Social Inclusion, Housing and Voluntary Sector Committee, 26 Jun 2000

Meeting date: Monday, June 26, 2000

Official Report 305KB pdf

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Drugs Inquiry

I welcome Chris Spry, chair of the greater Glasgow drug action team. I apologise sincerely for keeping you waiting—we had matters to deal with. Mr Spry and the DAT staff have been very helpful in assisting us with the inquiry and our visits and we much appreciate their co-operation and advice.

I am chief executive of Greater Glasgow Health Board and have chaired the greater Glasgow drug action team since February 1997. The drug action team is probably the single most difficult thing that I do, and I spend more of my time on it than on any other issue I deal with—although I do not spend enough time on it.

Drug action teams are difficult entities, but if they did not exist they would have to be invented. Wherever you draw the organisational lines, you have interfaces, overlaps and gaps that must be addressed. If a single agency was trying to provide specialist services, prevention and so on, you would still need to deal with the lines between different agencies—between social work and education, social work and primary care, primary care and mental health, and so on. So I think drug action teams are crucial, but it is difficult to make them work well.

Why is that? As the evidence that the committee has taken over the past few weeks has revealed, this is one of those truly wicked problems. It is complicated and difficult to understand, and every time we think that we are getting somewhere and understanding some dimension of it, we realise that it has changed, or that we have peeled another layer off the onion and it looks rather different. Understanding the scale and the nature of the problems is a major difficulty. At the end of drug action team meetings, I am usually pretty intellectually exhausted by the difficulty of what we have been grappling with. That is partly a result of trying to understand the scale and nature of the problem.

There are huge gaps in our knowledge of what works, especially in education and prevention but also in relation to the effectiveness of detox and rehab regimes. There are big tensions between trying to offer a strategic response to the problem, which is connected in all sorts of ways with other issues of social exclusion and so on, and dealing with the crisis situation that we face today.

Making effective links between agencies is difficult, as they have different budget cycles and different decision-making mechanisms. There is a plethora of initiatives and programmes, and we are bedevilled by short-term funding. The fact that money comes forward in dribs and drabs and in unco-ordinated ways makes it difficult to put together a long-range plan that we can be confident of unfolding over a particular time scale. Instead, things happen in bursts—when a bit of money comes into the system, everyone is galvanised into trying to use it, but because the funding is often short term, we are nervous about doing things that will fall about our ears in three years' time. There are also different degrees of corporate and top-level commitment from the agencies involved. It is difficult to make effective links between agencies, because different agencies have different cultures.

It is necessary to sustain energy in peeling away the layers of the onion. We never get to the point of thinking that we are on top of the problem and that all we have to do is carry on as we are. We have to keep at it, and not feel that it is all just too much and racing away from us.

Two years ago, when I had been chairing the greater Glasgow DAT for a year, we were still preoccupied with working through the complexities of a DAT on which the health board, the police and several local authorities were represented. We were trying to work out how to get the balance right between different local authorities, how to make effective links with councillors and so on. We had the option of going down the path that has been gone down in several other parts of Scotland and setting up separate drug action teams for each local authority area. We were also grappling with the rather sterile politics of harm reduction versus abstinence, which was absorbing a lot of the energy of DAT members.

Now our preoccupation is training and employment, which is a massive issue. It is clear to us that rehabilitation will be difficult to achieve as long as finding training and employment opportunities for users is so difficult. We are also grappling with the tension between long-term and short-term approaches.

We are beginning to address issues of equity of access to services. We want to create synergies with social inclusion partnerships and encourage through-care with prisons. Issues remain about security of funding: too many of our services are reliant on short-term funding and are uneasily aware that, when that funding drops out, either the health board or the council will have a problem about how to sustain services. We are dealing with a much bigger set of issues than seemed to be the case two years ago. The DAT is much more sophisticated than it was and deals with more interlocking issues. Collectively, we are more conscious of how difficult the challenges are.

Thank you; that was interesting.

We are getting a lot of evidence—from your organisation and from our visits—that shows that the scale of the problem is changing. I want to explore the impact of the increased use of heroin. We have an interest in deprivation issues and are examining the effect of heroin use on social inclusion issues.

What is happening in communities? What is the scale of the problem?

I am not an expert on patterns of drug usage. My contribution to the DAT is in driving forward the group of agencies as one. I do not sit in the chair pretending to be the world's greatest expert on drugs. I might not give you a reliable answer.

I am asking about the DAT's view as much as about the detail. Is heroin the major problem?

Undoubtedly. Heroin is the major problem by a mile. It is usually used in conjunction with drugs such as temazepam and diazepam, and is implicated in the most serious of drug problems. The DAT is focused on heroin, in terms of treatment. We are not conscious yet of having to deal with problems arising from cocaine. Cannabis gets dealt with on the educational side—we try to encourage young children not to get into addictive behaviour.

We are aware that many communities feel that enough is enough and that they want to take action, but are not sure what action to take. We know that they are frustrated with the system and doubt the ability of the criminal justice system, social work, primary care and so on to respond appropriately. The DAT has put a lot of work into building links with local communities.

I want to pursue that point. There seems to be a mismatch between the expectations of the communities and the expectations of the services as to how the issues can be resolved. There have been debates around the location of needle exchanges and so on. How does the DAT communicate with communities that are struggling, and gain an understanding of what they are experiencing? How can we develop services in the face of community opposition?

We have tended to work through local drugs forums, but—because of Glasgow's size—there are a lot of them. Some issues need additional support—from me, or from a senior person in the police. For example, we did a lot of work on that recent problem in Cranhill. We have had meetings in the Gorbals recently to deal with people's concerns about drug users congregating around chemists shops and so on.

We are conscious that there is a growing cohort of drug users—people are coming on to drugs and having a drug problem much faster than we can get them off. The natural history of addiction is measured in decades rather than years. That growing cohort means that it is difficult to deal with people where they live in ways that are socially unobtrusive, if you know what I mean.

Yes.

That is a problem for us, and we are not sure that we know quite how to handle it. We are worried about the burden on chemists shops and the impact on shopping areas. We will have to think of different ways of handling that.

I understand that the methadone programme in Glasgow has attracted praise and is regarded throughout the country as successful. Some people strongly support the methadone programme, but some general practitioners are quite resistant. How big is the resistance, and how do you deal with it?

I am not sure that it is resistance; it is more a reluctance to get involved.

Do GPs have that privilege these days?

Yes, they do. Taking part in the methadone programme imposes certain duties on GPs in terms of record keeping, providing us with data, and working with social work services to provide additional counselling support for the drug users. GPs are specially remunerated for their participation in the methadone programme, so it is not seen as part of their normal contract. But do not get me on to GP contracts, or we will be here all afternoon.

Participation in methadone programmes is voluntary. Many GPs regard dealing with difficult users as burdensome—some even find it threatening—and therefore choose not to take part. That is another problem that we face.

What can you do about that problem? What are your options?

One option is to continue with local encouragement. Another is to work with local health care co-operatives—we may be able to develop a plan with a co-op, whereas we may not be able to do so with a particular practice. Another option is to review the remuneration package for GPs. Those are the sorts of levers that we have, but options are limited.

We have been strengthening mental health services for drug users. GPs often have problems with the turbulent drug user who is very difficult to deal with. Sometimes, there is an undercurrent of violence, which can be associated with a mental illness. By strengthening mental illness services for drug users, we may be able to help to ease some of the burden that GPs feel when they are one-to-one with a turbulent drug user in their surgery.

We have had similar problems with getting GPs involved in Lanarkshire. How do you support GPs? Having spoken to some of them, I get the impression that they sometimes feel that they are isolated and lack support. Does the DAT have a role in supporting, training and providing back-up for GPs who are working on the methadone programme?

I have mentioned some of the back-up that GPs find helpful—for example, the quality of the mental health services that focus on people with addictions. It is also important to ensure that the pharmacies provide good support in the dispensing of methadone. It is not just a case of the user going in, swallowing the stuff, and then going off: a high-quality pharmacy service will provide rather more support than that to the user.

Counselling support through the social work services is also important, but it is an area of weakness. That is not in any way a criticism of social work services, but such counselling is very resource intensive, and departments find it difficult to stretch their resources to provide a level of counselling support to GPs that is commensurate with the number of users that they might have on their books. That is a stress area, and we want to improve the counselling support that is available to people who are on the methadone programme.

We have heard contradictory evidence about the scale of the problem in Glasgow. The Scottish Executive estimated that the drug problem in Glasgow probably affected about 12,500 to 13,000 drug misusers. However, when the Glasgow Association for Family Support Groups gave evidence, it put the figure at nearer 20,000, which is much higher. Does the DAT have a view on the scale of the problem in Glasgow? Is the figure nearer 20,000 or 12,000?

