The Scottish Government

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Chapter TWO: POLICY CONTEXT

Introduction

15. Over the years, there has been a growing recognition that the energies, commitment and professionalism of all agencies concerned with substance misuse have to be harnessed in order for all the issues to be effectively addressed. A Ministerial Task Force report ¹⁹ identified the roles that statutory and non-statutory bodies can play in the prevention of substance misuse and the provision of services for substance misusers.

Its recommendations place particular emphasis on the delivery of a co-ordinated, multi-agency approach involving local communities. This approach is very much in line with the current Joint Future agenda and will help to provide more effective services.

Summary of National Policy

16. This chapter summarises current policy in relation to drug misuse, alcohol and smoking. Although all three areas are covered in separate sections, each subject is seen as part of a single spectrum of substance misuse which requires a co-ordinated multidisciplinary response.

Drug Misuse

17. The first National Prevalence Study into Drug Misuse ²⁰ estimated that in the year 2000 there were 55,800 individuals in Scotland using opiates and benzodiazepines (heroin, temazepam, methadone, etc). Out of that figure, 22,805 were injecting drug users and 10,000 were infected with Hepatitis C. A follow-up study ⁶ which estimated the prevalence of problem drug use in Scotland in 2003 found a small but statistically significant fall in numbers to 51,582 individuals.

The overall figure for the number injecting opiates in 2003 was 18,737. Around 24% of schoolchildren have misused drugs at least once, with about half of these having been offered illegal drugs. Estimates suggest that a third of all recorded crime is drug-related ⁷ and that more than 3 out of 4 of those entering prison show signs of problematic drug misuse at the point of entry.

18. Current policy for drug misuse is set out in Tackling Drugs in Scotland: Action in Partnership²¹ and its subsequent Action Plan Protecting Our Future²².

These documents were published in 1999 and 2000 respectively. In March 2002, the Scottish Executive launched its Drug Communications Strategy using the "Know the Score" ( KTS) logo. Around £6m over 3 years is being invested on national campaigns to raise public awareness (via a website and information line) and improve media relations. The Summary and Action Plan from a Review of Drug Treatment and Rehabilitation Services ²³, published in October 2004, set out a package of measures to improve the quality and consistency of drug treatment services across the country.

19. The Scottish Executive works in partnership with 22 Drug and Alcohol Action Teams ( DAATs), and statutory and voluntary organisations to tackle Scotland's drug problems in a co-ordinated way. DAATs contain representation from local drug treatment agencies, local authorities, NHS Boards, the police, prisons and voluntary sector organisations, which act as the focal point for local action to implement the national strategy. These arrangements allow for services to be designed and delivered to meet local needs and priorities.

20. National targets, some subject to local target setting, were announced in December 2000 ²⁴. Key national targets include:

• Increasing the number of drug misusers in contact with drug treatment and care services in the community, by at least 10% every year until 2005
• Reversing the upward trend in drug-related deaths and reducing the total number, by at least 25% by 2005
• Reducing the proportion of drug misusers who inject, by 20% by 2005.

21. Parental substance misuse can, and does, cause serious harm to children at every age from conception to adulthood ⁴. A range of initiatives across the Scottish Executive aims to ensure better and integrated services for vulnerable young people and practice guidelines have been issued for working with children and families affected by substance misuse ²⁵.

22. In response to the need to tackle drug misuse among schoolchildren, the Scottish Executive, in conjunction with NHS Health Scotland, the Scottish Drugs Forum and Scotland Against Drugs, has produced a guide entitled Drugs: What Every Parent Should Know²⁶ to help parents discuss the dangers of substance misuse with their children. This guide, which is available from the KTS advice line [see Appendix XI] has been distributed to a range of outlets including GP practices, pharmacies and Social Work Departments.

Smoking

23. Smoking is the single greatest cause of preventable ill-health and premature death in Scotland ¹¹. It results in 13,000 (1 in 5 deaths) each year ²⁷. Some 35,000 hospital admissions are due to smoking-related diseases ²⁶ at a cost to NHSScotland of £200m per year in hospital care ²⁹. More than a quarter of women in Scotland still smoke during pregnancy ¹¹. This means that about 13,500 babies born in Scotland each year are exposed to toxic chemicals with potentially damaging consequences for their health ¹¹.

24. The annual cost of employee smoking in Scotland is estimated to be around £500m, - £450m for lost productivity (smoking breaks), £40m for higher absenteeism among smokers and £4m as a result of fire damage ³⁰.

25. Since devolution, the Scottish Executive has been driving forward in a Scottish context the comprehensive tobacco control programme set out in the UK White Paper Smoking Kills³¹. Working with partners, the Scottish Executive has delivered new and expanding cessation services, high quality communications campaigns, Nicotine Replacement Therapy ( NRT) on prescription, a ban on tobacco advertising, enhanced health warnings on cigarette packets and tobacco test purchasing pilots.

26. In January 2004, the Scottish Executive published the first ever action plan on tobacco control designed specifically for Scotland ²⁷. At the same time, a related report, entitled Reducing Smoking and Tobacco-related Harm: A Key to Transforming Scotland's Health¹¹ - a joint venture between NHS Health Scotland and Action on Smoking and Health Scotland ( ASH) - provides a platform for the implementation of the Action Plan.

