Meeting of the Parliament

Meeting date: Tuesday, June 20, 2023

Official Report 1073KB pdf

---

Medication Assisted Treatment Standards

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

14:28  

Every life lost to drugs is a tragedy, and we collectively feel the loss of the talent and potential of far too many of our people. I offer my condolences to everyone who has felt that loss and my unwavering commitment to continue the work to turn the tide on this public health emergency.

Families and people with real-life experience of drug and alcohol problems tell me that there must be a commitment to change at all levels from the front line to local leaders and from public services to national leaders. That is reflected in the report, “National benchmarking report on implementation of the medication assisted treatment (MAT) standards: Scotland 2022/23”, which Public Health Scotland published this morning.

The report covers the year up to April 2023 and charts the significant progress that has been made across the country since the first benchmarking report was published in June 2022. I am heartened by the progress that the report shows. However, there is still much work to do to fully implement the standards by April 2025 and for them to be sustainable by April 2026.

From my previous work in homelessness, supporting many people dealing with substance use issues, as a Scottish Women’s Aid worker and, indeed, as a councillor campaigning for change, I am fully aware that the targets that we have set for local areas to implement the MAT standards have always been ambitious, but the standards will save lives and make a long-term difference for people in treatment.

Today’s report includes maps comparing progress with the position in April 2022. The national picture is clearly improving, and the maps allow us to chart progress area by area. Naturally, much attention will focus on the red-amber-green implementation tables, which show good progress on MAT standards 1 and 2. There has been a transformation in rapid access to opioid substitution therapy, with 18 of the 29 local areas having fully implemented MAT standard 1, compared to just one area in 2022. Likewise, MAT standard 2, on choice, is now fully implemented in 27 of the 29 alcohol and drug partnership areas.

Overall, by April 2023, 66 per cent of MAT standards 1 to 5 had been fully implemented, compared to 17 per cent in 2022, and 88 per cent of MAT standards 6 to 10 had been partially implemented. I realise that we were aiming for 100 per cent implementation of MAT standards 1 to 5 and partial implementation of standards 6 to 10 for this report. That has not been achieved, and many will see that as not good enough. Although I absolutely agree on the need for urgency and pace around reducing harm and saving lives, I also know that, from the outset, many people did not believe that services could achieve what they now have achieved. It is better to aim high than not to attempt to make any significant change at all.

All ADP areas with remote and rural settings demonstrated innovation in terms of maximising the use of technology, subsidised travel and flexible models of care so that people could benefit from equitable care and treatment. I really thank those ADPs for thinking outside the box.

The report includes some case studies that reflect that change is already happening in many places. Over the past few months, I have had the privilege of speaking with a lot of groups, service providers and people accessing services, and I have visited drop-in centres providing MAT to see for myself improvements and change on the ground. I have seen and heard of the progress that is being made and the future plans for full and sustained implementation of the standards.

The report shows a dramatic increase in capacity and capability in ADPs for evidence collection, with almost all areas now collecting experiential feedback from people who have recently used services. However, putting in place reliable and sensitive systems for collecting that feedback is a major challenge. That will take some time to fully embed, but it is undoubtedly the most important measure for whether the MAT standards are in place. Strengthening the experiential feedback is one of the four key recommendations made in the report, along with recommendations on building sustainable numerical data systems, establishing systems for more direct support and further development of guidance for implementation and assessment.

The report also reflects on next steps for local and national partners to further improve the landscape to help services make necessary improvements. I expect everyone from every service to work collaboratively to deliver on that part of the on-going national mission. For the avoidance of any doubt, the Government remains committed to the continued funding of the mission over the course of this parliamentary session.

The report highlights the need for changes in healthcare models to support implementation of MAT in prisons. We will therefore be focused on establishing a more consistent approach to access and choice in justice settings; addressing data-sharing challenges; and sharing best practice on service models that will deliver better outcomes for people. A justice network for MAT implementation is already sharing experience across areas and identifying best practice models.

For the remainder of the national mission, we are also committed to focusing more on the care and support for people who have problems with benzodiazepines, stimulants and alcohol, rather than focusing only on opioid use. That is absolutely imperative.