The figure that you were quoted by the Glasgow Association for Family Support Groups is based on work done by Glasgow City Council, which is part of the DAT. As you probably know, the council added together a variety of data sources, asking, "What is this telling us?" It came up with a range of between 12,500 and 15,000 injecting drug users. The two sets of figures are probably not inconsistent, as I suspect that the council's figures, which were based on people who accessed services such as needle exchanges and so on, missed drug users who do not inject.

I suspect that the figure for problematic drug users is rather greater than 15,000, which was the council's estimate. You must remember that the last time that prevalence was measured in Glasgow, the figure was 5,000 to 8,000. Therefore, we revised our estimates upwards, and it is likely that those figures will continue to rise for some time.

When we visited Aberdeen to take evidence, nearly everyone we met said that the drugs problem in Aberdeen is now of crisis proportions. At the other end of the spectrum, we went to Cumnock, where one estimate was that up to 30 per cent of the population of Cumnock, which is a fairly small town in comparison with Glasgow, were involved in some form of drug misuse. Proportionally, how does Glasgow compare to that? Is Glasgow in crisis like Aberdeen? Is the proportion of drug misusers anything like 25 or 30 per cent?

I hesitate to get involved in measuring the problem in numbers that are a bit squishy and soft. However, I think that there is a crisis. There is plenty of evidence that whole communities are being torn apart by the drug problem, that quite a large number of young people are experimenting with drugs and that people from the most deprived areas get into terrible problems with drugs.

Members will have seen the data that shows that there is a thirtyfold difference in hospital admissions related to drug misuse associated with people from deprivation category 7 compared with people from deprivation category 1. The problem is of major proportions. Over the past year or so, the DAT has felt that the problem is in danger of running away from us.

What needs to be done? If there is a crisis, are the resources that are available to DATs and the plethora, as you described them, of agencies anything like on the scale that would be required to deal with that crisis?

No; not at all.

You mentioned both the availability of resources and the multitude of funding programmes, many of which are short term, which makes it difficult to plan ahead and so on. Given the numbers, if we accept that there is a crisis, what needs to be done as a matter of urgency to address the scale of funding available and to make that funding more effective?

It is hard to size it. For example, last year, the Scottish Executive put an additional £500,000 in drug treatment services. In Glasgow, the health board and the local authorities agreed an additional, matched funding supplement. Ultimately, we were able to commission £1 million-worth of additional services.

Is that a drop in the ocean if the problem is running away from you?

Yes. You have probably heard the details from other witnesses. Included in that £1 million was money for our first go at a comprehensive service to be based in Easterhouse. That service is expensive; I cannot remember the precise figure, but it is more than £300,000. Services such as that are needed in Drumchapel, in the Gorbals, in Pollok, and so on. That £300,000 will have to be multiplied several times to get a range of services going. In the meantime, there is the exponential cost of the methadone programme.

Are we losing the drugs war?

We ain't doing too well. I do not believe one should talk of having lost it, because that would be the counsel of despair, but we ain't doing well. However, we are trying very hard.

There is a tension between short-term and long-term aims. Most of the things that I have talked about relate to the short term, and there is a danger that we chase our tail in the short term and therefore do not do enough about long-term prevention. If we get certain things right—the social inclusion partnerships, the community schools, and the Starting Well project for children, for example—that will start to pay dividends, but it will take 10 or 12 years to see the evidence of that. We have to have the courage to stick with those things. Unfortunately, we still have today's casualties, and they are difficult to deal with. When I say that I think things are running away from us, I am thinking about today's casualties and feeling pretty desperate about them. I am rather more hopeful about the longer term, because there are a lot of resources for tackling the strategic issues. Art will be required to weave the short-term and long-term projects together to make them all effective.

With the establishment of the Scottish Drug Enforcement Agency, additional funding of between £10 million and £13 million is being made available on the enforcement side. Do you think that that is money well spent; or would it have been better spent on prevention, education and treatment?

I do not know. The jury is out on the effectiveness of the DEA because it has been set up only recently. There is no doubt that, for the public, the supply of drugs and the way in which the criminal justice system deals with suppliers are major issues. If the DEA can help us all to make progress on those issues, the public will regard that as a great benefit.

Keith Raffan is champing at the bit, but we will hear John McAllion first.

The submission from Greater Glasgow Health Board indicated that the methadone programme was introduced in 1994, and that between 1995 and 1997 there was a fall in deaths related to drug misuse. Recorded property crime related to drug misuse also fell steadily throughout that period. However, post-1997 there was a sudden upsurge in drug-related deaths, which reached its peak in 1999. Did a new phenomenon take place post-1997—apart from your taking over as the chairman of the DAT? Did something happen on the ground? Did heroin become cheaper? What happened to turn the figures around?

With the benefit of hindsight, we can see that the fall in drug-related deaths in 1997 was almost certainly due to a shortage in the supply of temazepam. Prior to 1997, it was available in gel form, but the regulations were changed. That meant that it was no longer available in gel form and, as a result, much more difficult for users to access. The black market has now resumed that supply. A lot of drug deaths are from heroin but are related to temazepam.

So, the methadone programme itself is not necessarily cutting the number of deaths from drug misuse?

I think that it probably is, because it means that there are many fewer chaotic drug users. The people who are most susceptible to drug-related deaths are the chaotic drug users and those who have been on drugs for so long that they have hit rock bottom; at that point, the despair of their predicament becomes overwhelming. Those are two distinct groups. In the natural cycle of drug addiction, it can take 10 to 12 years for someone to reach rock bottom. At that point, there is a tendency for addicts to commit suicide. The other group—the chaotic drug users—is younger and comprises people whose habit is out of control.

I was interested in your comments about the gaps in knowledge of what works in prevention—detox, rehab and so on. That is something else that we have picked up in our visits throughout the country. Do you agree with others who have given evidence to the committee that there is insufficient research into what works and that more of the drugs budget should be spent on research to find out what is effective instead of on fighting forest fires all the time?

Absolutely. Part of our DAT strategy, before the latest national initiative was launched to improve the level of national research, was to create a research programme to fill those gaps in knowledge. We felt that, in the absence of that research, we should set up our own research programme. We estimated that if we could create a recurrent fund of about £100,000 a year, our DAT would be able to sustain a reasonable research programme.

It is interesting that although the health board decided to put money on the table to help get that going, other local authorities put no money or very small amounts on the table. The police also were unable to put any money on the table. The argument was either that they did not have the money or, more important for the purposes of this discussion, that priority had to be given to treatment—the crisis of today—rather than to research. That encapsulates the situation.

Has the Scottish Executive said whether it is prepared to help fund that research?

Yes. The national research programme has recently been enhanced.

What about research by local DATs?

No. Not that I am aware of.

We must move on.

In the submission from Greater Glasgow Health Board, the main indicator of improvement is recorded property crime. Dr Laurence Gruer said that in Glasgow alone, shoplifting and burglary to finance people's drug habits costs the community £190 million a year. Do you agree with that figure?

Yes, but that figure was based on the lower level of prevalence that we were working on until fairly recently. It was an extrapolation from a survey of a cohort of users. If the number of people in Glasgow who have a drug problem is greater than we originally thought, the crime levels are, accordingly, likely to be higher.

You replied very tactfully and diplomatically to Alex Neil when he asked you about the DEA and the emphasis on enforcement. It must be pretty galling for you that the Greater Glasgow Health Board's submission states:

"Ring-fenced Scottish Executive drug misuse funding has not been linked to inflation resulting in drug misuse services effectively getting an annual cut in funding."

The problem is getting worse and you are facing an annual cut in funding, yet the Scottish Executive managed to find £10.5 million to set up the Scottish Drug Enforcement Agency.

I recall from my conversations with the police that some of that money came from the existing envelope of police resourcing and was not wholly new money.

The Executive would not agree.

I am not an expert on that.

Astonishing.

Let us not interrupt the witness. It is bad enough when we interrupt one another.

There seems to be a growing realisation in the Executive that more money needs to be provided and that the funding streams need to be more robust in the future. It seems to have a problem connecting appraisal of the situation with what comes out of the allocation process. I suspect that that will get better and that this is part of a learning exercise within the Scottish Executive.

You mentioned the lack of inflation uplift, which is galling because there is neither rhyme nor reason for its being cut out of the normal funding conventions that apply.

In The Economist last Friday, there was an interesting piece about cocaine. What it said applies to heroin, as Colombia produces much more heroin because it is more profitable. There is such a huge dividend for those who are engaged in the drug trade that it is difficult to cut supply, taking into consideration the cost of heroin in Colombia, the cost when it reaches the Caribbean and the street prices in New York or here. More emphasis should be placed on cutting demand.

