Meeting of the Parliament

Meeting date: Tuesday, December 19, 2023

Official Report 1076KB pdf

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Medication Assisted Treatment Standards

The next item of business is a statement by Elena Whitham on implementing the medication assisted treatment standards. The minister will take questions at the end of her statement, so there should be no interventions or interruptions.

15:52  

Today, I want to assure members that I am determined to continue to work across these benches, across all sectors and across each and every community throughout Scotland to embed the critical aims of the national mission to save and improve lives. My thoughts are with everyone impacted by the loss of a loved one.

I acknowledge the suspected drug deaths figures that were published last week by Police Scotland. That management information report provided an indication of current trends in suspected drug deaths. It covered the period from January to September 2023, and it reported that there were 900 suspected deaths, which is 13 per cent more than there were in the same period in 2022.

I am absolutely steadfast and determined to turn the tide on drug deaths. A real concern for me right now is the increasing appearance of synthetic opioids in the drugs supply. That increase is being seen across the United Kingdom; I will cover that later. Those new drugs, especially nitazenes, are being found in a range of substances, and they bring with them an increased risk of overdose, hospitalisation and death.

That is why the MAT standards are so important. The second annual benchmarking report, which was published in June, illustrated that clear progress was being made in a number of areas of Scotland. I take the opportunity to again thank everyone involved in working to change services for the better. Change is happening. In my meetings with individuals and various stakeholders over the past few months, I have heard about and witnessed for myself the will and drive to improve access to treatment and support. For example, on MAT standard 3, the MATS implementation support team—MIST—is working in collaboration with colleagues from across Scotland to develop guidance to ensure that all people who are at risk of drug harms are identified and provided with support, and to ensure that pathways extend beyond the Scottish Ambulance Service and the emergency department and into housing, family members and justice and third sector organisations, and include people who use any substances problematically.

It is important to acknowledge the hard work and determination in relation to implementing the MAT standards. However, I do not shy away from the work that there is still to do to ensure that successful implementation is achieved and sustained across Scotland.

That is why, following the ministerial letter of direction that was issued in June last year, I have maintained the requirement for the majority of areas to report quarterly to the Scottish Government. In seven areas, there has not been significant progress, and those areas will provide monthly updates on their progress. However, I do not wish to demotivate or demoralise any member of staff or individuals in those areas, who are working above and beyond to implement the standards, because there have been local challenges to overcome.

MIST is working closely with each of those areas, and I can report that, for most, good progress is being made with a view to the full implementation of standards 1 to 5. It is my intention to meet staff in those areas in the coming months to hear for myself how barriers are being overcome. I have heard from individuals, families and supporting services that our aims are not always translating into positive experiences on the ground, and I will discuss those cases when I meet local leaders.

We know from this year’s benchmarking report that standards 6 to 10 require new approaches. I acknowledge that some of those are taking time to embed, but I remain committed to implementation in 2025. What I see, however, is services working together more closely than before. For example, MAT standard 9 criteria and the mental health strategy set clear expectations that people with co-occurring mental health and substance conditions should have access to high-quality and integrated care. Work is on-going to improve care by getting the local foundations right, empowering the workforce and embedding clear lines of accountability. As part of MAT standard 8, we are working alongside Public Health Scotland and experts across the field to ensure that advocacy and support are in place at local level. For MAT standard 7 and primary care—although this can be seen as challenging—areas are exploring different service models such as shared care, non-medical prescribers and better joint working.

Community pharmacy also has a role in improving outcomes for people. For example, there is a programme of work that has been successful in improving education for pharmacy teams on substance use. That includes the roll-out of training on naloxone use for all community pharmacies and supporting the pharmacy network in Scotland to deliver undergraduate and postgraduate pharmacy training on substance use.

In justice settings, in partnership with others, MIST has led the development of a resource kit to support police and prison staff to implement the MAT standards. There is innovative work going on in HMP Perth to promote recovery and to ensure that those at the highest risk of drug harm are followed up by community services. There is improvement work being undertaken in NHS Highland to support those who are most vulnerable in police custody, offering nursing support at first point of contact. In Kilmarnock, the organisation We Are With You attends people who are in police custody to help them with regards to MATS.

