Meeting of the Parliament

Meeting date: Tuesday, March 21, 2023

Official Report 983KB pdf

---

Care of Co-occurring Mental Health and Substance Use Conditions

The next item of business is a statement by Angela Constance on improving care for people with co-occurring mental health and substance use conditions. The minister will take questions at the end of her statement, so there should be no interventions or interruptions.

14:25  

Today, I will update Parliament on our plan to improve care for people with co-occurring mental health and substance use conditions, but first I want to acknowledge the most recent figures on suspected drug deaths, which were published last week. Although I very cautiously welcome the 16 per cent decrease in suspected drug deaths in 2022 from 2021, I am only too aware that far too many people are still losing their lives to drugs.

As we all know, the link between mental health and substance use is clear and unequivocal. Unfortunately, however, the links between the services are not always as clear. We recognise that services must work together to deliver person-centred care, and that is why, last year, the Minister for Mental Wellbeing and Social Care and I commissioned a rapid review of mental health and substance use services. The recommendations from that review were preceded by the Mental Welfare Commission for Scotland’s report “Ending the exclusion: Care, treatment and support for people with mental ill health and problem substance use in Scotland” and the medication-assisted treatment standards, especially standard 9, which focuses on mental health.

Those reports set a clear way forward. Our vision is a joined-up healthcare system where people with co-occurring conditions get timely access to the help that they need. To deliver on that vision, our plan has three clear objectives. First, we have to get the foundations right in every local area. Secondly, we must empower the workforce to stop people being passed from pillar to post. Thirdly, we must embed clear lines of accountability so that we know that services are delivering better care for people on the ground.

The plan also forms part of our cross-Government response to the final drug deaths task force report, “Changing Lives”. The objectives of that work will help to fulfil the task force’s sixth recommendation—that

“the principle of no wrong door”

should be

“at the heart of a ... whole-systems approach.”

The plan is underpinned by funding of £2.4 million, which I announced earlier this year. Together, those things will deliver better outcomes for people with co-occurring conditions.

To have the right foundations in place in every local area, we need to be clear about expectations. To support our workforce to deliver the holistic joined-up care that we know they want to give, we have to make sure that it is clear how services will work together. To give that clarity to our workforce and, of course, the people who use the services, we will require every local area to have a publicly available protocol that sets out exactly how mental health and substance use services should work together.

To make sure that those protocols result in better care on the ground, Healthcare Improvement Scotland will develop a gold standard protocol against which all local protocols will be assessed. The protocol will set out how services should interact to meet all of a person’s needs, including their other healthcare needs and their social needs.

We must also acknowledge that care must be personalised depending on the substance that a person uses. It might look quite different for someone who uses cocaine from how it looks for someone who uses opiates. The gold standard will be available to local areas by October 2023.

To be truly person centred, we must address the additional needs that some groups may face when they seek support. For example, we know that young people face specific challenges with both substance use and mental health. We are undertaking work to co-design with young people what service standards should look like for young people who use drugs. That is in addition to our commitment to the expansion of the Planet Youth and Routes programmes of prevention. That work will build on and contribute to that work to support our young people.

The protocol will deliver on the recommendations of the rapid review, “Ending the exclusion”, and the relevant MAT standards and it will support the forthcoming adult secondary mental health standards. To make sure that we get it right, Healthcare Improvement Scotland will work with a reference group that will consist of the Mental Welfare Commission, NHS Education for Scotland, the MAT implementation support team, people on the front line and, most important, service users.

As important as the nuts and bolts of delivery are, a protocol is not enough; it must lead to change on the ground. We will therefore ask all chief officers of integration joint boards to nominate an appropriately senior person who will oversee and take ownership of the plan in their area.

Our dedicated workforce needs to be supported to provide the best possible care. I am pleased that NHS Education for Scotland has already begun to respond to the recommendations, including widening access to training on substance use to staff in mental health services. We will also work closely with local areas to ensure that staff are equipped with the knowledge, confidence and skills to support people with co-occurring conditions.

As well as ensuring that staff have the appropriate skills, we need to do more to tackle stigma and to provide trauma-informed care. We will draw on existing activity such as the stigma action plan, the national trauma training programme and wider workforce initiatives to drive forward change across both services.