We have already committed to all of that on-going work through the Scottish Government’s cross-Government action plan, which we published in January 2023. It sets out how we are responding to the final recommendations made by the Scottish Drug Deaths Taskforce and how the national mission is being taken forward through a whole-Government and whole-Scotland approach. It also includes detail on what we are doing to address the workforce issues that are raised in today’s benchmarking report, and to tackle stigma.

MAT standards are about delivering faster and more responsive services, but they are also about changing hearts and minds, including tackling stigma and discrimination. Make no mistake, Presiding Officer, I am acutely aware of the damaging nature of stigma, which we must challenge wherever and whenever we see it.

ADPs and local partnerships are taking forward innovations to help address drug deaths. One that I know is of great interest to members is the potential use of safer drug consumption facilities. I confirm that the Government remains committed to the introduction of the Glasgow pilot, and I will inform Parliament immediately a view is reached by the Lord Advocate on the proposals from Glasgow city health and social care partnership and Police Scotland.

Although clear improvements have been made in response to the letter of direction that was issued to local services last year, we need to continue with formal oversight procedures and clear local accountability.

We will maintain the requirement for quarterly progress reports from local areas against their implementation plans, with monthly reports from areas of concern. The new benchmarking report will allow us to identify the areas that we now need to focus on. I will be writing to local areas in the coming weeks to update the oversight arrangements accordingly.

I will also be meeting local leaders to challenge them on progress, particularly where we believe that more commitment is needed from senior colleagues. We all want people to exercise their right to treatment, but that will all be for nothing if the services are not in place. The letter of direction requiring local leaders to implement the standards will remain in place and I will continue to provide Parliament with regular updates on progress.

The benchmarking report concludes:

“There has been a transformational change in improved access ... and choice of treatment ... for people with problematic drug use ..., and significant improvement in the other MAT standards. This is a direct result of hard work and collaboration within and between ADPs (including clinical, third sector, and lived and living experience partners) and of a shift in culture that has overcome many barriers to change.”

Of course, the continuing commitment from this chamber and all members is helping to drive improvement as well.

I thank the MAT standards implementation support team for its continuing hands-on support, working alongside local areas, and Public Health Scotland for its vital report. MAT standards are about driving change and improving outcomes. The standards are empowering people to demand the treatment that they deserve and there is no going back. We can now only go forward.

However, to quote again the report’s conclusion:

“implementation of the MAT standards is a vehicle for change and not a sufficient end in itself.”

For this year and the remainder of the national mission, the priority will be full, equitable and sustained implementation of the MAT standards in all areas.

The minister will now take questions on the issues 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. I would be grateful if members who wish to ask a question were to press their request-to-speak buttons.

The minister may be heartened by today’s figures, but I am utterly dismayed. Originally, the Government planned to implement the standards by April 2022, but it was forced to push the deadline to April 2024 with the promise that only standards 1 to 5 would be fully implemented by April 2023—and here we are. Today’s analysis lays bare the failure of this Scottish National Party Government: a full third of standards 1 to 5 have not been fully implemented, despite the promise of 100 per cent implementation.

In the foreword to the report, Tom Bennett from the Scottish Recovery Consortium highlighted that in many Scottish local authorities the failure to meet those expectations is leading to “tragic outcomes”. The minister’s statement made scant reference to the prison system, but the report itself is totally damning. It states that

“Clinical capacity to deliver the MAT standards in prisons is insufficient”

and highlights

“structural and healthcare capacity issues”

across the prison service. So, it is shocking that the minister remained almost silent on the problem in our prisons in her statement. That is exactly the time when we should be intervening to support those who want to break the cycle of substance misuse. Given the emerging drug trends unfolding in our prison system, can the minister tell us specifically what has been done to break the cycle of addiction in prisons?

I thank Sue Webber for her question and I recognise the passion that she has in wanting to see change being driven forward. I am absolutely committed to working with her and with members right across the chamber to ensure that we can do that.

The MAT standards have to work in justice settings and we will be pushing and supporting local areas, including healthcare teams in prisons, to achieve full implementation by 2025, as previously announced. There are specific challenges in justice settings, as highlighted in the benchmarking report. However, we have already announced our intention to improve healthcare in prisons through new models of care, improvements in data collection and setting up better links between services in prison and services in local communities to address the issues that were identified in the report. This year, MIST will be supporting health teams in prison settings to embed MAT standard 3, in particular. That is about assertive outreach, but also anticipatory care that needs to meet people when they are coming out of prison—

And going in.