You agreed that current funding is a drop in the ocean and that we do not have sufficient facilities. Margaret Curran and I went to the Glasgow Drug Crisis Centre, where the number of beds is utterly inadequate. There is insufficient provision of residential rehabilitation services, aftercare, through-care or halfway houses. As you said, we are trying to put out an inferno with only one hose.

Yes, sometimes it feels like that.

I will move on, as we have a lot of questions.

I agree with Chris Spry that enforcement and supply are major issues for communities, and for poorer communities in particular. It seems that people who live in the area know the dealers and people who work to support addicts know who the dealers are. The only people who cannot do anything—either because they do not know who the dealers are or because they do not have the powers to act—are the police. Perhaps we should give more powers to the police or change the law. Do you have any suggestions that would allow the enforcement agencies to tackle the suppliers?

When I joined the DAT and got involved in this for the first time, I was struck at just how positive, active and co-operative the police were. The more I hear about the problem, the more it seems to be a product of that intrinsic dilemma in our criminal justice system that one is innocent until proven guilty. The process of people coming to court takes time and if people who have been sentenced go back into the community, too often they revert to dealing. That is a huge frustration for local residents.

The police will lift a dealer, but before they know where they are the dealer is back on the streets because they have no powers to detain the dealer indefinitely. The result is that the dealer carries on supplying. Even when dealers are sentenced, they may not be imprisoned for very long before they are back on the streets—or at all. That is coupled with the intractable problem of housing policy for people who are known to be dealers. Those issues are overlaid by the fact that many local dealers are also users who deal to sustain their own habits. The situation is muddled, muddied and mixed up.

My heart always lifts when I read about the really big importers being lifted. We must concentrate on the efforts of the police and HM Customs and Excise to intercept the supply at the more macro level. I understand that that is one of the main functions of the DEA, with which I wish it well.

Those of us who are active in Glasgow would bear out your comments on what appears to be the growing tide of the effects of drug misuse, which is very depressing.

I want to ask you about the figures. It is hard for you to be precise, obviously, but I wondered how the 12,000 to 15,000 figure that was mentioned in your response compares with some of the figures in the health board's earlier response to us. There was mention of the drug misuse clinic scheme with about 2,800 patients receiving methadone on prescription, which is a fairly small proportion of the needle-using population. What can be done to increase the number of people on that scheme? Do you know what proportion of drug users are receiving treatment through this programme or others, including needle exchanges? That would allow you to see how effectively resources are being used.

The proportion varies in different parts of the city and there are inequities—

Inequities in the deprived parts of the city that you have identified?

Between different parts of the city. Service use in some parts of the city is lower than it should be. A rough estimate would be that our services connect with perhaps only 20 to 25 per cent of users. That is probably a fair guess, but it is crude and not well-informed.

The problem is that a lot of users drift in and out of contact with the services and, especially if they go into prison, lose contact entirely. As you know, an enormous number of people are admitted to Barlinnie prison every month and a huge percentage of them are drug users. Unfortunately, once they lose contact with drug services, it is extremely difficult to re-establish contact. We are not reaching a vast reservoir of people.

What can be done about that? Is it possible to reach more of them using existing resources or could that be done only by increasing the resources available to the DAT?

More can always be done with the existing resources.

I meant in terms of making contact with the drug users.

To improve uptake, we have to make services more responsive to users; we have to provide users with more support and we have to show that being in contact with the services can have a good result. That is where my point about training and employment comes in.

The committee has talked to users and will be aware that many of them have an incredibly profound sense of hopelessness. That has to be broken. One way of doing it is by giving them support, allowing them to succeed and so on. That is time intensive and it would be hard to do it without a substantial increase in resources. As I say that, however, I am aware that that is what public servants always say. Even so, I cannot see how we can greatly increase our effectiveness without a step change in the shape and responsiveness of the services we offer.

You mentioned Barlinnie. I was part of a group of members of this committee who went there a month ago and saw a lot of the good work that is being done. We were told that the treatment drug users receive in the prison is limited by the length of their sentence and that they often do not reconnect with the facilities that are available in the community. What you are saying seems to be the mirror image of that: you said that people who are involved in the services that you provide before they go into prison are not reconnecting with the service when they are released. There is a clear need to marry the elements. Obviously, you work with Barlinnie, but people seem to fall out of the system at both ends. How can that gap be bridged to ensure that there is more continuity?

We have had several discussions with senior officers at Barlinnie prison about that. We all recognise that it is a major problem. It is difficult to achieve because the number of prisoners is so huge: the length of stay at Barlinnie is usually short, so the number of prisoners churning through the system is pretty huge.

The situation is exacerbated by all sorts of things. Many of the people in Barlinnie do not know their postcode or address, which makes the record linkages, which are key, quite difficult. We have talked to senior staff at Barlinnie about whether some strengthening of criminal justice social work support, for example, would improve the connections. We have discussed record linkages to improve information sharing with the world of primary care. That would mean being in contact with the prisoner before they go in and subsequently when they leave.

We also need to concentrate on some of the other, longer-stay prisons, where we have a better chance of improving continuity among prisoners. If we can achieve that, we will learn about what works and start to apply it to the churning of people through the system at Barlinnie, which I have already mentioned. At the moment, the number of prisoners at Barlinnie is so great that it is very difficult to know how to tackle the problem effectively.

Cathie Craigie referred to the 10 bullet points in Greater Glasgow Health Board's written response, headed "Key Issues In Greater Glasgow". I can see that they are not ranked in order of importance. One of them covers prisoner through-care and aftercare.

From memory, about £3 million a year is spent in Barlinnie prison on treatment for drug users. Are you satisfied that there are close enough links between the funding that Barlinnie prison gets and the money the drug action teams have to deal with what is effectively part of the same problem? Are the connections being made to the best possible level?

I do not think that that problem is necessarily one of money; I think it is one of how to devise systems of tracking individuals and sustaining their treatments at key points of change in their lives. If we knew how to achieve that, I do not think that the money would be a problem. The health board and, I would hope, criminal justice social work, would be able to work effectively with the Scottish Prison Service to put in place an effective support system.

The difficulty is with the churning of a large number of prisoners. There are break points in the person's experience. The night they spend in the police cells is a crucial break: they can go through a great crisis in the space of a few hours. When they get admitted to prison, there is also the time it takes to assess them and to get them on to the appropriate regime.

It is only a few hours, but it can be a crisis for the individual. They then come out early in the morning. They are free, they go off, all sorts of things happen to them and turbulence then sets in again. The problem is how to handle those crisis points in their experience.

I am very sorry, but we are running out of time. We have agreed a line of questioning. I will take Cathie Craigie for one question, then Robert Brown, Keith Raffan and Fiona Hyslop. Any other members should please indicate.

Chris, much effort has focused—appropriately—on the treatment and provision of care for drug users. How much importance do you place on prevention, including the prevention of drug misuse and of a transition from experimental use to misuse? What are your action priorities and plans?

The knowledge of what works is perhaps skimpiest in this area. As a drug action team, we have found it harder to get into education than into treatment and care. The situation is now a whole lot better. At the drug action team meeting last week, we had a really good discussion with the director of education of Glasgow City Council, examining how issues of health and addiction in particular were being played into the syllabus all the way through children's school experience. That and the community schools initiative offer some encouraging prospects for working together with education services.

As I said, we have been slow in getting our acts together effectively. Culture comes into that—the world of education has all sorts of preoccupations and problems of its own and has not found it easy to make connections with the world inhabited by drug action teams. However, we are beginning to get there.

Do different drug action teams share information about their experiences? The Lanarkshire drug action team has produced an excellent information pack for schools that is based on research from around the world. Do you think that that kind of information should be shared; or should each DAT invent, or reinvent, its own material?

A fair bit of sharing takes place, but material usually has to be tailored to local circumstances. Our health promotion people work closely with people in education on printed and audiovisual materials. When I said that it was not easy to get into the world of education, I was really asking how the work schools are doing can be connected with some of the other environments in which messages about drugs should be got across. Connectivity has been difficult to pursue.

I was struck by some of the figures on drugs and alcohol that we were given in the papers from the Ayrshire and Arran Primary Care NHS Trust. There have been 227 drug-related deaths and 33,000 alcohol-related deaths. The latter arguably represents the real crisis, although I know that the figures have to be considered over the long term.

On page 5 of your submission, you say that the Castle Craig study showed that the proportion of recovering drug addicts who achieve abstinence in the medium term is lower than the proportion of alcoholics who achieve it—in other words, that the recovery rate for drug addicts is lower. You spoke about the problems of helping people to move on, wondering what happened to them after they had been put on to methadone. What would you like to happen? Should we provide specific training and employment opportunities? Should we provide drug regimes and health counselling? What would be the best way of moving people past methadone?

