Rights, respect and recovery: alcohol and drug treatment strategy

Chapter 7: A Public Health Approach to Justice

Outcome: Vulnerable people are diverted from the justice system wherever possible and those within justice settings are fully supported.

Commitments to achieve the outcome
Ensure that people who come into contact with justice agencies are provided with the right support from appropriate services.	J1
Pro-actively review local services in prisons to ensure they meet the new Inspecting and Monitoring Standards for Health and Wellbeing.	J2
Support the work of Police Scotland, to ensure that those groups involved in drug dealing or distribution are being effectively targeted for prosecution.	J3
The Scottish Government will set up a group to advise Health Ministers on the contribution and limitations of the Misuse of Drugs Act 1971 in support of health outcomes in Scotland.	J4

Introduction

1. The publication of the Community Justice Strategy in 2016 introduced a new model for community justice which brings together “individuals, agencies and services that work together to support, manage and supervise people who have committed offences, from the point of arrest, through prosecution, community disposal or custody and alternatives to these, until they are re-integrated into the community”^[97].

2. It is a preventative strategy which recognises the relationship between problem alcohol and drug use and community justice, encouraging those partners involved in delivering the strategy to focus on improving health and wellbeing and reducing inequalities as an approach to reducing offending.

3. Diverting those with problematic alcohol and drug use away from the justice system and into treatment, support, and other interventions that reduce harm and preserve life, is an aim of justice and health partners. However, depending on the circumstances of individual cases, including the impact on victims, prosecution will be in the public interest. It is for the Lord Advocate alone as independent public prosecutor to set prosecution policy, including policy on diversion in appropriate cases.

4. People with alcohol and drug problems are far more likely than average to come into contact with our justice system. In, addition, they typically have high rates of mental health problems and other long-term conditions, as well as problematic alcohol and drug use and may have experienced trauma as children or adults.

Furthermore, they disproportionately come from the most disadvantaged communities in Scotland. In many instances the criminalisation of this group of people only presents further challenges and risk of harm and life.

5. To facilitate partnership working, the Scottish Government has established the Health and Justice Collaboration Improvement Board^[98], bringing together senior public sector leaders from across Health and Justice organisations to provide strategic leadership on issues where health and justice systems intersect. The Board is focusing on improving the service response in three priority areas: where people in mental distress present to the police; health and social care in prisons; and healthcare and forensic medical services for victims of rape and sexual assault.

Police Engagement

6. The role of the police has changed, and while it is still important that there remains a focus on the tackling of serious organised crime groups, there is now a recognition that these groups often exploit our most deprived (and neglected) communities and through their activities supply illegal drugs. Police Scotland have committed to delivering a more targeted response, through a Contact Assessment Model. This model will ensure that a robust assessment of risk and vulnerability is undertaken when deployment decisions are made, ensuring a person-centred response.

7. We also welcome work being undertaken by Police Scotland to change the way they engage with people associated with problematic alcohol and drug use (alongside other criminal behaviour). Examples include: working with recovery communities and national organisations to explore ways to better deal with drug related deaths, including how they engage with the family of the recently deceased and the offer of bereavement support.

Delivering the outcome

Diverting vulnerable people away from criminal justice and into treatment

8. A public health approach means focusing our community justice response on improving health and wellbeing, reducing inequalities and reducing crime. This means that where appropriate, we must focus on diverting vulnerable people away from the justice system and into treatment and support.

9. Where possible, this support should be provided in the community where most people’s support networks will already exist. This includes their family, support from others in recovery, treatment services, and other community based support which can help people to change their behaviour and reduce the harm that both they and their communities experience. The approach needs to provide these opportunities along the community justice pathway, before arrest, police custody, sentencing and prison and back into the community.

10. The police regularly come into contact with people with alcohol and drug problems, often in challenging situations. These contacts can offer useful opportunities to divert people into treatment and provide them with other interventions that would reduce harm, reduce offending and preserve life. Making use of these opportunities demonstrates a clear commitment to Scotland’s public health approach and is aligned to the police’s key function which is to preserve life.