27. These two documents examine current smoking trends in Scotland, summarise the most up to date evidence about smoking and tobacco-related harm and how it can be reduced. They also consider current prevention, control and treatment policies and services in Scotland and make recommendations about what further action should be taken.

28. Actions are set out in the following four broad categories:

• Prevention - action to accelerate reductions in smoking prevalence including a major review of prevention, education and communications efforts
• Provision of Services - action to further extend and improve cessation services
• Second-hand Smoke [Passive smoking] - action to reduce the health risks from second-hand smoke
• Protection and Controls - legislative and other action to reduce the attractiveness and availability of cigarettes.

29. A consultation document, Smoking in Public Places, was issued in June 2004 ³² . This has helped to facilitate an open national debate on the dangers involved in passive smoking and how to reduce exposure.

30. In the context of pharmaceutical services, the Action Plan will assess the success of current communication and education programmes and establish a new, integrated, long-term strategy aimed at young people to raise awareness of tobacco addiction. It will also allocate additional funding to smoking cessation programmes, particularly those which are targeted at the most disadvantaged communities, and agree annual cessation targets with each NHS Board.

31. Current targets, set by the Scottish Executive in Towards a Healthier Scotland³³, aim to reduce adult smoking from 35% to 33% by 2005, and to 31% by 2010, and to reduce smoking among young people from 14% to 12% by 2005, and to 11% by 2010. These targets will be reviewed and consideration will be given to setting new targets or milestones to drive change in key groups. The Scottish Executive has already announced in its Tobacco Control Plan that it proposes to adjust the adult target to 29% by 2010. In many ways, pharmacists have led the way with pharmacies being designated as smoke-free zones more than 20 years ago.

32. NHS Boards and their partners in health improvement will be required to set and monitor local targets to underpin achievement of the national targets. The Smoking Atlas of Scotland [due in 2005], a source of guidance to NHS Boards and local authorities on the level of smoking and related harm in their area, will help to inform this process.

Alcohol

33. Alcohol is widely used and enjoyed but carries serious consequences if, and when, it is misused. It is a known fact that problem drinking is on the increase in Scotland. The level of binge drinking is rising rapidly and young people, especially women, are drinking more than ever before ⁹. There is also a sharp upward trend in alcohol-related illness and death, particularly in alcoholic liver disease in women, which is being seen at younger ages ⁹. Current figures estimate that problems relating to alcohol cost £1bn per year, including £96m to NHSScotland ³⁴.

34. The national policy on alcohol is contained in the Plan for Action on Alcohol Problems (January 2002) ³⁴ and its accompanying framework document entitled Alcohol Problems Support and Treatment Services Framework (August 2002) ³⁵.

35. The Plan for Action on Alcohol Problems³⁴ sets out a comprehensive package of measures to reduce alcohol-related harm in Scotland (not alcohol per se). This includes action to develop support and treatment services. The Plan has both short- and long-term aims. These aims centre around the need to promote a change in attitude towards the consumption of alcohol and to develop local strategies to reduce harmful patterns of drinking among young people. The Plan acknowledges the need to look at issues such as prevention and education and the need to find alternatives to, the "drink culture" ( e.g. the establishment of Youth Cafés). The Plan aims to adopt a positive, non-judgmental attitude which embraces both the context and the causes of alcohol problems, and is generally considered to have led the way in the UK.

36. The Framework which supports the Plan sets out a four-pronged approach to help local alcohol action teams, NHS Boards and local authority departments to assess local needs, identify gaps in service provision, clarify referral processes and develop plans for the provision of integrated support and treatment services for people with alcohol problems. The two key priorities are to reduce binge drinking and to reduce harmful drinking by children and young people. With regard to the latter, the Scottish Executive, in conjunction with NHS Health Scotland and Alcohol Focus Scotland, has produced a guide entitled Alcohol: What Every Parent Should Know³⁶ to help parents discuss the dangers of alcohol misuse with their children. This guide, which is available from the Drinkline advice line [see Appendix XI] has been distributed to a range of outlets including GP practices, pharmacies and Social Work Departments.

37. The Framework is not intended to be prescriptive nor to set out minimum service levels or standards. It does, however, identify service elements of proven effectiveness that should form the basis of all services across NHSScotland.

38. To date, a total of 22 Local Alcohol Action Teams are working in consort with Drug Action Teams ( DATs) and most of the action points within the Plan have been delivered.

39. Current priorities, which have been set by the Partnership Agreement ³⁷, include a commitment to expand alcohol-free environments and examine the scale and costs of alcohol misuse across Scotland. Advertising campaigns will place a far stronger focus on young people, especially young women. There is also a commitment to strengthen links between the Scottish Executive and those who have responsibility for delivering the programmes at local level.

Conclusion

40. Policy to tackle substance misuse cannot operate in isolation from other strategies. There is therefore a need to link with other national strategies [ e.g. the Mental Health Strategy, the Sexual Health Strategy and the Information Management and Technology Strategy ( IM&T)] and key players within the Scottish Executive Health Department, the Scottish Prison Service, the Community Justice Service Division, Drug Treatment and Testing Orders ( DTTOs) and Drug Court Teams in order to ensure that there is a full and informed contribution towards the treatment and care of the substance misuser. There is also a need to link in with other partnership agencies in relation to the formulation and delivery of policies.

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