—which we know is an absolute area of concern, with the potential for people to come to harm.

We will continue to learn from best practice in the implementation of the MAT standards and we will engage with experts on the ground on the most appropriate ways to deliver these vital changes in all settings. I was in Glasgow this morning to hear about the wonderful work that Sustainable Interventions Supporting Change Outside—SISCO—is doing in prisons to deliver peer-to-peer harm reduction within that setting, but also to make sure that they are doing proactive outreach work when people are coming out of prison.

I am happy to go and visit anywhere else in the country where we are seeing such work so that we can passport that learning between different areas.

I call Dame Jackie Baillie. [Applause.]

I will get you back later, Presiding Officer.

I thank the minister for her statement, but it represents an alternate reality. Let us be clear: today’s report shows that, once again, the Scottish Government has failed to deliver on its promises about tackling the public health emergency. There have been three drugs ministers in four years and none of them has made a dent in the problem.

I remind the chamber that, originally, all 10 MAT standards were to be fully implemented more than a year ago. In March 2021, the minister’s predecessor said in the chamber:

“We will ensure that those standards are fully embedded across the country by April 2022”—[Official Report, 18 March 2021; c 52.]

The Government failed. Then, the implementation date became April 2023 for standards 1 to 5. Guess what: it failed again.

That has real consequences, because Scotland’s drug death figures hit their worst level in two years earlier this month, despite the Scottish Government declaring a public health emergency more than three and a half years ago. Will the minister guarantee that all 10 standards will be fully implemented by April 2025, three years later than originally planned?

I thank Dame Jackie for her question. I recognise that she has a keen interest in the area. I am determined that we will see sustained implementation of the standards by the dates that are set out in the benchmarking report, because there is no option but to ensure that we prevent harm and save lives.

I will ensure that the areas that are not where we want them to be continually have monthly meetings with me, because the letter of direction will remain in place. However, I also want to engage with local leaders on the matter. Local elected members need to work in partnership with us to ensure that we drive change forward.

What steps are being taken to ensure local accountability in implementing the MAT standards with a view to driving improvements across Scotland?

Ministers have directed the chief officers of health and social care partnerships to work with chief executives of their national health service boards and local authorities to implement the MAT standards. For each local authority area, a senior figure has been identified to lead on the implementation of MAT, which includes the publication of, and reporting on, MAT implementation plans. Reports are provided quarterly for most areas, although areas of specific concern are required to report monthly on their progress and have lots of meetings with me. Ministers and senior Government officials will continue to meet regularly to try to ensure that there is local accountability.

I have also recently met Councillor Kelly, the health and social care spokesperson for the Convention of Scottish Local Authorities. We both agreed that we need to harness the drive and commitment of locally elected leaders to help to drive our national mission forward. I will attend an upcoming COSLA board meeting to hear directly from local elected leaders about their concerns and to work in collaboration with them.

I declare an interest as a practising NHS general practitioner.

Drug deaths are still worryingly high, to our national shame. The Scottish Government needs to act and it needs to back our proposed right to addiction recovery bill.

One of the actions that the minister outlined is the pilot for safe consumption rooms in Glasgow. I have had people speak to me who have concerns about a consumption room being in their area. The Scottish Conservatives support the concept of the pilot for drug consumption rooms but, before any decision is made, will the minister publish a long list of areas where the Government might place consumption rooms? Will there be an opportunity for residents around those sites to feed into the consultations and will ministers listen?

I recognise that, across the chamber, we have an agreed position on the pilot for a safer consumption facility to be rolled out once we get the go-ahead from the Lord Advocate, if that is the decision that she reaches. Once the Lord Advocate reaches that decision, there absolutely has to be consultation with the local community around the area that has been identified for such a facility. It is correct that we consult the local community.

I would say to Dr Gulhane, however, that there is no doubt in my mind that a safer consumption facility—indeed, multiple safer consumption facilities, if we get to that point—are a key part of harm reduction and saving lives. They are not the only part of that but, around the world, they have been shown to save lives. Nearly 50 of them are now in operation across in Canada.

As the minister will know, I have been working with her and with her predecessor to tackle drug and alcohol-related stigma, which affects individuals, families and communities, and which can have a negative effect on recovery. I welcome the fact that NHS Education for Scotland now has specific information for health and social care staff on Turas, the NES learning platform, but although there is education around stigma, there is a wee bit of room to go further. NHS Inform has some great drug and alcohol-related stigma information in a short, comprehensive format.