By the end of this year, we will move into phase 2: implementation. To support local areas to implement an effective protocol, Health Improvement Scotland will provide strategic change management support and act as a centre of excellence, sharing best practice and facilitating learning across Scotland.

We will agree individual milestones with local areas for the implementation of the protocol, based on their current status. It is important to note that we will not be overly prescriptive. Areas will be able to adapt the protocol to their local circumstances. However, my expectation is that all people with co-occurring conditions should be able to access high-quality care, regardless of their locality.

That is why it is important that people with lived and living experience are closely involved in the adaptation and implementation of the protocol. I will ask all areas to ensure that the people who use services, and their families, are able to meaningfully contribute to the process. We cannot hope to improve services unless we listen to the people whom we want to help. Indeed, we will not truly know whether we have succeeded unless we hear that change is happening on the ground.

Given the work’s close links to the wider MAT standards, we will align the timelines. We expect all areas to be rated as green for the implementation of MAT standard 9 by April 2025 at the latest. Of course, we expect that many areas will achieve that much more quickly, and we will set ambitious but achievable timelines for each area as we move into phase 2.

By the end of the phase, all service users should feel that they are listened to and treated with respect, and that they are receiving support in a way that makes sense to them.

To move forward to April 2025, the final phase of the plan is about sustaining the change. Health Improvement Scotland will continue to support local areas in that phase, to ensure that service users continue to feel an improvement in the care that they receive.

In addition to our work with local areas, we are taking forward national recommendations. We will commission an alcohol-specific rapid review, as suggested by the mental health and substance use rapid review, and we will undertake the exploration of an annual needs assessment and areas for further research.

I have set out our plan to deliver better care for people who have co-occurring mental health and substance use conditions. We will report on our progress through the national mission report, and I will keep the Parliament updated.

I end my statement by sharing a quote that articulates how important it is that we get it right. It comes from a person with living experience who spoke to the Mental Welfare Commission. He said:

“People with ... coexisting mental health conditions and substance misuse problems can and do recover, I have seen broken people with mental health issues and addiction's achieve this who are now in full time employment, living life, and are out there helping others.”

I sincerely believe that we will hear more such testimonies if we deliver on the vision that I have set out.

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. I would be grateful if all members who wish to ask a question could press their request-to-speak buttons now.

In 2021, 1,245 people lost their lives due to alcohol and 1,330 died due to drug misuse. With suspected drug deaths increasing by 26 per cent over the previous quarter, progress on this vital issue is heading in the wrong direction.

The minister’s statement perfectly encapsulates the Scottish National Party’s current strategy. We have the Drug Deaths TaskForce’s “Changing Lives” report, the Mental Welfare Commission for Scotland’s ending the exclusion report, the MAT standards—which should have been implemented in April 2022—and now we have new gold standards and protocols. I have no confidence that the statement today will change anything on the ground.

The minister just said:

“As important as the nuts and bolts of delivery are, we know that a protocol is not enough; it must lead to change on the ground.”

Services are not meeting the needs of people who have mental ill health or problems with substance use, or both. The minister promised to fully implement the MAT standards by April 2022. MAT 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.”

Delivery has now been pushed back to April 2025 at the latest.

Faces and Voices of Recovery UK’s slogan is:

“You keep talking, we keep dying.”

April 2025 is two years away. I ask the minister this: how can we stand here once again discussing another report and another set of protocols on person-centred care, when people cannot access the services that they need for their mental health or substance misuse right now?

I have always sought to lead by example by demonstrating my accountability to this Parliament and to the people of Scotland.

The plan that I have set out today is essentially about joining up healthcare, ensuring that people with co-occuring conditions get the right treatment at the right time, and bringing forward how we will get absolute clarity about who leads when on the ground, so that our people are no longer being bounced between services or falling between two stools.

The importance of the statement is that it shows to Parliament that we are diligently building a better system and that we are bringing the detail of delivery to Parliament. This is not about the headlines; this is about the hard graft.

