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Executive Summary

Introduction ( Chapter 1)

This document reports on the findings of a survey of needle exchange provision in Scotland. The study was part of a larger UK-wide study carried out in partnership with the National Treatment Agency ( NTA) in England; the Welsh Substance Misuse Policy Development Team; and the Northern Ireland Department of Health, Social Services & Public Safety. The Scottish arm of the study was funded by the Scottish Executive under the Drug Misuse Research Programme and was carried out between 15 January 2005 and 30 September 2005.

The aims of the study were to:

• Map needle exchange provision in Scotland
• Investigate the nature of service provision
• Identify areas of good and innovative practice in this area
• Identify barriers and difficulties in commissioning and delivering needle exchange services.

Methods ( Chapter 2)

The study was designed to gather information both from people responsible for planning and commissioning needle exchange services, and those responsible for delivering those services. A combination of qualitative and quantitative methods were used. The quantitative element consisted of three postal questionnaire surveys sent to:

• Drug Action Team ( DAT) co-ordinators / commissioning managers, or their equivalent
• Non-pharmacy needle exchange service providers
• Pharmacy needle exchange co-ordinators

The qualitative element consisted of three focus groups - one with each of the three groups listed above. Through these different means, data was gathered about needle exchange services in every part of Scotland. Survey responses are shown below:

• All of Scotland's 22 DATs were surveyed, 19 responded (response rate = 86%)
• Fifty out of 52 non-pharmacy services were surveyed, 45 responded (rate = 90%)
• Twelve out of 15 pharmacy co-ordinators were surveyed, 10 responded (rate = 83%)

FINDINGS - PART 1: NEEDLE EXCHANGE PROVISION AND ACTIVITY IN SCOTLAND

Mapping needle exchange provision ( Chapter 3)

The study identified 188 needle exchange outlets - 136 pharmacy exchanges, 43 specialist exchanges, six police custody suite exchanges and three hospital A&E exchanges. Some form of needle exchange was available in every DAT area of Scotland. Nearly half of Scotland's specialist service provision was through mobile / outreach facilities. Across the whole of the country, pharmacy exchanges outnumbered specialist services by a ratio of 3:1.

Accessibility of needle exchange ( Chapter 4)

Not surprisingly, needle exchange was least accessible in the most remote and rural areas of Scotland. However, half of Scottish DATs said that all injectors living in their area had access to some form of needle exchange within five miles of their place of residence. Injectors living in mixed rural / urban areas appeared to have access to the widest range of needle exchange services.

Needle exchange activity, 2004-05 ( Chapter 5)

A lack of robust monitoring systems for needle exchange services was especially apparent in relation to questions about basic needle exchange activity - that is number of "transactions" (or needle exchange contacts), number of clients, number of syringes distributed and number of syringes returned. Questions on number of clients and number of syringes returned, in particular, had only a small number of responses, and therefore, these data must be treated with caution.

Number of transactions / contacts: 36 (out of 45) non-pharmacy services reported 82,389 transactions in the period April 2004 - March 2005. The median number of transactions per service was 1,054 (mean: 2,289). ¹ Pharmacy co-ordinators (n=10) reported a total of 169,117 transactions in this same period, representing the activity of 116 pharmacies. The mean number of transactions per pharmacy was 1,458. ²

Number of clients: 29 (out of 45) non-pharmacy services reported a total of 14,229 clients in 2004-05. The median number of clients per service was 221 (mean: 491). Three (out of 10) pharmacy co-ordinators reported a total of 17,726 clients in the same period, representing the activity of 37 pharmacies. The mean number of clients per pharmacy was 479.

Number of syringes distributed: At least 3.5 million syringes were distributed by needle exchange services across Scotland in 2004-05. The actual totals are likely to be considerably higher, since these figures do not include numbers from three DAT areas, and some of the figures submitted by other DATs were incomplete. An approximately equal number of syringes was distributed by pharmacy and non-pharmacy services overall. However, this statement masks enormous geographical variation. The total number of syringes distributed by pharmacy services across Scotland was skewed by the very large number of syringes distributed by Glasgow pharmacies.

A calculation of the number of syringes distributed per injector (using estimates of injecting prevalence taken from the National Prevalence Study) showed very wide geographical variations in levels of syringe distribution, and suggested that in many areas, there was far from sufficient distribution of syringes.

Return of used syringes: At least 1,563,312 syringes were returned to needle exchange services across Scotland - 849,113 to non-pharmacy services and 714,199 to pharmacy services. These figures can only be taken as estimates. It is difficult to obtain accurate data on returns because, for obvious health and safety reasons, sharps bins are not opened.