Because people on methadone often feel that they have a lack of prospects, it is difficult for them to contemplate coming off. I do not think that there is a quick fix to that. The world of employment and training has, in the past, been slightly disconnected from the world of health services and sometimes even from the world of social work. They are now beginning to come together. Those of us who are working on trying to make those connections are finding it incredibly complicated.

Bringing the user to the point of being capable of working, or bringing the employer to the point of thinking that employing the user is a worthwhile proposition, is extremely difficult. Making the move from detoxing to sustaining somebody in a stable state—perhaps on methadone—and then to getting him or her into a job or training feels like the new frontier. We have to crack that; if we cannot, we will see the number of people who are just sustained on methadone growing year by year. They will not have the incentive or the encouragement to come off, and will therefore have no prospect of coming off.

Is that where the lack of finance bites deepest? You have talked about worthwhile aftercare projects, counselling and crisis points. Is the problem a lack of knowledge or is it a lack of finance to implement the knowledge?

It is partly a learning curve issue. How, in a relatively short time, can we make up for an individual's lack of education and self-confidence? We are talking about people who have been incredibly damaged and who lack self-confidence. Trying to repair that through a training and education programme is incredibly difficult, but if we cannot do that how will we ever reach the point at which employers will decide that those individuals are worth taking a chance on? That is the new frontier.

There are quite a lot of resources out there—in all sorts of different pockets. One would have to be Henry the Navigator to get the most out of what is out there, because there is so much of it.

To go back to the alcohol-drug problem, to what extent is an overlap of facilities a good thing, or do you deal with alcohol and drugs in totally separate pockets? What is more important, the fact of addiction or the separate nature of the two addictions?

We have separate drug and alcohol action teams in Glasgow, although they are inter-agency teams. We take that approach because the issues are so huge for each addiction that trying to handle them through a high-level inter-agency team would be unworkable. However, the detailed planning and an increasing proportion of the services are delivered jointly by health and social work. We are trying to bring them together. Eventually, we may well end up with a combined drug and alcohol action team, but it was all too big and difficult to start from that point.

Greater Glasgow Primary Care NHS Trust has an alcohol and drug directorate. Our next witness is from Ayrshire and Arran Primary Care NHS Trust, which has an alcohol and drug action team. Forth Valley has a substance abuse team. Because of the prevalence of cross-addiction and the early use of alcohol being seen as a gateway to other drugs, it would seem sensible for the action teams to become addiction action teams.

In principle, I agree with that, but the drug and alcohol situation is so huge that we had to find some way to divide up the deliberations in a workable way. There is quite a bit of common membership—people go to the drug action team and the same people can be found sitting around the table talking about alcohol. Although the teams operate through different channels, in terms of brain power, there is quite a bit of convergence.

Robert Brown gave the statistics on alcohol use in Ayrshire. In the written evidence, Charles Lind says that

"Alcohol presents the greater problem".

There is some concern that the high profile of drug misuse and the attention that is given to it by the UK Government and the Scottish Executive overshadows a much more severe health problem for the population at large.

Part of what we have to do involves giving communities a sense that they can make a contribution to tackling the problem. Most communities feel fairly united about tackling the drug problem, but if we tell them that we are going to tackle the alcohol problem, lots of ambivalent feelings start to emerge.

One of the phrases used by ministers about the 22 or 23 DATs throughout Scotland is their variability—a rather diplomatic term. Your DAT is often referred to as the success story and as being the model for many of the other teams. Why? Is it because you have managed to integrate your approach and have encouraged the different bodies to work together?

There is a fair bit of high-quality expertise round the table. Moreover, a number of people around the table genuinely invest a lot of personal commitment in making the DAT work. It comes down to individuals' determination to address the issue successfully. As I said at the outset, the chair has to be very strongly committed to make it work.

In Fife, the DAT is chaired by an assistant chief constable. You are chief executive of the health board. Is that the right emphasis? Should the DATs be more treatment and prevention-led rather than enforcement-led?

On the whole, that approach would be more appropriate, although I can see that the emphasis might differ from place to place. In some senses, it is not necessarily ideal for the DATs to be health-led. Because of the range of their responsibilities, local authorities really need to feel that they own the problem, and there is no better way of owning the problem than being responsible for chairing the DAT.

Our difficulty is that, as you know, Greater Glasgow Health Board works with six different local authorities. We consciously decided to keep the greater Glasgow DAT because we felt that benefited more from the expertise and commitment of the people around the table than we would have if we had split into separate DATs, which might become overstretched and have a bit less expertise. However, keeping the DAT together has made it very difficult for any one authority to chair it, for reasons that I am sure you will understand.

One of the reasons why the DATs were formed was the hope that the different component bodies would bring resources to the table. However, in many cases, that has not happened. I am not being critical—the pressures on their own budgets have probably forced them to draw up certain strategies. Should the money be channelled through the DATs? The committee has heard concerns, particularly when we visited Ayrshire, about a lack of co-ordination: money has been going directly to a social inclusion partnership and the DAT has not been aware of what the money is being used for. I have taken the matter up with ministers, as there is always a danger of duplication and waste in such situations.

We would get into pretty murky waters. Many of the services are provided by local authorities, and I do not see how local authority money can be channelled through a DAT without getting into huge difficulties with local authority budget setting processes.

So how do you co-ordinate funding to ensure that that does not happen?

That is a difficulty that we have to grapple with. What is more important is transparency about how resources are used. Good progress will likely come from transparency and a commitment to a clear strategy or practical plans, and you do not necessarily need a single channel through which all the money flows.

That said, there is no doubt that if a health board is committed to a DAT's work, is transparent and is not salting money away in different ways, channelling the money through health usually provides more flexibility than other sources. The area is incredibly complicated, and there is no one-bullet answer about the right approach to it.

I have one final question on the reports. I had a letter from the clerk that I have managed to lose already; however, from memory, it says that the Scottish Executive has not been keen for DAT reports to be published. They have been described as a management tool, and, as such, the issue of confidentiality arises. Obviously, confidentiality is paramount in individual cases, but in terms of the general strategy, do you think that the reports that you make to the Executive should be published?

Do you mean the template?

Yes.

I have no difficulty with publishing the template. However, we found the template a particularly cumbersome and not very useful document. The strategy document that we developed was set out in a format that we could actively use in our discussions with the people with whom we work. The template was a fairly predictable product of what happens when you ask a Government department to gather information. It gathers information, but does not necessarily present it in an understandable or user-friendly form.

I will be brief to let others in. I will ask about the money that goes through SIPs. How can the drug action team be accountable for the drug action plan if the money goes through another agency over which it has no control?

I understand that social work has a strong lead in Glasgow. How does it interact with health board provision and the voluntary sector? The health board submission says that there will be redirection and reshaping of services. Could you explain more about that?

The fact that the money goes directly to SIPs highlights the fact that the responsibility for the DAT is partly to persuade other agencies and bodies to contribute to an overall strategy that will be effective. Therefore, my accountability for working with SIPs relates not so much to how they use the money as to the success of our relationship with them: it is about whether they understand what the DAT strategy is trying to achieve and whether they use the money in a way that is supportive and takes the strategy forward. I am happy to be measured by that test. It matters less whether we are able to influence how £10,000 is used here and £5,000 there. I am reasonably relaxed about that.

On the shift of emphasis on services, we have been trying to encourage more local authority specific approaches to planning drug treatment services in the Glasgow area. The pattern was very uneven. A lot was concentrated in the city, but there were very patchy services in other local authority areas. Under the umbrella of the DAT, we have tried to pursue local authority specific approaches. In the city, there is an elaborate planning mechanism to examine a whole range of aspects of developing drug treatment services. That is basically a joint effort by the local authority, the health board and various providers in the voluntary sector. Those bodies work under the umbrella of the DAT strategy.

What does Glasgow social work department bring to the table?

It brings a huge amount of planning effort and increasing transparency in the way in which money is used. I am encouraged by how that is going.

You said earlier that you only touch around 25 per cent of the chaotic drug abusers in Glasgow. It has been estimated that there are 4,000 individuals who have taken part at some point in the methadone programme. If we accept that there are potentially between 15,000 and 18,000 chaotic drug users, what plans do you have to meet the shortfall in methadone provision?

An additional allocation of money for treatment has just been announced. The drug action team considered that last week. Our view was that the top priority was to strengthen shared care services—stronger support for counselling and other services associated with the methadone programme. In effect, we will want to use the next tranche of available money to strengthen support for the methadone programme.