MATS implementation needs to be based on hearing and listening to the voices of people who use services. However, areas need to go further than listening. We need to drive improvement based on the feedback that is gathered from those with lived and living experience. That will often mean making changes to how we do things.

Last week, I had the pleasure of attending the launch of the national collaborative’s draft charter of rights. The charter helps people to understand their rights and sets out the kind of actions that public bodies, including the Scottish Government, will be expected to take in the context of the forthcoming Scottish human rights bill. That strengthens efforts that are already under way as part of implementing the MAT standards, and, crucially, it ensures that people are involved in decisions that affect them.

The successful implementation of MATS and our national mission requires a skilled and resilient workforce. It is therefore crucial that services are able to attract, retain and support staff. We are engaging extensively with partners to get a clear understanding of the specific steps that are required to drive improvement. Those steps are set out in the drugs and alcohol workforce action plan, which was published earlier this month. The action plan details the key workforce priorities that we will deliver over the next three years, and I want to offer reassurance that significant progress has already been made towards delivering a number of those.

Although I am committed to ensuring that MAT standards are fully implemented, I fully recognise other emerging threats that we need to be aware of and tackle, including the threat from synthetics such as nitazenes. We have improved our surveillance to monitor drug trends and what is in the drug supply through our rapid action drug alerts and response, or RADAR, system. That has allowed Public Health Scotland to issue two public health alerts this year on specific substances, one of which was for synthetic opioids. Alerts aim to raise awareness of risks for individuals and families and to alert service providers to deliver vital harm reduction, including the provision of naloxone.

Through surveillance, we have already seen synthetic opioids appear in the supply. Those substances, which are significantly stronger than regular opiates, are a massive concern for everyone, not just in Scotland but across the UK.

In the summer, the UK Government issued its own alert about nitazenes, and, last week, the National Crime Agency published information estimating that, in the past six months, there had been 54 nitazene-related deaths in the UK, nine of which were in Scotland.

I discussed the issue with the UK Government and other devolved Administrations at the UK drug ministerial meeting that was held last month, and I am committed to continuing to work with UK colleagues on the issue. I also recently met international experts to discuss their experience, and I will hold a round-table event with stakeholders to discuss operational issues early in the new year.

We know that naloxone works on synthetic opioids. Therefore, our aim is to continue to increase the number of kits in general circulation, with the public to provide initial medical treatment.

In addition, we are working with our cities to establish drug-checking facilities and the aim is to submit licence applications to the Home Office to allow those to be established in the coming months.

In Glasgow, we are supporting the setting up of a safer drug consumption facility in which emergency care can be offered if someone overdoses. That will be even more important if there is an increase in consumption of synthetic opioids as overdose is more likely due to their increased strength.

In Glasgow, the enhanced drug treatment service treats people with prolonged heroin use who have had little or no response to traditional opioid treatment methods. The service has been evaluated to work safely and effectively, and it has ensured a safe supply of diamorphine as a harm-reduction method for that population.

We have also seen an increase in the use of cocaine and its associated harms. No medicine is available that can act as a substitute, but other types of treatment such as psychosocial interventions and supervised detoxification are available. Third sector organisations are leading the way in helping people with cocaine problems. Indeed, a blog was recently published on the Healthcare Improvement Scotland MAT learning system website detailing how Harbour Ayrshire, which is a charity, is helping people into recovery from cocaine.

Moving forward, continued implementation of the MAT standards will drive further change. I remain committed to the timelines that have been set out. We must also be alive to emerging threats and services must adapt—as they have been doing admirably thus far—to meet the new challenges.

MAT implementation should remain at the forefront of what areas are doing. The work is saving lives, stigma is being tackled, the workforce is being valued, and areas are sharing learning and best practice. Everything is coming together to save and improve lives.

I must pay due respect to the continuing commitment from parties in this chamber. Members’ challenge and desire for change are welcome as we look to full, equitable and sustained implementation of MAT standards in all areas across Scotland.