11. The Recorded Police Warning (RPW) Scheme provides police officers with an alternative disposal option for those found in possession of small quantities of specified controlled drugs. The scheme exists under the authority of the Lord Advocate, rather than the Scottish Ministers, as part of the Lord Advocate’s constitutional responsibility for prosecuting and investigating crime. The scheme provides the police with a timely and proportionate response, in accordance with guidance from the Lord Advocate, as an alternative to arrest in appropriate cases.

Diversion at the point of arrest

12. In 2017/18 people were taken into police custody in Scotland on 130,749 occasions^[99]. Research suggests that a third of people in police custody have hazardous alcohol intake or are alcohol dependent, with between 11% and 35% dependent on a range of substances including cannabis and heroin^[100].

13. Healthcare provision in police custody is now the responsibility of Integrated Joint Boards or (where still appropriate) NHS Boards. The Police Care Network’s guidance on ‘Delivering Quality Alcohol, Drugs and Tobacco Healthcare Services to People in Police Custody in Scotland’^[101] sets out an evidence informed model of care for people coming into police custody who use alcohol and drugs.

14. This includes a clinical needs assessment which meets the person’s immediate healthcare needs and health improvement interventions such as the delivery of alcohol brief interventions, overdose prevention advice and the provision of take home Naloxone. Work is being done with a wide range of partners to provide in-reach services into police custody and/or referral to other health, social and third sector services where appropriate.

15. Historically, arrest referral has played a key role in supporting people who have been arrested or attending court to access community treatment and recovery services. However, more integrated approaches are developing across Scotland including the Custody Hubs approach led by Police Scotland. This recognises that people who have alcohol and drug problems, and are in contact with the justice system, are likely to have a range of needs, such as mental health problems and homelessness, which cannot be met by treatment services alone.

The Scottish Government will work with key partners to ensure that people who come into contact with justice agencies are provided with the right support from appropriate services. (J1)

Diversion at the point of sentencing

16. There are a range of sentencing options, including Community Payback Orders (CPOs), Drug Treatment and Testing Orders (DTTOs), and Alcohol Treatment and Testing Orders (ATTOs), which provide alternatives to custodial sentences. Evidence suggests that DTTO’s, can have a positive impact on both drug use and offending with even non-completers demonstrating reduced reconviction rates. Individuals released from a custodial sentence of 12 months or less are reconvicted nearly twice as often as those given a CPO^[102]. A shortened form of DTTO can be particularly effective for women offenders, young offenders, and those who have had no previous contact with drug services^[103].

17. Conversely, there is evidence to suggest that custodial sentences can place people with alcohol and drug problems at greater risk of harm. We know, for example that individuals leaving prison who are currently or previously dependent on opiates are at a higher risk of overdose, therefore the provision of take-home Naloxone is imperative. There is also a recognition of the dangers to health and increasing alcohol and drug use relating to unsupported liberation.

Healthcare delivery in prisons

18. Compared to the average rates in society, there are higher rates of problem alcohol and drug use amongst the prison population. The 2017 Scottish Prisoner Survey^[104] revealed that 38% of people in prison stated their drug use was a problem for them on the outside and one-third of people in prisons admitted that their drinking affected their relationship with their family. Alongside this, positive testing for illicit drugs at reception in prisons remains high, with sampling in 2017/18 finding that 78% of people who are in prison test positive for illicit substances, with 28% of people testing positive for illicit opioids,

19. Our public health approach should ensure that every opportunity is taken in the prison setting to ensure people with problem alcohol and drug use are identified and are offered appropriate treatment and support.

20. Accountability arrangements for the delivery of alcohol and drug treatment services within the prison are complex. Health and social care services in prisons are delegated to Integration Authorities (IAs) for health and social care in many areas of Scotland.

21. However, the Scottish Prison Service retains the responsibility for overseeing the general welfare of individuals within the prison. The ethos behind these arrangements is to ensure parity of healthcare services within the prison and equivalent services within the local community.