You are saying that you support the 4,000 chaotic drug users whom you currently reach, but that you have no plans to extend the methadone programme to cover the 11,000 people whom you are not reaching.

I do not think that we contemplate making such a jump. We do not think that the programme could be extended so far in one step. Huge issues would arise from doing that, as such a large number of users would flood the current pattern of service, so there would have to be an entirely different service model. We are thinking about different service models, but we have not reached a conclusion.

I have heard concerns from service users about how methadone is dispensed. In particular, concerns revolve around the lack of confidentiality at pharmacies. Even where health information booths have been set up, they have rapidly become known as the junkie booths and there has been no improvement in protecting people's confidentiality. What is the drug action team doing to find alternative ways of dispensing methadone, for instance, through the community-based drug services?

It is important to take into account that health advice points are used for other health problems and are not just for people swallowing methadone. The more that is understood, the more that image of those facilities will be broken down. We are steadily spending more money to provide more pharmacies with advice points, where people can be dealt with in private without being seen or overheard.

On your question about other models, complications arise when one considers dispensing drugs through channels other than pharmacies. There are regulations about how drugs can be dispensed in a community setting outside the bounds of a pharmacy. The planning group has to grapple with such issues.

Are you saying that you are examining the concept of using community-based drug services for the delivery of methadone, or that that model of delivery is so complicated that you will not adopt it?

We are examining that model, but in arriving at a different model one starts tripping over such things as the pharmacy regulations.

Clearly, much of what you have said relates to our ability to take people from chaotic drug use to controlled drug use, and then to reintegration into the community. Do you accept that it may be worth while to look at the studies in Switzerland and Holland and to consider seriously the prescription of heroin to stabilise, but more important to decriminalise, people and undermine the organised crime that runs the drugs industry and other elements of the drug abuse problem in Glasgow?

The drug action team has not discussed that. Your question highlights one of the huge difficulties in this field, which is that thinking aloud about radically different models—

There is nothing new or radical about this, as it was the situation in the United Kingdom from 1908 until 1968.

We have had huge problems with local public opinion about our giving methadone to people who are addicted on opiates.

But you are doing it.

I know we are. However, the rhetoric that surrounds the issue—the abstinence versus harm reduction debate—makes it feel like shark-infested waters. I remember that I came to Glasgow just after Mary Hartnoll, who was then director of social work, remarked that more harm was done by alcohol than was done by ecstasy. I recollect that she was crucified for saying that. It is difficult for drug action teams to talk publicly about such choices. Our experience is that the environment of public debate is pretty intolerant and unforgiving. This country struggles with that major difficulty.

Are you discussing that concept behind closed doors?

No.

When you examine methods that are used in other countries, is your first priority to decide whether you will get a bad headline, or is it to find appropriate methods to reduce chaotic drug abuse in Scotland?

We have to operate in the environment in which we exist. The debate about whether you should consider heroin prescribing is beginning to take off in this country. You can be assured that we would find ways of exploring the evidence and getting it into the system in an effective way. That sounds a rather arch comment, but DAT does not see itself as a lobbying entity; it sees itself as learning from research, observing what is going on in the development of national policy—

On that point—

Lloyd, we have to draw to a close now. You have one last question.

You have just said that you are prepared to look but not to talk. I am asking you straightforwardly, would the drug action team consider taking action against chaotic drug abuse? Within your DAT area, would you consider prescribing pharmaceutical heroin to appropriate individuals as a stabilisation measure?

You would have to be satisfied that you could do it in a sustainable way, and that you did not get leakage of the drug into the wider environment. There are many practical issues. First, you would have to look at the evidence for its effectiveness, so you would examine the effectiveness of the Swiss experience. You would then have to ask how you would set up a system that would work effectively in the turbulent environment in which we operate.

We have to draw matters to a close. That was an interesting discussion, which I am sure will continue. Chris, thank you for your evidence today. It has been extremely useful to the committee in our inquiry. As ever, we may contact the DAT if we want more information. As usual, we are well over time. We will have to move on swiftly, so I am afraid that your departure will be abrupt.

I welcome Charles Lind, associate medical director and lead consultant in addiction from Ayrshire and Arran Primary Care NHS Trust. Thank you for coming today. We are grateful for the information that you provided. You gave us an informal briefing some time ago, the contents of which have stayed with a number of members. Could you give a brief introduction, because you will appreciate that we are running over time.

Thank you for inviting me. We are moving away from the concept of a DAT in Ayrshire. As Mr Raffan mentioned, we have never had anything that was specifically designed to deal with the drug abuse problem. Historically, there was a mandate from the Scottish Office in 1989 to produce alcohol misuse co-ordinating committees. We used that to bring together all the addiction agencies under one banner. The DAT emerged—almost organically, in 1995 or whenever it was—from an alcohol and drug action team, not a drug action team. That reflects the way in which we have worked.

We have worked in a way that is characterised by unusually high levels of cross-agency co-operation. That is true at the level of inter-agency working, although perhaps less so at managerial level. It has enabled us to maximise scarce resources and has allowed us to move about within each other's professional confines. For example, I will do clinics out of voluntary agencies, and voluntary workers will come and work within health service provision. That allows for a useful and interesting flux of personnel such that they can move through the various parts of our addiction services.

I caught the tail-end of what Chris Spry said. I was interested in that, because we are beginning to move away from seeing drugs, or indeed alcohol, in isolation. The last time I was here I referred to the fact that there is a vast political backdrop to this issue, which encompasses not just alcohol and drugs but all sorts of other issues, such as mental health, physical health and general well-being, all of which are almost indivisible and come within the remit of social inclusion and exclusion.

It becomes increasingly difficult for me to understand where I should draw lines and why I should draw lines in certain ways. Our service reflects that difficulty. For example, we have a flourishing dual diagnosis service, which I think is the first of its kind in Scotland. It is certainly the first residential one in Scotland. It is turning over something like 500 new referrals a year in its second year of operation.

Probably the most important part of our operation is the teaching, research and development arm, which is flourishing. It tries to ensure that, in their normal day-to-day work, generic workers maintain an understanding of the difficulties that are associated with drug and alcohol use. Those workers include community midwives, general practitioners, the police, prison workers, social workers and those from voluntary agencies.

I am aware that I am rambling a bit, so it might be easier if I took questions.

Thank you. We have a range of questions and issues that we wish to raise. We want to encourage a dialogue.

I appreciate the holistic picture that you are painting. That is the direction in which we are heading, but I wish to focus on one aspect that concerns us, which is the pattern of heroin use. I am probably guilty of focusing on heroin use myself, because I represent an urban area of massive deprivation and I have my own views on the pattern of drug use and issues surrounding it. But it must be different for you. How different is it? Is too much of this debate dominated by urban centres? What are the issues across Scotland, and how do we understand them?

The issue is what was deprivation, what is exclusion, and what is now inclusion?

Why is that?

Because deprivation is not monopolised by inner-city urban areas; it happens in many different contexts. It can happen in postcode areas that apparently are affluent. It can happen in the house on the corner, where someone who is deprived and is excluded moves in. More broadly, in Ayrshire we have a hinterland of what is now absent heavy industry. We have Cumnock and the Doon Valley, which has the highest level of unemployment in Scotland.

Unemployment is not an inner-city phenomenon. When I moved to Ayrshire it was as much of a surprise to me as it may have been to you recently. I was expecting the bulk of my custom to come from Kilmarnock and Ayr, but it did not; it came from small ex-coalmining villages, where unemployment in the 25 to 35-year-old age bracket among males was in the region of 85 to 90 per cent. That is vast. Huge swaths were decimated. There were no jobs and no chances of jobs. The talented people in those types of communities either leave or beat their heads against a brick wall of gradually declining community awareness. That is one of the things that is often overlooked in areas of rural deprivation. At least in inner cities you can usually find a platform. In areas like Cumnock and the Doon Valley or Kelty it is difficult to find a platform to be heard. People must understand not only that there are difficulties of exclusion and deprivation, but that Stagecoach is not the most magnanimous company in the world.

That is on the record.

If someone has two children and needs to take four bus rides to get to the nearest service that they want to access, whether it be leisure or health facilities or signing on, it can be very difficult indeed, as they must devote a day to doing that. Child care is much more difficult to access in rural areas. There is a notion of the extended families and an agrarian idyll, but that no longer exists.

I accept that point, which you have expressed well. How does that link into the problem of drug abuse? What is happening in your part of the world?

What has happened in our part of the world is pretty much a mirror image of the emerging drug use patterns in Glasgow. There is not a substantial difference. When I arrived in the area, I quickly became aware of a substantial problem with the use of Temgesic and temazepam, which is exactly what Glasgow was experiencing at the time. I became aware that at least two of our smaller villages were being used as staging posts between Manchester and Glasgow for heroin transport.