The minister will now take questions on the issues that were raised in her statement. I intend to allow around 20 minutes for questions, after which we will move on to the next item of business. It would be helpful if members who wish to ask a question could press their request-to-speak button.

I thank the minister for the advance copy of her statement—this one was sent timeously.

Last week, data released by the Scottish Government revealed that drug deaths have risen for the first nine months of 2023 by 13 per cent compared to the same period in 2022. It is unacceptable that an additional 103 lives have been tragically lost to drugs.

The Scottish Government is focused primarily on harm reduction and the destigmatisation of drugs. The 10 MAT standards are its vehicle to achieve that, but they are one that it is failing to deliver, having pushed back their full implementation until April 2025.

The minister mentioned in her statement progress with MAT standards 7, 8 and 9, but perhaps the most important MAT standard is standard 1: same-day access to treatment. The standard is to enable people to access treatment or support on the day that they present to any part of the service. However, national drug and alcohol treatment waiting times that have been published today show that five out of 13 health boards did not meet the standard that 90 per cent of people who are referred for help will wait no longer than three weeks for specialist treatment. If health boards and alcohol and drug partnerships cannot provide treatment within three weeks to 90 per cent of the people, how many are capable of achieving same-day access to treatment—in other words, MAT standard 1?

The minister stated that she is

“absolutely steadfast and determined to turn the tide on drug deaths.”

If that is true, every avenue must be explored. Will the minister finally get behind the proposed right to recovery bill?

I recognise Sue Webber’s commitment to and passion for this subject.

Access to specialist treatment is slightly different from access to same-day treatment in the MAT standards. Perhaps I need to do a bit of work to communicate that more effectively. We are making progress in achieving MAT standard 1 across the board, which is very welcome.

Harm reduction is a form of recovery; I do not think that we can separate the two. I am committed to extending access to residential rehabilitation. We have committed more than £37 million to seven capacity projects, and people are accessing those services in numbers that we have never seen before. Last year, 812 people accessed a publicly funded placement in residential rehab, which represented a 50 per cent increase.

I am committed to working with members across the chamber and to considering the proposed right to recovery bill when it is published. I will be interested to see how some of the concerns about unintended consequences that were raised during the consultation have been addressed. I give a commitment to looking at the bill once we see the details of it.

I remind all members who wish to ask a question to ensure that they have pressed their request-to-speak button.

I thank the minister for advance sight of her statement, although I found it to be wholly depressing.

MAT standards 1 to 5 have still not been fully implemented, and there is no guarantee that standards 6 to 10 will be delivered by 2025. As we have heard, the fact that the number of drug deaths has increased by 13 per cent from last year is simply shameful. Since a public health emergency was declared four years ago, almost 5,000 lives have been lost, so any progress on MAT standards and on the safe consumption room pilot in Glasgow represents steps in the right direction, but much more needs to be done.

The massive cuts to health and social care partnership budgets that have been handed down by the Scottish National Party Government have resulted in a reduction of men’s rehab services and the planned closure of Turning Point, which provides women’s rehab services in Glasgow. Its funding was slashed by £850,000. Despite the rising number of drug deaths, the SNP has cut funding to alcohol and drug partnerships by £46.3 million in real terms. That tells us all that we need to know about the SNP’s priorities. What is the minister doing to stop the cuts to drug rehabilitation and treatment services so that more people do not lose their lives in Scotland?

I absolutely recognise that we have lost far too many people in our country to wholly preventable deaths.

There have been significant increases in funding for drug and alcohol services as a result of the national mission. Funding for drug policy has increased by 67 per cent in real terms from 2014-15 to 2023-24, according to figures that were published by Audit Scotland last year. Although I recognise that there are funding issues, we should also recognise that, since the year prior to when we traditionally think of the services having a reduced budget, there has been a 67 per cent real-terms increase in funding.

Decisions regarding Turning Point and other such services are not taken by the Government, but I understand why people are afraid of what might happen if such a service closes. I am looking for the health and social care partnership to explain how it will support some of the most vulnerable women, especially those in Glasgow city centre, who have multiple and complex needs.