On-site interventions provided by needle exchange facilities ( Chapter 6)

Many needle exchange facilities in Scotland provide services and interventions beyond the simple distribution of sterile needles and syringes. This study found that a majority of non-pharmacy services in Scotland provided their clients with face-to-face harm reduction advice, a list of other needle exchange facilities in the area, referral to structured treatment, and brief motivational interventions. Only about half provided any form of on-site intervention related to BBVs, with the most common being HIV and Hepatitis C pre- and post-test counselling. There appeared to be an association between on-site provision of BBV interventions and NHS Board.

Less than half of non-pharmacy services provided key working, structured counselling, care for minor infections or complementary therapies. Fewer still provided overdose prevention training for clients; housing, social welfare or legal advice; nutritional advice; primary care sessions or well-woman clinics.

Pharmacy schemes across Scotland offered a much smaller range of interventions to injectors than non-pharmacy services.

In terms of distribution of other injecting paraphernalia, the majority of both pharmacy and non-pharmacy services provided sharps bins and wipes / swabs. However, there was variation between services in relation to the distribution of other forms of paraphernalia (citric acid, filters, stericups, etc.). This variation was also associated with NHS Board.

Needle exchange policies and procedures ( Chapter 7)

There was variation across Scotland in policies and practices related to syringe distribution. The majority of non-pharmacy services said there was a maximum number of syringes their service would give out at any one time. However, when asked to state what this maximum number was, nearly one-third of services stated a figure which bore no relationship to official guidance on syringe distribution issued by Scotland's Lord Advocate. ³ Nearly a quarter of Scottish non-pharmacy services said that the maximum number of syringes they would distribute depended on circumstances such as whether the client was known to the service, the number of syringes returned, where the client lived and whether the service had concerns about the health of the client. Responses from pharmacy co-ordinators were similar.

The majority of services in Scotland discouraged secondary (or peer) distribution of injecting equipment. However, only a few services had written policies on secondary distribution.

Just over a third of non-pharmacy services had a written policy or protocol on the provision of injecting equipment to young people under 18. Only three of these had agreed their policies with the local area Child Protection Committee.

Only about half of Scottish non-pharmacy services and two of 10 pharmacy schemes had mechanisms for assessing client satisfaction.

Comparisons with England ( Chapter 8)

Specialist services made up 23% of all Scottish needle exchanges, compared to an estimated 20% in England. In Scotland, pharmacy services comprised 72% of all facilities, whereas in England, they made up approximately 79% of services.

Non-pharmacy needle exchanges in Scotland provided better out-of-hours coverage than similar services in England, but English pharmacy services provided better out-of-hours coverage than those in Scotland.

Scottish services had more contact with female injectors than English services.

In both Scotland and England, returns to non-pharmacy services were higher than returns to pharmacy services.

Services in Scotland were significantly less likely than their English counterparts to provide Hepatitis B immunisation on-site. Only one service in Scotland provided tetanus vaccination, compared to 11% of services in England.

Scottish services were significantly less likely than English services to offer their clients a range of other on-site interventions including: motivational interviewing, key working, structured counselling, GP / primary care sessions, housing / social / legal advice and well-woman clinics.

In terms of paraphernalia distribution, Scottish services were significantly less likely than English services to distribute filters, sterile water, stericups and Vit C to their clients. Scottish services were more likely than English services to distribute wipes or swabs. There were no statistically significant differences between Scottish and English services in relation to the distribution of sharps bins, citric acid and tourniquets.

Compared to Scottish services, a much larger percentage of English services said that there was no limit on the number of syringes they would give out during any one needle exchange transaction. This is probably because there is no equivalent to the Lord Advocate's guidance in England.

Scottish services were significantly more likely than English services to report that they would provide injecting equipment to young people aged 16 or 17. However, there was no difference between Scottish and English services in relation to distribution among under-16s. English services were more likely to have a written policy on needle exchange among young people, and to have agreed their policy with the local area Child Protection Committee.

FINDINGS - PART 2: PLANNING AND COMMISSIONING OF NEEDLE EXCHANGE

Co-ordination, planning & commissioning ( Chapter 9)

Needle exchange activity in Scotland is co-ordinated at the level of NHS Boards, rather than DATs. This is because needle exchange is largely funded by Blood-borne Virus ( BBV) Prevention monies - an annual allocation made by the Scottish Executive Health Department to NHS Boards. This arrangement was seen to cause tension in some areas of Scotland where the boundaries of NHS Boards were not co-terminus with DAT boundaries.

This study found a lack of robust systems for monitoring needle exchange activity at a DAT level in many areas of Scotland, suggesting that the strategic planning activities related to needle exchange were limited. Greater standardisation in data collection and better use of the data was called for.

Systems for monitoring discarded sharps and needle stick injuries to the public appeared to be largely absent. The majority of DATs either did not have such systems, or were unaware of how to access them.