Ms Webber rightly pointed to the tragedy not just of drug-related deaths but of alcohol-related deaths. Part of my work now is to expand and develop specific alcohol treatment, notwithstanding the synergy that the national mission brings, for example, around residential rehabilitation placements. Figures that have been published today demonstrate that, for the latest quarter, we have the highest-ever number of statutory funded residential rehabilitation placements, which demonstrates that we are reaching out and providing care to people with substance use issues.

The suspected drug death information for the previous calendar year shows a 16 per cent reduction. We have also seen figures published today that demonstrate the impact of minimum unit pricing on alcohol deaths. However, I acknowledge, of course, that there was a spike in suspected deaths in the last quarter of last year. That is why I reported to Parliament the work that is happening around public health alerts and what we are doing to combat our concerns around synthetic opioids.

I thank the minister for advance sight of her statement. I offer my condolences to anyone who has lost a loved one to drugs here in Scotland

Perhaps especially this week, it is worth taking a moment to stop to assess the progress of this Scottish Government in getting to grips with this public health emergency, which was declared more than three years ago. Tragically, the statistics tell a sobering story. Scotland has recorded 2,269 confirmed drug-related deaths and, last week, we learned that there were 1,000 suspected drug deaths last year, including a significant spike in the last quarter.

It is also concerning that there have been delays and, at times, a seeming lack of urgency. MAT standards implementation was, for instance, promised and then delayed. We have known about the correlation between mental health and substance misuse for many years, but, by the minister’s own admission in her statement, work to deal with that has not always been clear or, indeed, quick enough.

I have two questions for the minister. The first is about timescales. The minister has stated that implementation will start by the end of this year. Can she guarantee to Parliament that that will happen? As she knows too well, there have been too many delays already in addressing this public health emergency.

Secondly, it strikes me that the big thing missing from the statement is data, which was a key recommendation of the rapid review. Last week’s publication in relation to the suspected spike in drug deaths clearly demonstrates that there is a problem in knowing exactly where the issues are and how we should tackle them, and indeed whether action is working. What will the minister do to get data right?

The Government is gathering and publishing more data than ever before, because, when it comes to accountability, we are determined to lead by example. We need accountability at every layer of government and not only at the national level but at the local level.

I can point to the suspected drug deaths stats, which is information that we started publishing every quarter. There is the RADAR—rapid action drug alerts and response—work, which gives us early warnings. There is work that we are doing on data linkage, so that we get better and more timely information, not just about how people die but about the lives that they lead and where and how we can intervene more effectively. There are also pilot projects on toxicology, testing and emergency departments. I am happy to write to Mr O’Kane about some of the nuances and detail.

On the timelines, phase 1 will be completed between May and December this year. The implementation of phase 2 will be between January 2024 and April 2025. We will be sustaining that between 2025 and 2026. There is a range of activities, so it might be better if I write to Mr O’Kane about the action that I expect, month by month, between April and November this year.

The minister has been working with me to address stigma, particularly for those working in health and social care, and not just those who work in alcohol and drug services. I thank the minister for her letter to me yesterday setting out that NHS Education for Scotland is working to incorporate substance stigma across all its learning modules. Does she agree that we must do all that we can to tackle stigma if we are to enable successful recovery, and that the media has a key role to play in that?

Ms Harper is quite correct to point to the importance of tackling stigma. As politicians, we all have a role in that, as do the way in which matters are reported in the media and how services are provided. That is why trauma-informed approaches are so important. Anything that is a barrier to treatment must be removed, and we have to kick stigma into touch.

A survey last year found that 90 per cent of GPs had experienced difficulties in referring patients to mental health services and addiction services, including when the patient presented in crisis. That is something that I have experienced as a GP this year.

GPs also reported that people with such issues are often turned away from those services, with GPs having to re-refer them. Does the minister think that it is acceptable that people with those issues are being turned away, with GPs being left to pick up the pieces?

To be candid, no. That is not acceptable. Part of the improvement plan is to give absolute clarity about who leads and when. Mr Gulhane might well have read the findings of our rapid review. I am sure that he has also looked at the Mental Welfare Commission report, which talks about the four quadrants of care. It is an extremely helpful guide that can, I hope, move people on from inane debates about who should be leading and who should be supporting.

Mr Gulhane, and anyone who is interested in data, might be interested to know that recommendation 2 in the rapid review is that we will evaluate referrals that have been rejected. It is about our boring down into the detail and ensuring that every part of the system is getting it right.