Would the minister consider working with NES to put that information into a mandatory module on the Turas platform for all health and social care staff, not only those who work in drug and alcohol addiction services, so that we can truly help to combat drug and alcohol-related stigma?

I thank Emma Harper for raising the crucial subject of tackling stigma, which I know she is a champion of. As she knows, stigma prevents people from accessing the treatment and support that they need and to which they are entitled. Tackling stigma is a cross-cutting priority of our national mission on drugs, and we published our stigma action plan in January.

The former Minister for Drugs Policy, Ms Constance, wrote to Ms Harper earlier in the year to advise her that officials had met representatives of NHS Education for Scotland. Although there are not currently plans to develop a specific module on drugs stigma, it is a theme throughout the core skills modules within the developing Scotland’s substance use workforce section of the learning platform. I will be happy to discuss making that training module a compulsory component of workforce training, and I will be happy to update Ms Harper and the Parliament on progress.

While I note the minister’s comments on overdose prevention facilities—the principle of having such facilities is surely a good thing—progress is still painfully slow. I hope that we can work together across parties in furthering that agenda under my member’s bill.

The minister will be aware that the original target date for MAT standards 1 to 5 was April 2022. Despite the minister saying that she is “heartened by the progress” in the report, not a single ADP in Glasgow had fully implemented standards 1 to 5 by April 2023, 12 months after the original target date. That was not a stretch target, as the minister characterised it; it was a baseline—particularly in cities such as Glasgow.

Last year, after the target was missed, the former Minister for Drugs Policy told the Parliament:

“When it comes to implementing MAT standards, I am not asking and I am not taking no for an answer.”—[Official Report, 23 June 2022; c 71.]

However, here we are, 14 months after the original target date, and we are still miles off full implementation. Can the minister please tell us when she expects to see full implementation of MAT standards 1 to 5 across Scotland, given that we have now missed two critical target dates? Will she give a cast-iron guarantee that ADPs in Glasgow will have achieved full implementation of standards 6 to 10 by the target date of April 2025?

I am fully committed to ensuring that ADPs right across the country, including in Glasgow, reach those targets. Although I accept that they were not originally a stretch aim or a stretch ambition, we cannot fail to recognise the amount of work that has gone on within local areas to drive forward change. I am committed to working with everybody across the chamber on this issue, and I am committed to working with local leaders in their local areas—senior people in charge of services or elected members in charge of driving forward the changes. I give my guarantee that I will work with my colleagues, with MIST and with everybody across their local areas as hard as I possibly can to deliver on that promise.

The recently published “European Drug Report 2023” highlights that, across Europe, opioids, in combination with other substances, remain the group of substances that are most commonly implicated in drug-related deaths. It also notes that the proportion of deaths among older age groups is increasing. Furthermore, the report highlights that the hidden and stigmatised nature of high-risk drug use makes preventing and responding to drug harm extremely difficult.

With reference to MAT standard 3, can the minister outline the progress that is being made to ensure that people at high risk of drug-related harm are proactively identified and offered support to commence or continue MAT?

One key aim of the national mission is to get the people who are most at risk into treatment that provides protection and to wrap other support around them. We know that being in treatment offers people protection, but we also know that that protective factor decreases as time goes on, so the implementation of MAT standard 3 is crucial to ensuring that that support is in place.

Under MAT standard 3, all people who are at high risk must be proactively identified and offered a choice of treatment and support. That can be achieved through assertive outreach by services, especially for those who have stopped attending those services. We must ensure that there are clear pathways for those who have suffered a non-fatal overdose so that services respond to that need and assertively go out to find those individuals and get them into protective treatment services.

We must also ensure that there is support for transitions at key points, such as when someone leaves a justice setting or is discharged from hospital. MAT standard 3 focuses services on those who have left residential justice and in-patient services.

The minister’s predecessor sought and won cross-party consensus for the implementation of the MAT standards, but it is concerning to note how many targets have been missed. In particular, we were meant to have universal coverage for same-day treatment by now, but more than a third of ADPs do not have that in place. That treatment can save lives, so not having achieved that target may cost lives. What specifically will the Government do to ensure that ADPs are equipped with all the resources necessary to achieve the standard for same-day treatment, particularly in rural areas?

