The Scottish Government

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Chapter one: INTRODUCTION

Introduction

1. Since July 1999, Scotland's health has been a matter for the Scottish Parliament. Devolution has brought about many changes, including the way in which the National Health Service functions in Scotland. Patients are already benefiting from the publication of The Right Medicine¹, the Scottish Executive Health Department's ( SEHD's) strategy for pharmaceutical care. This document, which contains 60 actions in five main areas, has opened the way for pharmacists and their staff to be more integrated within the healthcare team and to offer a greater and more extensive range of services than ever before.

2. The five main areas in The Right Medicine are concerned with improving health, improving access, helping patients to make better use of their medicines, service re-design and workforce planning. These areas will form the basis for the new pharmacy contract in Scotland which, in turn, will help to deliver strategy by focusing on the nature and quality of pharmaceutical care.

3. A separate document, Pharmacy for Health: The Way Forward for Pharmaceutical Public Health in Scotland, (December 2002) ² builds on and complements The Right Medicine, taking forward the development of the profession to benefit the people of Scotland. It explores the numerous opportunities to develop and enhance the profession's involvement in delivering the health improvement agenda through the efforts of pharmacists working in the community and in hospitals, and of specialists who work within multidisciplinary public health teams. Several references to services for substance misusers are contained in the report.

4. The consultation document, Modernising NHS Community Pharmacy in Scotland, ³ issued in April 2004, outlines the Executive's proposals for legislation that will allow the NHS in Scotland to deliver a number of the community pharmacy objectives set out in The Right Medicine¹ and, in particular, to support the future implementation of the new community pharmacy contract. Among other things, it will help to ensure that service provision is based on locally identified care needs and that patients have convenient access to a full range of services. It also clarifies and extends the current pharmaceutical list and control arrangements to allow for innovative ways of providing dispensing and supply services giving patients and pharmacy contractors greater flexibility in the way that pharmaceutical care services can be accessed and delivered.

Background

5. Scotland has had a considerable drug problem for several decades. Recent data has revealed that:

• Between 4% -6% of all children under 16 have a problem drug-using parent ⁴
• 19% of 15 year olds and 6% of 13 year olds take illegal drugs (mainly cannabis) ⁵
• Approximately 51,582 individuals take opiates and benzodiazepines ⁶
• Half of all recorded crime is said to be drug-related ⁷
• An average of 8 people die each year in Scotland from volatile substance abuse. Many of them are under 18 years of age ⁸
• 33% of adult men and 15% of adult women exceed the recommended weekly alcohol consumption limits ⁹
• One in four Scottish women admit that they binge drink ⁹
• 20% of 13 year olds (boys and girls), 46% of 15 year old girls and 40% of 15 year old boys reported drinking alcohol at some time during the past week prior to a survey that was conducted in 2004 ⁵
• At least 20-25% of deaths in Scotland are due to smoking: 11,600 to 14,500 in 2002 ¹⁰
• Around 1.2 million people smoke - 30% of the adult population ¹¹
• About 25% of girls and 16% of boys are regular smokers by the time they are 16 ¹¹
• A quarter of women smoke during pregnancy with serious consequences for their children's health ¹¹

6. These statistics suggest that substance misuse has a significant effect on the nation's health. For example, more than half of Hepatitis C cases are estimated to be directly attributable to drug misuse ¹²; a significant number of short-term admissions to hospital are alcohol-related ¹³ and smoking is a major cause of coronary heart disease ( CHD), stroke, several types of cancer, chronic obstructive pulmonary disease and premature death ^14,15. It is well known that there is also a link between alcohol and accidents (including road traffic accidents) and violence (including domestic violence).

7. The misuse of drugs is pervasive. It affects all sectors of society. Numerous factors, which may be genetic, environmental, psychological, neurochemical and pharmacological, are said to influence risk of addiction to legal and illegal drugs. In the case of some illicit drugs, ( e.g. cocaine), the nature of the drug or substance has changed rapidly which makes it very difficult to predict what will happen in the future. Pharmacists play an important part in controlling the availability of medicines and other substances liable to misuse through the implementation of legislation such as the Misuse of Drugs Act ¹⁶ and the Medicines Act ¹⁷.

8. Pharmacists provide general information and advice about substances liable to misuse and the associated risks to children and young people, parents and adults. Substance misusers are advised on harm reduction, including safer injecting, alternatives to injecting, safer sex and wound treatment. Pharmacists also refer people to other services and to sources of information and advice.

Remit

9. The present multidisciplinary Group was established by the National Pharmaceutical Forum ( NPF) and the Scottish Medical and Scientific Advisory Committee ( SMASAC) as part of the process to drive forward the pharmaceutical strategy with the intention that its deliberations and recommendations would embrace the Joint Future Agenda.

10. The remit of the Group originates directly from one of the action points contained in The Right Medicine namely to explore ways to maximise the contribution of pharmacists to services for substance misusers in Scotland and to report on the findings to the Chief Pharmaceutical Officer. In particular, the Group was asked to:

• review current service provision
• explore opportunities for new services
• consider strategic and practical issues, and
• advise on an integrated pharmaceutical care model for substance misusers.

11. The term "substance misuse" encompasses a wide variety of behaviours with different characteristics and relates chiefly to the misuse of illicit drugs [mainly opiates and psychostimulants], prescribed medicines, over the counter ( OTC) medicines, volatile substances, alcohol and nicotine.

Methodology

12. The Working Group met on seven occasions between March 2003 and June 2004. The Group, which was multidisciplinary in composition, included representation from the medical, pharmacy and nursing professions as well as representatives from Social Work Services, the Drug Action Team Association, Scottish Drugs Forum ( SDF), the police, the Scottish Prison Service ( SPS) and the Scottish Executive Health Department ( SEHD).

13. Contributions were invited from a number of individuals and organisations in order to inform the work of the Group. A list of acknowledgements is given in Appendix II. Attempts were made to take on board user participation via the Scottish Drugs Forum and other user groups but it was not possible to undertake a fully representative Scotland-wide survey given the timescale and the resources. The Group did, however, take account of previous research identifying the barriers that substance misusers experienced in accessing services when making its recommendations.

14. The Group would also wish to thank Professor Christine Bond, (Consultant in Pharmaceutical Public Health, NHS Grampian) and colleagues for permission to make use of material from a report entitled Drug Misuse and Community Pharmacy: Issues for Pharmaceutical Care¹⁸. This report, which was prepared for the Scottish Specialists in Pharmaceutical Public Health ( SSiPPHs), focuses specifically on illicit drug use. It is more restricted in scope (but also more detailed) than the present report. To a certain extent it covers similar ground and should be read in conjunction with the present report in order to give the reader a fuller understanding of the issues involved.

Key Aims of the Report

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