If there is a difference in rural areas, it is that, before supply lines get properly established, there is a tendency towards inventiveness. For example, we had a vast amount of bathtub amphetamines being produced, and for some time that was the bulk of the drug abuse in the Cumnock area. In other areas, the problem progressed in parallel with the rest of the west of Scotland.

That is interesting. What are the implications for service development? Do services have to be different, or do we have to deliver or resource them differently?

That is a difficult question to answer. The comparison is not one that I particularly want to make. However, if one is serious about delivering a service to an excluded group, one must take that service to it. It makes no difference whether that excluded group lives in the middle of the city or in a small housing scheme with no social infrastructure in the middle of nowhere—one must still deliver the service.

The Stimson studies on the original needle exchanges in Glasgow showed that people would not travel more than a mile and a half to get there. That problem is not peculiar to rural areas, but the scale of it is perhaps peculiar, because one has to get services out there in some way or another. Our needle exchange backpacking exercises have huge levels of uptake, much bigger than for our original static sites. That is largely done by word of mouth, village by village and visit by visit, and involves taking injecting equipment to individuals.

I understand that the service delivery mechanisms in Ayrshire are quite distinct, but how does the system work? John McAllion and I visited Fife, where there are also small communities that need delivery to the doorstep, or nearer than some of the centralised facilities. You mentioned the backpacking needle exchange. Exactly how do you deliver those services to small communities?

We started off with a little white van but, like most little white vans, it rapidly became known for what it was. In my village, the little white van is the vodka supplier. Among the other villagers, it rapidly became known that it was the needle exchange service. Our workers now use their own cars. They have Crown indemnity by way of insurance and carry a large amount of injecting equipment in their car boots. They make appointments at prearranged places with pre-arranged people, so that they are aware of roughly what the routine will be.

They also provide other services. We are beginning to provide services specifically for women and for disabled people on the back of that service. Once the infrastructure is established, those more specialised services can be provided in addition. We now have a cohort of something in the region of a dozen workers providing that service. We ran into a small difficulty with one of our local authorities, which did not want us to perform that kind of operation out of its housing stock, but that was resolved quite rapidly. I cannot say much more about it than that. It is pragmatic; we simply take a service where it is needed.

That is a medical model for needle exchange, but it integrates with other services. There are concerns that it is difficult to connect with women and encourage them to use the services that are available. Are there other services that are not just about health, but which connect with the work that you do?

I am not sure that I would describe the needle exchange workers as health workers per se; they see themselves as addiction workers. One of the joys of working in our model is that we do not divide things up into social work, voluntary work and health work. We are addiction workers and we work within that conglomerate.

How effective is your work with GPs and your shared care model? In Edinburgh, there are efforts to ensure that support and information services are available at the time when people see GPs. However, there must be agreement with GPs to share their facilities to provide that information and see patients. What are your views on that?

We do not use primary care premises very much. We have a different form of shared care. In fact, I suspect that calling it shared care might be stretching it slightly, and we have been criticised in some quarters for what we have done. Our local general practitioners made it quite clear very early on in the proceedings that they did not want to be part of the substitute prescribing programme, and I have some sympathy with that view. It does not fall within what is generally recognised as general medical services and it requires a level of expertise that can be quite difficult to sustain, unless substantial specific support is provided, as happens in Glasgow.

We have employed GPs on a sessional basis at strategic points around the area, so that they work for one session a week in each of the drug agencies to provide substitute prescribing facilities. Other services may well be provided from community centres or from other community facilities, but rarely are they provided from primary care facilities.

The convener touched something that, although I do not want to labour it, I think is an important point—[Interruption.]

That is Dr Lind's pager going off. I usually have to warn members to switch off their pagers.

Yes, it is usually our pagers that interrupt the meeting.

You said that there are no adequate indices for measuring deprivation in rural areas, and you mentioned Carstairs and Townsend. Do you think that that leads to distortion in resource allocation, given that overall resources in Scotland are inadequate?

I have absolutely no doubt that there are substantial schisms and skews in resource allocation. The way in which the Arbuthnott report was constructed reflects that. Ayrshire came out reasonably well from the Arbuthnott review, but only because we have a large aging population. It had nothing to do with the fact that we have the highest level of unemployment in Scotland in one of our areas.

The appendix to the Arbuthnott report, which is as close to impenetrable as any I have ever seen, shows that the report's compilers have followed the Carstairs and Townsend logic to the limit. That includes such issues as car ownership. If one has a car, one cannot, by definition, be deprived. Given the lack of public transport in most rural parts of Scotland, it is quite impossible to live in a rural community without a car. The car may not be MOT'd or insured and the driver may not have a licence, so it may not be entirely legal, but one must have a car none the less.

In chapter 2 of your written submission, you make a point very forcefully about the variability and lack of recording of alcohol and drug information across general services, making analysis difficult. You say that at present each local authority uses different recording systems. That makes it very difficult to estimate the true levels of need for service and the extent of the problem. Do you think that the Scottish Executive should bring uniformity to the recording of crucial information?

That would be an ideal to work towards. To begin with, we must decide what constitutes crucial information. However, in my view, this is crucial information. We have rectified the problem to some extent by using something called the common database, which extends information and statistics division data and has been signed up to by all local authorities. None the less, it is difficult to work out, for example, how much contact the police have with people who may be drunk or intoxicated. We can guess, they can guess and we can agree on an estimate. However, it is still no better than a guess. The same applies to children in care—we do not know about that, because it is not routinely recorded.

There is a cultural problem that people are not used to including alcohol-related issues in their data. As Chris Spry said earlier, they record drug-related information much more readily. Drugs are something solid, coherent and tangible that communities tend to latch on to. Alcohol issues are more amorphous, ambivalent and difficult to grasp. The culture must change and people must confront the ambivalence that surrounds alcohol and, to a lesser extent, drugs. Frankly, in many of our cultures drug taking is regarded as normal. It is what people in huge sectors of the population do.

Ayrshire and Arran's services are held up as a model for other health board areas. As you know, I represent Fife, where the services are nowhere near as good, but which is not dissimilar from Ayrshire and Arran demographically and topographically. I know that you can only answer this question subjectively, but why do you think that Ayrshire and Arran has been so successful? Is it because the services are consultant led?

Not entirely. It is because we are lucky enough to have a group of people who are genuinely interested and motivated, and who do not really care what professional grouping they belong to. The key thing is that they are interested in trying to provide an answer to a problem. Having a consultant to champion services is a great strength. It is more of a strength—which is unfortunate, and perhaps should not be the case—than having a social worker or a junior doctor in that position. It carries some cachet.

We went to the Bentinck centre, and the total commitment of the people there is very impressive. How do we replicate that commitment? Do you think that there is enough sharing of best practice and of the methods that you have used to motivate people?

There is not nearly enough sharing across Scotland. There are many areas of practice in which we could learn from other places. I regularly have conversations with Brian Kydd, my counterpart in Forth Valley Health Board, about setting up joint training programmes and ways of evaluating what does and does not work. Until we are able to foster commitment and interest at all levels, it is difficult to produce anything other than a disjointed service.

There is something very interesting about the area that you come from. I know some parts of it very well, as I lived in Cumnock and Auchinleck during the 1984-85 strike. We refer to the area as rural, but I would suggest that it is home to some post-industrial villages, which have a radically different mindset from the genuinely rural villages in Ayrshire. Cumnock, Auchinleck, Mauchline, Bellsbank and Drongan operate in an entirely different way from genuinely rural villages. As you said—and as I know from experience—bathtub amphetamines were the drug of choice for young people in the mining communities in the run-up to, during and after the strike. I am led to believe that villages such as Ochiltree and Sorn do not have as endemic a chaotic drug use problem as the post-industrial villages have.

That is a valid point, although I suspect that there is a great deal of overlap. There are two categories of rural community. One is the post-industrial community, which is common across the central belt of Scotland, and the other is the more traditional rural agrarian community. However, if we take that argument too far, there is a danger of buying into the myth that the more agrarian communities have a tradition of sustainability and self-propulsion that post-industrial communities lack. I remain enormously impressed by the power of the community in small villages such as Drongan. Despite the difficulties under which they labour, people remain optimistic about regeneration.

Agrarian communities are suffering along with post-industrial ones. Although Lloyd Quinan is probably right to say that drug use is not yet as intense there as it is in places such as Drongan and Cumnock, it is getting to be. Agriculture-related employment is on the wane; the more intensive agriculture becomes, the more jobs in that sector dry up. What was previously a sustained and intensive employment opportunity is vanishing. That is common throughout Scotland, and there is nothing new in it.