I am alive to all those issues, and I am determined to ensure that the budget of which I have control goes to where it is needed, so that we get the best results for our investment.

A number of members wish to ask a question, so we will need briefer questions and answers.

During recent engagement with my local ADP service lead, the issue of medication costs was raised. Can the minister provide an assurance that health boards are meeting the costs of medications that potentially save lives, such as Buvidal and naloxone, in the same way that other patient groups have access to life-saving medication?

I thank Audrey Nicoll for asking that important question. Buvidal and naloxone are medicines that need to be available everywhere to help to save the lives of some of the most vulnerable people in our communities. It is simply unacceptable for health boards and integration joint boards to single out those medicines and treat them differently from all other medicines. Stigma is pervasive in all areas of our culture when it comes to issues relating to drug use. My officials have met chief finance officers and ADPs to ensure that the costs of those medicines are being provided for appropriately. For boards where there may still be some confusion, we will be writing out shortly to give clear instructions on the need to properly fund the availability of Buvidal and naloxone.

I declare my interest as a practising national health service general practitioner.

The minister’s statement today, like many statements that we have heard before, does not actually say anything except that drug deaths have gone up by 103 more people—real people with real families. That is completely unacceptable. The minister also stood there and said that she is

“absolutely steadfast and determined to turn the tide on drug deaths”,

yet her record does not back up her rhetoric. When will we see the introduction of safer consumption rooms in Glasgow?

I recognise that, across the chamber, we all want a reduction in drug deaths, and I recognise that each and every one of those people is an individual. So far in my time in this job, I have met several families who have been affected, and I know of far too many people and families who have suffered that loss.

I will remain steadfast. A safer consumption facility is one thing that we can do to support those individuals who are sometimes at most risk of harm in Glasgow city centre and who are injecting in public. We know from the 2016 report “Taking away the chaos—The health needs of people who inject drugs in public places in Glasgow city centre” that they require a safer consumption facility. The Glasgow health and social care partnership is working at pace to ensure that it has staff members in place come the spring. We hope that the facility will be open by the summer months, once we have the infrastructure in place.

The minister will be aware that I have been working to ensure that the MAT standards are implemented for rural parts of Scotland, such as Dumfries and Galloway and the Scottish Borders. Will the minister provide an update on how implementation is working in rural areas versus urban areas? Will she comment on how stigma reduction work is progressing in rural Scotland through, for example, the important work of local recovery cafes such as those that are run by Borders In Recovery, which has cafes in Hawick, Gala, Kelso, Eyemouth and Peebles?

Small teams and those in remote and rural settings have particular challenges. However, ADP areas with remote and rural settings have demonstrated innovation in maximising the use of technology and flexible models of care so that people can benefit from equitable care and treatment. Those in our remote and rural communities have always had the adage that, as my grandpa would say, “‘Huv tae’ is a guid maister”, and they are very innovative in their approaches.

Emma Harper mentioned Borders In Recovery, which is an organisation that I would like to visit in the new year to discuss how it delivers its support services in that rural setting. I am keen to ensure that our rural services develop.

We know that stigma prevents people from accessing the treatment and support that they need and are entitled to, and that there can be specific impacts in rural areas. Work is taking place locally to reduce stigma, with all ADPs reporting that they consider stigma reduction in written strategies or policies, including the MAT standards implementation plans, alongside a range of other actions.

Nationally, we published our stigma action plan last year, which outlines our plans to develop a voluntary accreditation scheme to tackle structural stigma and to implement a national programme of activity to challenge social stigma. I will keep the Parliament updated on the progress of that plan.

An evaluation of Glasgow’s diamorphine-assisted treatment service pilot found that people who engaged with the service decreased heroin use and experienced improvements in their overall health and wellbeing. Those are very positive signs. The evidence shows that diamorphine-assisted treatment works, but the Glasgow service has helped just 30 people since it was launched in 2019, which is a very restricted capacity. What is the Scottish Government doing to increase that capacity so that more people with complex needs who use drugs can access the treatment, in line with MAT standard 2, on choice?

