institutions to find accommodation (such as prison and care leavers).
The Ending Homelessness Together plan (2020) is the Scottish Government's plan to end homelessness and rough sleeping. The plan sets out a commitment to learn from the Covid-19 response and to further improve drug services. This includes partnership working between Public Health Scotland, COSLA and local authorities to support implementation of the housing, health and social care actions in this plan. Public Health Scotland will also join forces with health and social care partnerships to explore what further contribution can be made to tackling and preventing homelessness, including through the equivalent of housing contribution statements where appropriate.
We have also commissioned a rapid review of mental health services that will set out the needs of people who experience these problems, review existing provision and provide recommendations about how we can best support people who experience these problems. This will be published in Autumn 2022.
The rapid review will support other work such as implementation of the MAT Standards and the work of Healthcare Improvement Scotland who are working with five Health Board areas (Tayside, Lothian Grampian, Greater Glasgow and Clyde, Lanarkshire) to establish integrated pathways of support for people who experience mental health and substance use problems. This work will engage clinicians and people with lived experience in improving access to effective mental health and substance use services.
The Mental Health Strategy has specific actions on how to take a person-centred approach to care. This includes pilots to find improved arrangements for dual diagnosis of substance use and mental health disorders, and better assessment and referral processes.
People with drug problems – particularly those who have used drugs for many years – often have complex physical health conditions and we need to ensure that health services take a holistic approach to care. We are working with PHS to map the different models for providing drug treatment within primary care across Scotland and the UK. These will be published at the end of this year and will inform the implementation of MAT Standard 7 – All people have the option of MAT shared with Primary Care.
A revised community justice strategy is currently being developed with aims to publish by summer 2022. This will build on work already done to ensure that third sector interventions are available for those who use drugs.
The Health and Justice Collaboration Board meets with the aim of providing strategic leadership to accelerate progress on issues where health and justice systems intersect, and is currently focused on improving front line response to those at risk of drug harms and drug deaths and delivery of the National Mission to reduce drug deaths.
Improved integration between services is needed to address complex and multiple needs. The National Care Service (NCS) will fundamentally reform the health and social care system in Scotland, including addiction services. The National Mission will align with the principles of the NCS and oversee the transition to a new model of care.
5.5 Outcome 6 – Children, families and communities affected by substance use are supported
The use of drugs by a loved one can cause untold hardship and trauma to families. Families require dedicated support to empower them and allow them to support the recovery of their loved one. They also need access to services to enable their own recovery. We also know the traumatic impact parental drug use can have on children and the risk that drug use becomes intergenerational. Robust interventions are required to ensure we get it right for every child.
In December 2021, we published 'Families Affected by Drug and Alcohol Use in Scotland: A Framework for Holistic Whole Family Approaches and Family Inclusive Practice.' Developed in partnership with a range of stakeholders, this framework sets out principles of how we will improve holistic support for families affected by drugs and alcohol by taking a whole family approach and using family inclusive practice. This is aligned to the Government-wide programme of work to improve support for children and families, such as The Promise, Getting It Right For Every Child, the National Framework Principles of Holistic Whole Family Support and the Whole Family Wellbeing Fund.
Since publication, we have been working with a multi-disciplinary group to support local areas to implement the framework. This implementation support will continue in the coming years as we continuously support local areas to improve their family support and embed family inclusive practice.
Our progress towards outcome will also be delivered through the government's approach to tackling child poverty, child protection, supporting children in care, and improving employability among those recovering from drug use.
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