How does the minister intend to ensure that people in rural areas have sufficient access to mental health support?

Although aspects of our response to the rapid review and the action plan might seem quite specific, it is important to recognise that the improvement plan sits in the context of the wider national mission and indeed the wider work that my colleague Kevin Stewart is taking forward. I hope that in my statement I demonstrated that we are clear about the level of expectation that must be met in every part of the country. Whether we are talking about implementing the rapid review or about medication-assisted treatment standards, there is flexibility for rural areas that need additional support to overcome the barriers that exist in those areas.

The minister knows that substance use is often a form of self-medication for underlying mental health disorder and trauma. Yet the recent budget accounted for £290 million for mental health for the coming financial year, which is merely a reversal of the £38 million cut in the emergency budget review. That effective freeze will have a direct impact on services and risks increasing the likelihood of people using substances to self-medicate in the absence of professional help.

Today’s announcements are welcome, but does the minister not accept that the Government could prevent such harm in the first place by going to the root cause of the problem and increasing the mental health budget in line with the 10 per cent commitment of overall NHS expenditure that was made previously?

The Scottish Government is investing in and reforming services like never before. It is important to remember that there are always debates about the absolute quantum of services, but it is crucial to at least acknowledge that the mental health budget has more than doubled since 2020-21. Through the national mission to save and improve lives, we have made an additional investment of £250 million over this parliamentary session, which Audit Scotland last year acknowledged was a significant real-terms increase. However, notwithstanding the importance of investment, our approach should also be about what we do with that money and ensuring that it gets to where it is needed most.

Will the minister outline the action that is being taken to ensure that all mental health and substance use staff are trained on how to effectively assess and manage co-occurring mental health conditions and substance misuse disorders?

That is where the work of NHS Education for Scotland is imperative. It is important that we expand the training opportunities that are available to mental health and substance use staff on the impact of other co-occurring conditions. As I outlined in the statement, that work has already started. On the previous occasion when I was on my feet here, which was on the subject of MATS, I made a commitment to members that I would be coming back to outline to Parliament where we were going on our workforce support strategy.

I, too, welcome the recommendations that the Mental Welfare Commission has made in its report. The link between substance use and mental ill health is well documented and has been well debated in the chamber. The report offers a welcome road map on how we might address that, but the minister will be well aware that substance use is not limited to those who have attained majority or who can access adult services. Children and young people in this country take substances, too, and will have mental ill health as a result. What is the interplay between the recommendations in this report and the ecosystem in our child and adolescent mental health services?

That is an absolutely excellent question. We know from the latest quarterly figures that more than 5,500 children and young people have begun treatment in the CAMHS system. That is the highest number ever, and represents an increase of 11 per cent.

However, we must acknowledge that young people use substances differently and tend to use different substances. We also know that prevention is important, because people with lived experience have told us that they often started their drug use very early in life. Services therefore really need to meet the needs of young people. There needs to be service specifications as standard, and that is what we are currently co-producing with young people. That point is crucial, because we have to be informed by the views and opinions of young people about what will meet their needs best, and where and when it will do so.

I remind members of my entry in the register of members’ interests, which shows that I am vice-chair of Moving On Inverclyde.

The minister has ensured that many third sector organisations have received funding to assist their activities and help people with addictions. Will that continue with regard to mental health organisations and the opportunities for vital partnership working that they might wish to pursue?

We have very clearly taken a belt-and-braces approach to the national mission to save and improve lives and reduce the number of drug deaths. We have increased funding for statutory services and alcohol and drugs partnerships, and we have funded about 200 projects thus far via funds that we provided to the Corra Foundation. There is a synergy between that and the work that Kevin Stewart has undertaken, in that 1,800 awards from the £36 million communities mental health and wellbeing fund have also been made. The Government values the crucial role of our voluntary and third sector organisations.

We know that, as well as poor mental health being a driver of addiction, addiction can be a catalyst in the deterioration of someone’s mental health. How can we ensure that people receive appropriate support in order to address that interaction holistically, whichever way round the conditions occur? How can we ensure that the entire treatment pathway, from diagnosis to pharmacy, is stigma-free?