I absolutely understand the issues facing remote and rural areas. It is very difficult to deliver same-day services and meet MAT standard 1 in settings where people cannot get access to treatment. It is important to support innovation on that standard and to passport innovation, where that has happened, because we know that some remote and rural areas have been able to achieve MAT standard 1. I am happy to work across different sectors and areas to ensure that we can passport that information, and the meetings that we have with ADP chairs will help us to do that work.

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

Will the minister say whether the families of people living with drug and alcohol misuse have been involved in the design of recovery services and treatments, including in the implementation of the MAT standards?

As part of the national mission, the Scottish Government provides local areas with £3 million per year to ensure that those with lived and living experience, and their families, are involved in the design and delivery of local treatment and recovery services. We also provide £3.5 million per year through our whole family approach fund to enable local services to provide support to families impacted by drugs and alcohol.

We must remember that the MAT standards were developed by the Scottish Drug Deaths Taskforce, which benefited from hearing the views of those with lived and living experience, including family members. The MAT standards are not only of the Scottish Government’s making but are led by those who are at the front line. Those voices were also reflected in Public Health Scotland’s benchmarking report on MAT standards, which included forewords written by people with family experience.

I met family organisations after their empowering families on the front line conference back in March. Those families feel empowered to help to drive change on behalf of their loved ones, and for themselves, and we must listen to them.

We know that women, particularly those with caring responsibilities or young families, face specific barriers. What is the Scottish Government doing, through the MAT standards, to support those women who are going through recovery from problem substance use?

Through the residential rehabilitation rapid capacity programme, the Scottish Government has committed funding for the development of several projects that will support women in Scotland, and their families, through recovery. More than £5.5 million has been committed during this session of Parliament to support the establishment of two houses at Aberlour that will be specifically designed to support women, and their children, through recovery.

We have also seen the opening of Harper house in Ayrshire, which will specifically support women to sustain themselves in recovery with their children. We know that women experience specific problems with trauma and with the related issues of poverty and deprivation, and we must ensure that we support women who no longer have their children with them, due to issues such as domestic abuse and complex trauma.

I recently met members of the Simon Community’s women’s group, who told me directly that they are working towards creating a safe space for women in Glasgow city centre, because they recognise the intertwined issues of homelessness and substance use. Women have their own needs, and I am committed to ensuring that we deliver on them.

The report identifies a clear lack of support for people tackling problems with alcohol, cocaine and benzos such as fake Valium, which is a drug that was present in six out of 10 drug deaths last year. It identifies clear implementation gaps on standards 5 to 10. Not enough progress is being made and too many people continue to die. Is it not the case that all we have here is a new minister with the same old excuses?

I thank Craig Hoy for his question, but I refute his characterisation of me. I will bring my own work experience to the role, and I am absolutely determined that we will see change.

I recognise the important point that Craig Hoy has raised about the new and emerging substances that we are dealing with, which Sue Webber mentioned that we now see in prison settings. Wherever those new substances come to the fore, we must ensure that we are responsive to them, which is why the MAT standards will consider benzodiazepines and stimulants including cocaine and crack. We must ensure that we recognise the breadth of substances that people are using.

When it comes to alcohol, I look forward to working with the UK Government on the alcohol treatment standards that are coming forward, so that we can make sure that we wrap those into the MAT standards.

Will the minister provide an update on the support that is being provided to establish advocacy services in local areas to empower families to have a voice in ensuring that systems and services are non-discriminatory and to actively put their lived experience at the heart of services?

I thank Rona Mackay for her question. I know that she is very passionate about this issue. People with lived or living experience are greatly valued in our fight against drug deaths. They are often best placed to help people who currently have problematic drug use, and they can be trusted by people who want help, especially in an assertive outreach situation.

Around the world, harm prevention models have often been driven from the grass roots by people with lived and living experience, so we must harness that experience, too. We are building on our previous work of involving people with lived and living experience, for example with the Drug Deaths Taskforce, the residential rehabilitation development working group and the national mission oversight group.

Local services must involve people with lived and living experience in local decision making. I am heartened to see, across the country, people in that situation being involved in the local commissioning of services. That is when we have people creating services in their local area that best reflect their needs, and we must harness those people who have that unique input to give.