Staff training and qualifications ( Chapter 10)

There is no standard training for needle exchange workers in Scotland. Consequently, staff competency and qualifications vary. This was considered by some participants in this study to be an impediment to good practice.

Regular training and on-going support were seen to be especially important for pharmacy needle exchange providers (including counter staff). This was seen to be the key in overcoming negative attitudes among pharmacy staff.

Good practice / Difficulties and impediments ( Chapter 11 & 12)

Good and innovative practice in needle exchange was related to: providing a range of different services; use of outreach; good joint working relationships between services; use of pharmacy consultation rooms by specialist harm reduction nurses; the involvement of service users in the developing or delivering services; developing trust with service users; and ensuring good training and support for service providers - particularly pharmacy providers.

The biggest problems, or impediments to good practice were seen to be related to: funding shortages; lack of consistency and inability to implement recognised good practice in paraphernalia distribution; negative public attitudes; negative staff attitudes (especially among pharmacy staff); and staff shortages.

Conclusions and recommendations ( Chapter 13)

This survey has highlighted variation in practice in relation to all aspects of needle exchange provision in Scotland. In some cases such as the provision of paraphernalia and on-site BBV interventions, this variation is associated with NHS Boards. But in other areas, it would seem that some needle exchange services simply do things differently to other needle exchange services. The question which must be asked is: Is this variation acceptable?

While it may be acceptable for pharmacy exchange services to be different from police custody suite exchanges, and for specialist services to deliver different interventions than A&E exchanges, it is not clear why there should be large variations in practice between specialist services, or between pharmacy schemes in different parts of Scotland.

Many of the needle exchange professionals, and commissioners of needle exchange services who participated in this study argued for greater standardisation. People wanted to see more standardised training for needle exchange providers, and greater standardisation in data collection and monitoring systems. People also wanted to see official guidelines in relation to paraphernalia distribution.

However, many also pointed out that their aspirations for service development were limited by lack of funding. Having said that, there were clearly also instances where local Health Board policy, rather than funding per se, was the main limiting factor.

Given the findings of this study, the following recommendations are made.

Recommendations to the Scottish Executive

• In co-ordination with the Scottish Drugs Forum and other stakeholders, develop standards for needle exchange services in Scotland. Different standards may be required for specialist, pharmacy, police custody suite and A&E exchanges.
• In co-ordination with STRADA and NHS Education Scotland, develop a module or standard training course for all specialist and pharmacy needle exchange providers, and ensure that this training is regularly updated.
• Develop guidelines regarding paraphernalia distribution in Scotland, and put in place mechanisms to ensure compliance with the guidelines by NHS Boards. There may be some delay in this until the results of on-going research regarding the safety and effectiveness of injecting paraphernalia are published. In the meantime, however, the Executive should ensure that citric acid is distributed for free by all needle exchange services throughout Scotland.
• Increase funding to needle exchange services, to ensure that services are able to distribute an adequate number of syringes and other paraphernalia to their service users. Increased funding would also allow local areas to develop greater use of outreach services.

Recommendations to NHS Boards and Drug Action Teams

• Provide funding to all needle exchange services for citric acid distribution.
• Ensure that there is a balance between pharmacy and specialist needle exchange provision in local areas.
• Put in place systems for regular monitoring and reporting of needle exchange transactions (including gender and age of contacts) and numbers of syringes and other items of paraphernalia distributed.
• Put in place systems for regular reporting from local authority Environmental Health / Public Health services on discarded sharps and needle stick injuries to the public.
• Ensure that all needle exchange providers receive appropriate training, particularly in relation to injecting techniques, prior to providing a needle exchange service.
• Ensure that pharmacy exchange providers receive on-going training and support from a specialist harm reduction provider.
• Ensure that all needle exchange services have written protocols / policies on the distribution of sterile injecting equipment to young people under 18 and separate policies for under-16s. Ensure that these protocols / policies are agreed with local area Child Protection Committees.
• Reduce barriers to accessing BBV testing and immunisation services, by making such services available through needle exchange facilities.
• Improve integration between needle exchange and other local services, by arranging on-site access to primary care sessions, wound clinics, nutritional advice and housing, social welfare or legal advice.

Recommendations to needle exchange providers

• Put in place mechanisms for assessing the needs of clients and regularly reviewing those needs.
• Put in place mechanisms for assessing client satisfaction at regular intervals.
• Develop written policies and protocols regarding needle exchange provision to under-18s, and separate policies / protocols for under-16s. Involve local area Child Protection Committees in this process.
• Develop methods of better engaging with and educating injecting drug users, and share both failures and successes with other service providers. This can be done through the Scottish Needle Exchange Workers Forum.

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