I refer Ms Mackay to what I said to Sandesh Gulhane about the four quadrants of care. That tool is highly recommended and supported not just by our rapid review that was undertaken by clinicians but by the Mental Welfare Commission. We have to cut through some of the old debates that have persisted for long and weary. We must have clear protocols, leadership and accountability in relation to who leads when and which service provides support. I hope, and I am confident, that the plan that we have brought forward today will help to cut through some of that.

Earlier today, it was announced that John Wyllie, the chair of the Dundee alcohol and drugs partnership, will stand down at the end of March—just four months after his appointment in November 2022. As the minister says, a joined-up approach requires leadership. It requires leadership nationally and locally. We now face another potential tender process for an independent chair, with interim measures in place in the meantime. What support will the Scottish Government provide to the ADP and local partners to ensure that momentum is not lost on the response to Dundee’s horrific drug deaths record?

I appreciate Tess White raising that issue. I was very sorry to hear that the independent chair of the ADP will be stepping down. My understanding is that he is doing so for personal reasons. I give her an absolute assurance that my officials and I will be liaising with, and reaching out to, the local service to ensure that interim arrangements are put in place and that another appropriate chair is found as soon as possible. Tess White makes a fair point.

Will the minister provide an update on the steps that are being taken to alleviate the demand on our acute hospitals and our emergency mental health services that is caused by alcohol use disorders?

I am sure that members will have noted the information that was published today by Public Health Scotland and the University of Glasgow on the reduction in the number of alcohol-related deaths as a result of minimum unit pricing. In that regard, the number of related hospital admissions might have been reduced by about 400 a year.

Ruth Maguire makes an important point, because the whole raison d’etre of getting people into the right treatment at the right time is, first and foremost, to save lives. The information that we publish regularly on hospital admissions demonstrates that there is a constant need to intervene earlier, quicker and in better ways.

I will follow on from Tess White’s question regarding the departure of the chair of Dundee’s ADP. There were real concerns in the community when the previous chair—not this one—departed, with clear frustration at the lack of ability to drive and deliver change. Now, just months on, we are in the same position again. I share my colleague’s concerns about the lack of leadership. Does the minister have confidence that the ADP can deliver change under the current model? What can we do to ensure that there is long-term, sustained leadership in Dundee, where these problems are so ingrained?

I fully understand Mr Marra’s frustration in that regard.

On the specifics around the current chair resigning for personal reasons, I cannot add any more to what I said to Ms White, but let me make a more general point. I am absolutely focused on ensuring that all ADPs, including the one in Dundee, get the right support, but there is an issue that we in the chamber often forget. Sometimes we are very critical—rightly so, at times—of alcohol and drug partnerships when the issue lies with senior leadership, and that may be senior leadership at this level in the Scottish Government.

One thing that we need to do as we embark on this journey of reforming alcohol and drug partnerships and services is ensure that leadership at IJB and health-board level steps up to the plate, because ADPs are sometimes left to hang out to dry when the problem lies elsewhere, and that, I assure Mr Marra, is not lost on me.

The minister is right to highlight the importance of leadership, which is why my question is very simple. All three candidates for the leadership of the SNP have stated their support for my friend Douglas Ross’s proposed right to recovery bill, so will the minister take the opportunity, whether it is her last appearance in the chamber as a minister or not, to express her personal support for the legal provisions that are contained in the bill?

I start by assuring Mr Kerr that whether I am on the front or the back benches, I will always seek to serve my country, my constituents and those people who have touched my heart who are impacted most by drug and alcohol deaths. Perhaps unlike him, I am not all that worried about what next week may bring.

On the right to recovery bill, I have not heard any candidate make any remarks that are out of sync with what I have said repeatedly to the Parliament, which is that we are all united in ensuring that people know their rights and can claim their rights.

I look forward to seeing the detail of Mr Ross’s bill when it is introduced; it will get a fair and very sympathetic hearing. In the meantime, the Government will continue with our work on the human rights bill, which is about ensuring that people can know and claim their rights in practice.

I point Mr Kerr to the work of the national collaborative, which at its core is about holding all our feet to the fire and making rights real in this country.

That concludes the ministerial statement.