I absolutely recognise the issue that Paul Sweeney raises. The model that is on offer in Glasgow started during Covid, so there was an interruption to the number of people who were brought on board. We know that the number is increasing as time passes after Covid, but I am also aware that there are other models that we can implement across the country. Funding has been made available for projects to carry out scoping exercises in local areas and to look at taking on that approach. I have had discussions with Cranstoun and other organisations about how that can perhaps be delivered in different parts of the country with different models, and I am willing to work with any local area that wants to do that. The Government is ready to stand side by side with local partners.

I remind members that I am the vice-chair of Moving On Inverclyde, which is a local recovery service.

There are important differences in drug-related deaths data collection methods across the United Kingdom. Can the minister speak to those differences, the consequences for the comparability of the figures and the continued steps that are being taken to ensure that improvements in data collection take place in Scotland?

The definitions that are used for drug deaths statistics are consistent across the UK, but there are important differences in data collection methods and in the death registration systems that affect the comparability of the statistics, due to there being different levels of missing data across the UK nations. The same comparability problem that is found with identifying drug misuse deaths applies to the figures for all individual substances and drug categories. The drug misuse death definition is the main headline figure that is used in Scotland, but the drug poisoning death definition is the more accurate comparator with the rest of the UK.

The Scottish Government remains committed to improving our data and surveillance on drug deaths and harms through, for example, our rapid action drug alerts and response—RADAR—surveillance system. That system, which has come into its own recently, assesses emerging threats, shares information to reduce the risk of drug-related harm and recommends rapid and targeted interventions.

There have also been great advances in toxicology reporting in Scotland. Ministers in the rest of the UK have looked towards us for leading on that. The more we can identify the substances, the more we can introduce harm-reduction measures.

The minister will be aware that she carries the good wishes of Liberal Democrat members for her mission with regard to drug deaths.

In November, I raised with her the threat posed by synthetic opioids, which can be up to 100 times stronger than morphine. In the United States, in 2012, 2,500 people died after using them. By 2022, that number had leapt to nearly 80,000 deaths a year. That could be the canary in the coal mine for what is happening in Scotland. There has been an increase in the use of nitazenes, a synthetic opioid, which has been linked to nine deaths in the past six months. Will the minister commit to more regular monitoring of, and updates to Parliament about, nitazene use and mortality, so that we can be clear whether that wave is about to break here?

I have been pondering how we ensure that we collate the information that we get from the RADAR reports and collect from the Queen Elizabeth university hospital’s programme, which monitors people in real time as they come into accident and emergency, and examine that information in totality. I am concerned about what might be coming down the line to us. I visited local organisations this week and heard that four doses of naloxone have had to be deployed in a service to reverse an overdose. That is concerning.

I am also concerned about the fact that nitazenes have been found in substances that are not linked to heroin, which means that somebody will not anticipate that they are taking a nitazene. They might be buying an illicit benzodiazepine or using what is supposed to be a cannabinoid-type vape, and nitazenes are contained therein.

I commit to keeping Parliament abreast of the emerging threats, but I will also try to figure out how we respond in an even shorter timeframe.

In her statement, the minister said that there has been a rise in cocaine use and its associated harms. She also stated that there are no medicines available as substitutes. Other treatment methods are available, one of which is supervised detoxification. Will she explain how supervised detoxification will be delivered and whether there will be a requirement for residential rehabilitation? If there will be such a requirement, will she explain how residential placements will match demand?

Annie Wells asks an important question. Cocaine use is rising across the country in different age groups and cohorts of individuals. Although there is no medication substitute for such a stimulant, detoxification can work well. We have committed £5 million per year to look at our stabilisation and detoxification provision across the country. Of that, £3 million is to increase the provision, and £2 million is for a rapid capacity-building fund.

I ask that local areas work together collectively on services so that we can increase the provision of placements for stabilisation and detox, because they are a key part of our mission. They are also the key link between community recovery settings. People might go into the detoxification and stabilisation setting and then on to residential rehabilitation, if that is right for the individual.

I am happy to keep Annie Wells informed as we go along.