22. Healthcare services in prison, including alcohol and drug services, should be of equal quality to those delivered in a community setting. This does not necessarily mean identical services, but equity of access to services appropriate to patient’s needs. Services in prisons should also have close links to community services in order to improve continuity of care for individuals in prison.

23. IA and Health Boards are expected to work collaboratively with the Scottish Prison Service and wider partners at both a strategic and operational level and to share good practice and provide a coordinated approach to the delivery of prison healthcare across prison estates. Community Justice Social Work are responsible for prison throughcare services for those who returning to their local area.

24. Every opportunity needs to be taken to ensure people who need treatment are identified and are offered effective support. Survey data reports that around a quarter of people in prison said they have been offered alcohol or drug treatment services, with 25% and 14% accessing alcohol and drug services respectively during their sentence. However, over 80% of those who accessed treatment stated that they found it useful^[105].

25. In terms of the treatment of opiate and other dependencies, treatment services should ensure the continuity of provision of OST and other medication therapy from the community to the prison and where possible initiate OST within clinical guidelines^[106].

26. Those with alcohol problems are likely to have been detoxed at the point of admission and our focus must be the provision of psychosocial support. This approach needs to apply to both remand and sentenced prisoners. Further work is needed to better understand what would be required to improve access to alcohol and drug treatment within prisons.

27. There also needs to be a focus on continuous improvement within treatment services, in line with developments within the community. An inspection regime for prison healthcare services is already in place and set out in Inspecting and Monitoring Prisons in Scotland^[107], including standards for Health and Wellbeing in prisons. This includes specific standards for the provision of alcohol and drug services.

28. IAs and Health Boards should ensure that alcohol and drug treatment services work within the Drug Misuse and Dependence – UK Guidelines on Clinical Management and also ensure their delivery is in line with the National Prisoner Healthcare Network’s Drugs, Alcohol and Tobacco Health Services in Scottish Prisons: Guidance for Quality Service Delivery^[108] which reviews current service delivery and best practice.

Health and justice partners will work together to pro-actively review local services in prisons to ensure they meet the new Inspecting and Monitoring Standards for Health and Wellbeing. (J2)

Particular issues for remand prisoners

29. The Scottish Parliament’s Justice Committee inquiry into the use of remand^[109] notes that those remanded in custody face challenges in terms of service continuity, including the continuity of relationships with individual workers and access to medication. This suggests remand is a challenging environment in which to provide alcohol and drug treatment and also that access to these services and other harm reduction initiatives needs to be improved.

30. Fifty percent of men and thirty percent of women remanded in custody will go on to receive custodial sentences. Given the heightened risk around overdose and other harms that people with opiate problems encounter, the focus must be on ensuring that they receive harm reduction interventions particularly around safer injecting, overdose prevention and the provision of take-home Naloxone.

31. People with alcohol and drug problems must receive continuity of care between prison and community services.

32. We will work with the third sector to assess the viability of providing navigators/link workers/throughcare support specifically targeted at the remand population, with an aim to using a period of remand as an opportunity to engage with patients and strengthen their links to community services.

Throughcare

33. The period immediately after release from prison is known to be a period with greater risk of harm or death for people who use opiates^[110] and possibly for people using other drugs and alcohol. Currently, all prisoners whose sentence is longer than four years are required to leave prison under the supervision of Community Justice Social Work. Those whose sentence is less than four years have voluntary access to throughcare services.

34. The period immediately after release from prison is known to be a period with greater risk of harm and death for people who use opiates and possibly for people using other drugs and alcohol. Currently all people who are in prison whose sentence is longer than four years, or are subject to specific post-release orders, are required to be supervised by Community Justice Social Work officials after their release. However, this engagement focuses on supervision, to ensure that they comply with the license conditions set by the court. Individuals released from a sentence of less than four years are required by be supervised, but can access a range of voluntary through-care services. Any support and guidance provided, either under mandatory or voluntary services, can help to signpost and engage individuals into appropriate health, mental health, drugs and alcohol support provision in the community.