When people have limited choice in what they can do with their lives, they are more likely to cross the boundary from experimental drug use into problematic drug use. That is the critical point. I am concerned less with whether people decide to use drugs in the first place than with what propels them into problematic drug use. Those are different issues. The crossover point reflects the extent to which people have choice in their lives. That is where the issue ties in with the inclusion-exclusion agenda. If people live in a fundamentally excluded community—no matter where it is—it is much more likely that problematic drug use will be regarded as normal. It is much more likely that their choices will be limited to the point where they do not have the same variety of options as my children might have.

Conversely, we need to ask why someone lives in Drongan and does not use drugs, or why someone lives in Easterhouse and does not use drugs. Those are fascinating questions. Why do people live in those horrendous environments and not become depressed and use drugs? If we turned the usual questions on their head, that might produce more interesting answers than the ones that we are looking for at the moment.

You were here when I asked this question earlier, so I will trim it down. Should anything be counted out, or should everything be counted in that could lead to the stabilising of people's lives and decriminalisation? Do you consider that returning to the pre-1968 situation would give us more freedom, end the classification of large numbers of people as criminals and—more important—hit harder at the criminal organisations that are running the drugs business in Scotland? Do you think that the ability to prescribe heroin pharmaceutically on an individual basis—to some degree, at the individual's request—would be a means of bringing stabilisation into lives and communities?

I take it that, by 1968, you are referring to the second Brain report.

Yes.

The second Brain report was a series of recommendations, not a series of mandates. It is within the clinical remit of every physician in this country—if they apply for a licence—to prescribe heroin. I have not applied for a licence, for some of the reasons that Chris Spry gave. I would rather comment on that practice with the comfort of some statistics behind me, rather than off the top of my head, and I hope that I could do that in private.

This meeting is not private. This is on the public record.

Okay. I will not say anything that I have not said before in public.

I would count nothing out. We have a series of examples, both historical and from other countries, which suggest potential ways forward. Simply saying that something works in Holland or in Switzerland does not mean that it will work here. Drug use has changed historically and geographically. For instance, in this city in the 1960s, drug use was the preserve of the political middle-class youth, but it is that no longer.

My concern about simply going ahead and prescribing heroin revolves around the kind of argument that Chris Spry made. There is a huge volume of public opinion to be taken into account, although public opinion tends to be shaped by a few slightly idiosyncratic people.

We will not ask for their names for the Official Report.

No. I would not name them on the public record.

None the less, those are powerful people who are able to push buttons. I was enormously impressed by the job that Laurence Gruer was able to do in Glasgow, in switching round the debate on methadone in the way that he did, from an environment that was profoundly antipathetic towards any kind of substitute prescribing—and I include my psychiatric colleagues in that, as having almost set the tone for that act—to one in which, for the most part, such prescribing is regarded as a good thing.

I also admire the fact that Laurence went public with his feeling that heroin should be available on prescription. I would echo that. There are groups of people in my practice who clearly are not benefiting as much as they should from the prescription of methadone in any way, shape or form—including the prescription of injectable methadone. Several of my colleagues in England, as a matter of course, prescribe heroin in a variety of forms.

At the beginning of the methadone debate, one of the difficulties in Glasgow, where the problem was most virulent, was the issue of leakage. In the west of Scotland, unless reassurance could be provided—which is much more difficult to provide for heroin than for methadone—that some control could be taken over leakage, the debate would be long, drawn out and unpleasant. One of my colleagues from England, who now works in New Zealand, invented the heroin reefer somewhere outside Manchester. Those reefers regularly turned up on our doorstep, so there was evidence of substantial leakage. However, the public must grasp the nettle by recognising that whatever is being prescribed will leak at some point, and that sometimes leakage is not, by definition, a bad thing.

In the west of Scotland, one of the things that characterised drug users up until the past seven or eight years was their preference for pharmaceutically pure drugs, in the form of Temgesic and temazepam. It is only in the past five or six years, as the availability of those drugs has diminished, that they have begun to use cut substances, with the results that we have seen over the past two or three months.

The number of drug abusers is nebulous—we do not know their precise number, and differing opinions were expressed earlier. That being the case, the percentage of users who utilise the service that you provide in your health board area cannot be calculated. Clearly, however, that percentage is not as high as we would like. What steps could be taken to ensure that more drug abusers use the service? You made the point that you have to take the service to them; what other steps are necessary?

That is a critical issue. Our home detoxification team started out as a venture that was designed to deal with alcohol detoxification at home, as an alternative to using up psychiatric in-patient beds. Around 30 per cent of its users are now on a course of heroin detoxification.

Normally, the male to female ratio across service uptake is about 65:35, and sometimes 70:30. However, in the take-up of our home detoxification programme—which is much more private and anonymous—the gender ratio is roughly 50:50. If we are serious about tackling the addiction problem among women and people with mental health problems, the issue of taking the service to people is critical. Such a service is very resource-intensive.

That might be a case of taking the horse to water. What percentage of drug abusers would you estimate have no intention of kicking the habit?

That varies from moment to moment, from day to day, and from week to week. People move through cycles. I do not think that, as they move through their cycle of drug use, an injecting, chaotic heroin user is particularly different from you or me, concerning the reasons for which, and the methods whereby, they make decisions for change. I make decisions for change on a balance of the pros and cons of what is going on at a specific point in time. A heroin user will do the same. Some days, they will say that having a habit is a wonderful thing and that they really enjoy it—it is exciting. On other days—usually after they have just been busted or developed an abscess—the habit becomes less heroic and exciting, and they require the service.

I would guess that there is a hard core of between 25 and 30 per cent of drug users, in the area that I deal with, who are not interested in accessing the services that I can offer. If heroin were to be offered in some shape or form, around 15 per cent would still not be interested in accessing any service because they like it the way they are. No matter how strange it may seem to us, sitting round this table, there is a group of people who enjoy that lifestyle.

Yes. That must be generally recognised.

I will now ask you the $64,000 question, and I would like you to relate your answer to resourcing, as it is the crux of the matter. What steps are necessary to increase the number of drug users who become drug free and who take a course of treatment?

Drug free or drug stable?

Drug free.

Outwith methadone programmes?

Yes.

Having successfully graduated?

Yes.

The first step is to recognise that successful graduation from a methadone programme, with adequate counselling and support facilities, will take 10 or 12 years from the moment a person enters the programme to the moment that they leave it. I have been providing the service in Ayrshire for 12 years, and it is only in the past couple of years that people have begun to leave the programme with some success. Patience is needed, as well as the understanding that such programmes are long-term events. All the international studies from America, Switzerland, Holland, Europe and Australia support that view.

Secondly, there has been a cultural shift in people's understanding. We have to understand that drug use is a normative event, that it has always been so, that—although the drugs that people use and the ways in which they use them vary and shift over time—drugs have always been there and will probably always cause problems in one way or another. There needs to be an understanding that a substantial subsection of society is moving away from the traditional drugs that we have been used to in the past 50 years—alcohol and tobacco—and towards other drugs. We must understand that the days of drug stratification—going to one dealer for amphetamines, another for cannabis and another for heroin—are gone and that there are big dealers who deal in everything, which means that the notion of gateway drugs is redundant. There are no gateway drugs; there is a gateway where all drugs are available.

Along with those cultural shifts in understanding, there must be an adequate needs assessment, which has never been done in Scotland. We have no idea of the true scale of the problem. Worse, we have no idea of the true scale of the need. The only way in which we can measure need is by the number of people who contact the support services. We need to have some way of knowing what the people involved want to happen.

We need more money.

That is the answer to the $64,000 question.

I have a background in mental health, so I know that we should not simply throw money at problems. The reason why I prefaced the request for more money with my other comments is that there needs to be a better understanding of what the services should be tailored towards. At the moment, we are juggling balls in the air without knowing which way they will come down.

There is an argument that the easiest way to stop people taking drugs is to deny them access to drugs. That is the enforcement argument. By the shaking of your head, I can tell that you are opposed to the idea. What is your chief opposition? Do you think that it is simplistic?

Yes. It has been tried for a long time. The Americans have made an industry out of it and have failed miserably. The kind of people about whom I was just talking—the ones who do not want services—enjoy the situation. Some people enjoy being Rimbaud; they like keeping to the shadows and they enjoy the thrill of the chase. People go to Oxford, get degrees, become cannabis smugglers and get rich writing books about their lives. There is a piratical thrill involved and enforcement simply magnifies that.

We need an understanding that humans have always used drugs in one form or another. Opiates go back for centuries.

But the scale of the problem does not.

The scale of the problem is such that the Houses of Parliament in Westminster were built with drug money.