The MAT standards emphasise a multipronged approach to treatment and recommend residential rehabilitation as a potential course for support. Will the minister provide an update on the progress that is being made on expanding and improving access to publicly funded residential rehabilitation?

Following on from the question that Annie Wells has just posed to me, Jackie Dunbar has asked another really good question. We are committed to expanding access to residential rehab. We are investing £37 million in seven residential rehabilitation capacity projects across the country. Through that and other funding over the course of this session of Parliament, we are working to increase overall residential rehabilitation capacity by 50 per cent, which is an increase from 425 to 650 beds.

We are moving at pace to develop a standardised approach to commissioning residential rehabilitation services through work with Scotland Excel, which has also supported us to create an online service directory, which will be available soon, to allow services and individuals to see what is on offer across the country.

We are providing funding to support residential rehab placements, including £5 million per year to ADPs, and additional funding through our prison to rehab scheme and our capacity programme.

This morning, Public Health Scotland published a report that shows a further increase in the number of referrals in the first two quarters of 2023-24, with a total of 477 statutorily funded placements being approved. That is an increase of 126 placements on the figure for the same period in the previous year, when 812 placements already showed a 50 per cent increase in the number of placements overall. We aim to increase the number of statutorily funded placements by 300 per cent over the next five years so that, by 2026, at least 1,000 people will be publicly funded for their placement in residential rehab.

Drug use is not a simple issue, but one that is compounded by factors such as deprivation, poverty and exclusion. What training is being provided to ensure that those interrelated and interlinked issues are being dealt with? Given the minister’s acknowledgement that experiences on the ground are not always good, how are we ensuring that, when things go wrong, those situations are evaluated and addressed and, where appropriate, are used to improve knowledge and individual practice?

I thank Gillian Mackay for that question, which is a very important one that has several facets to it.

As per MAT standard 8, the Scottish Government is working with Public Health Scotland and experts across the sector to ensure that people who use drugs have access to independent advocacy and support for their housing, welfare and income needs. The Scottish Government is committed to ensuring that those who use alcohol or drugs are supported to access services and that staff are trained to understand the wider complex needs of people who use drugs.

In order to ensure that those important and complex interlinked issues are recognised, Reach Advocacy has been awarded funding to deliver training on the implementation of MAT standards as part of a wider human rights-based approach. The training allows front-line staff and managers across statutory and third sector services to develop their knowledge of MAT standards and human rights legislation in order to provide holistic and rights-respecting care.

There is also a fundamental part about really taking on the learning when we recognise where things have gone wrong. That learning can then be cascaded to other front-line services. After hearing directly from front-line services yesterday, I am cognisant of the impact that repeated overdose reversals are having on members of staff. We are looking to support members of staff’s wellbeing.

I refer members to my entry in the register of members’ interests, which states that I hold a bank staff nurse contract with NHS Greater Glasgow and Clyde.

As the minister is aware, standard 9 states:

“All people with co-occurring drug use and mental health difficulties can receive mental health care at the point of MAT delivery.”

I note that the minister mentioned standard 9 in her statement. Can she give further information on the progress that is being made in implementing that MAT standard?

I thank Clare Haughey for the question, because it is on the fundamental aspect of ensuring that people who have co-occurring issues with substance use and mental health are not bounced around services, which happens far too often.

We have commissioned Healthcare Improvement Scotland to produce an exemplar protocol, which will build on best practice from across the country and internationally. It will ensure that every area has access to a high-quality document on which they can base their own protocol. Once the exemplar protocol has been made available to the local areas early next year, HIS will offer strategic change management support, which will help local areas to adapt the exemplar protocol to their own circumstances, pilot elements of it and then implement it fully. In addition, we will work with HIS and stakeholders, including NHS Education for Scotland, to ensure that we have the appropriate training and data reporting to support and monitor improvements.

By implementing the exemplar protocol, local areas will also be implementing MAT standard 9, with co-occurring support being provided where it is needed. However, the protocol is not limited to opiates or medication-assisted treatments; it will support many more people in relation to their substance use.

That concludes the statement. There will be a short pause before we move on to the next item of business.