35. Throughcare Services can not replace the delivery of the appropriate support services. Across the custody and community justice sectors, our approach needs to be proactive, and ensure that individuals engage with the necessary health, alcohol and drug services, before, during and after their release, within a appropriate time frame. This needs to be part of a joined up approach including the Prison, Criminal Justice Social Work, health, wider public sector and third sector to respond to each individuals needs in a planned and co-ordinated way.

36. Specific focus should be given to any medical treatment, such as OST. People should also be made aware of, and proactively supported to access, services including needle exchange services, mutual aid and other health and social care support services in the local area to which they are returning.

37. In 2016-17, 700 take-home Naloxone kits were issued to people on release from prison to help prevent harm, including drug deaths associated with overdose, following liberation from prison.

38. Healthcare services in prisons and the Scottish Prison Service will ensure that all those at risk of an opiate overdose are issued with take-home Naloxone kits on their release from prison.

Workforce development

39. Workforce development and training for prison officers to support people who are in prison with problematic alcohol and drug use to achieve their goals is essential. While health care is delivered by NHS Colleagues, it is recognised that prisoners may have opportunities to develop positive relationships with prison officers and, therefore, it is necessary that we ensure training opportunities to Scottish Prison Service staff are available as part of local recovery oriented systems of care.

Family link

40. Incarceration of a loved one impacts on the whole family but it also offers an opportunity to engage with family members of those in prison through family visitor centres and provide support and advice around their loved ones alcohol and drug use.

41. Prisons provide family centres where there is an opportunity to identify needs and refer on as appropriate. This may include referral on to support in the community or may be specific support for those whose family member is in prison.

Reducing the supply of illegal drugs

Links to serious and organised crime

42. Police Scotland lead the response to controlling the supply of illegal drugs. Our approach is set out in the Serious Organised Crime (SOC) Strategy^[111] published in 2015, which focuses on four areas: Divert, Deter, Detect, Disrupt. The strategy highlighted that 65% of SOC groups in Scotland are involved in drug crime, with heroin being the most common ‘commodity’.

43. There have also been improvements in the gathering and sharing of intelligence and in the work to analyse and map the threat posed by organised crime groups in Scotland, all with the goal of supporting more sophisticated detection and disruption of these groups. This has been supported through the opening of the Scottish Crime Campus; joint working with the UK Government to strengthen the Proceeds of Crime Act^[112] (2002); and the introduction of the Serious Crime Act^[113] (2015) which included the introduction of confiscation orders to enhance deterrence.

Online supply

44. The internet and digital communication have significantly changed the drugs supply chain, from the use of the internet and dark web by bulk manufacturers to the use of mobile phone technology by local suppliers. It has contributed to the accelerated pace of development and distribution of new substances and allowed markets to be reached beyond traditional geographic and socio-economic boundaries^[114]. This has required changes to how drug markets are controlled, particularly when UK legislation cannot be applied.

45. The Organised Crime Unit will carry out regular updated analysis of the current Scottish drug markets, including internet supply, to support our understanding of challenges and harm.

The Scottish Government will support the work of Police Scotland, to ensure that those groups involved in drug dealing or distribution are being effectively targeted for prosecution. (J3)

46. Recognising that there are limitations, in relation to public health outcomes, associated with the Misuse of Drugs Act (1971), there is a need for a piece of work which would examine the links between the law relating to illegal drugs, and the prevention and treatment of drug harm.

47. The creation of a group to provide advice to Health Ministers on those links, as well as to advise on how the evidence suggests further devolved powers might be used in the future to maximise partnership working across justice and health and social care, to reduce harm and support care, treatment and recovery, seems appropriate. The aim of this group would be to develop our understanding and build an evidence base so that future debate on this topic is well informed, therefore, ensuring that any decisions regarding legislation on the use and classification of drugs, as it affects the people of Scotland, are made giving full consideration to public health outcomes.

The Scottish Government will set up a group to advise Health Ministers on the contribution and limitations of the Misuse of Drugs Act (1971) in support of health outcomes in Scotland. (J4)