This could be a fascinating discussion, but I must move us on.

I will return to what Dr Lind said about heroin and methadone prescribing. In Ayrshire, you met with difficulties in getting GPs to agree to prescribe methadone. Do you agree that many people not only in the community but in the medical profession would have to be convinced of the merits of prescribing heroin?

Yes. Heroin prescribing needs to be a specialist area. None of my colleagues would think that GPs should become involved in it. It would be contentious if they were.

In Ayrshire and Arran, methadone is prescribed centrally. When we visited the area, we were told that that arrangement works well but that there can be problems when the limit is reached and the programme cannot take any more people. That is why Lanarkshire, a part of which I represent, has been reluctant to go down that road. Have you encountered such problems?

That potential problem has always been one of the drawbacks of the model. Set against that is the fact that, whenever we have neared the limit, we have been able to increase it. There has never been much difficulty in persuading people that there is a need for that.

Another thing in the model's favour is quality control. With the best will in the world, it is difficult to guarantee quality prescribing through primary care; GPs would probably agree with that. We make it a condition of prescribing that the individual must come for counselling, no matter how unwillingly. All the evidence shows that, although methadone on its own makes some difference, a good outcome is much more likely to be produced with methadone plus good quality counselling plus a range of other activities.

The primary care-based prescribing systems often struggle to be more than a methadone-dispensing service. Daily, I become more convinced that a good quality addiction service is about much more than simply dispensing methadone. It is about making sure that good detox is available, that women's issues are addressed, that child care issues are addressed and that ethnic minorities have their needs addressed. I mean no disrespect to primary care, but those issues can be lost in that sector.

With the advent of primary health care trusts and local health care co-operatives, I hope that the financial issue is no longer as much of a problem; we are all working from the same budget these days and should be making co-operative decisions about how the money should be spent.

Has Ayrshire and Arran Primary Care NHS Trust taken any specific action to ensure that the services that it provides meet the needs of drug users and their carers?

That is difficult to do. In 1983, I invited one of our more stable drug users to what was then the addiction strategy committee, which was the forerunner of the drug action team. I have never forgiven myself for that. Without any training or preparation, that poor man was exposed to a degree of unpleasantness and patronisation that no one should have to be exposed to. Our reaction to that experiment was to set up a series of events aimed at ensuring that users and carers could use the forums that are available rather than being taken into inappropriate situations and asked for their opinions.

Having said that, I admire Argyll and Clyde for getting a drug user on its drug action team. I would be interested to see how that works out. I am glad that I am not that drug user, as he or she is in a difficult situation. I hope that he or she is properly supported.

Do you agree that it is important that drug users' carers influence the DAT strategy and how it operates? You have made some good points about how that can be problematic, but do you feel it is important that they have a voice? Do you have any suggestions, based on your experience of the difficulties that can exist in making that possible? We are all saying that this is a great idea, but we are not considering how we enable those communities and those drug users to have that voice.

The problem is that drug users are an unpopular group of people in any community outwith the drug-using one. Communities do not necessarily want to listen to drug users. They will listen to families and to the fallout that drug use has in the community, but drug users are often the last people who are listened to in the process.

There are a couple of honourable exceptions. The smaller the community, the more likely it is to be supportive of its drug users, because they are less anonymous and less able to hide behind other people. On your original point about empowerment and facilitation, the issue is that people need to be trained. I do not know how much training you have had in sitting on committees and in chairmanship and so on.

That is a sore point.

Not enough.

Not enough, certainly.

I have had little such training and have had to dig myself out of some deep holes as a result. I do not like putting other people in that position. Our action plan includes a specific section about providing training, education and resources for users and carers, to enable them to become fully involved in the debate. The milestone for that is March next year, by which time we hope that all the carers groups and users groups will feel able to sit in a committee that can get quite fierce sometimes and put their point across effectively, without taking the hump if things do not go their way.

As I listen to and read the evidence, I am becoming aware that certain strategies exist. They may be the wrong ones, but at least they exist. For example, we have a strategy for enforcement in locking up drug users. We also have a strategy that is aimed at moving from chaotic and problematic use to stability under methadone or heroin, or whatever. What is the strategy for the next phase, which is moving from stability to reintegration into the community?

Chris Spry thinks that how we get someone stable on methadone and into education and training is the new frontier. Do people have to be drug-free to make that jump back into the community, or are you suggesting that people who are still taking methadone can go back into education and training, hold down a job and cope with life as part of the community?

The latest employment figures from our methadone maintenance programme show that about 30 per cent are in employment—proper employment, not made-up jobs.

You made the point about society having to learn to live with drugs as a reality. It is a myth that we can be a drug-free society. We should stop trying to attain that and concentrate instead on what we can do practically to get people with a drugs problem back into the community.

Principled responses are probably not the way forward. I used to have principled responses to such matters; I am now a pragmatist. The way it works is that we respond to a situation in the way that makes things easier for people and gives them a good result.

Conversations such as this always come back to methadone, which is an emotive word. First, it is a minor part of what we do. Secondly, it is only a tool to try to introduce stability into somebody's life. Because methadone has a longer half-life than heroin, it has to be taken only once a day, as opposed to three or four times a day, so all it does is replace the need for someone to go out and buy heroin. Unless someone wants to use on top of that and continue to be intoxicated, the methadone replaces heroin until such time as the person is willing to come off it. Methadone sits in the system and does nothing—it does not intoxicate people. We are trying to get that thin line between intoxication on the one hand and withdrawal on the other.

The body produces drugs all the time; they are simply being replaced. What happens in heroin addiction is that the body depletes itself of its natural opiates. A person has to take more heroin to make up for that. When they stop taking heroin, the body takes ten days or so to get that opiate factory moving again to the point where it works properly. The difficulty is that that ten-day period is extremely painful; that is where methadone comes in.

Methadone should not be used as a tool to judge people by, any more than insulin is a tool to judge diabetics by. It is simply there. It is a medication. It is helpful in certain circumstances with certain people. People are quite capable of gainful employment while they are on methadone.

Ayrshire and Arran cover three local authority areas. To what extent is there a variation in the response of the local authorities? At the bridge project in Ayr, which is in South Ayrshire, there is a drop-in needle exchange, but there are no similar projects in Cumnock and Kilmarnock in East Ayrshire. Why is that?

There has been a drop in the number of people taking up the service at the bridge project in Ayr. I am not sure why. Perhaps we are curing the problem in South Ayrshire, but I find that impossible to believe.

Perhaps I will be more direct. Is East Ayrshire not too keen on needle exchanges taking place?

At one point, East Ayrshire was not too keen on needle exchanges taking place on its property, including its housing stock. We have resolved that problem now. For example, there are two bridge projects in East Ayrshire—in Cumnock and Kilmarnock—and we are expecting to start needle exchanges in the near future.

That is one of your difficulties—bringing all those disparate councils, organisations and bodies together.

It has some practical difficulties. We resolved both those issues by using backpacking exchanges. That is why backpacking is over-represented in East Ayrshire. We compensated by using that way round the problem, until East Ayrshire decided to change its mind. Some of those decisions feel capricious from time to time.

It is a measure of the amount of education that is needed, even for those who hold public office.

Even those—the most difficult people I have talked to are local councillors. They are sometimes difficult to move from their fairly entrenched positions. I find them more difficult than general practitioners, which is saying something.

I remind you that you are on the record.

On the hepatitis issue—as the two issues are related—how serious is the hepatitis situation in your health board area?

I hate to think.

We do not have any figures on that either. There is a little footnote below the Scottish figures from the Scottish Centre for Infection and Environmental Health to say that those figures could be an underestimate by severalfold.

The rumour doing the rounds of drug agencies in the west of Scotland is that 70 to 75 per cent of intravenous drug users are coming across the threshold. I am cagey about that, because we had the same kind of debate when HIV was first around.

What has become clear is that the way we did needle exchange to begin with was probably not terribly effective with hep C, although it was with HIV. We have re-examined that fairly substantially and made some changes to the advice that needle exchange workers offer. I have been loth to test people for hep C, because I am loth to test people for something for which there is no apparent intervention.

What about interferon?

That is out to some debate at the moment. There is a fairly substantial argument about its effectiveness. It seems likely that it is a delay rather than a cure, per se.

I am sorry, but I need to push things on. Keith, have you finished your questions?

There is one final one, but—

I am sorry, but we must finish. We may well come back to you, Dr Lind, especially on the details and for information. Many of the issues you have talked about have been extremely interesting. You have given us many quotes for our report.

As long as they do not get back to the health board.

We will do our best to protect you—we know how it feels. Thank you for all the work you have done for us. It will very much help us with our report, of which you will receive a copy.

Meeting closed at 16:31.