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FINDINGS PART 2: PLANNING AND COMMISSIONING OF NEEDLE EXCHANGE

Chapter 9: Co-ordination, planning and commissioning issues

Headlines from this chapter

• Throughout Scotland, needle exchange activity is co-ordinated at the level of NHS Boards, rather than DATs. This is because needle exchange is largely funded by Blood-borne Virus Prevention monies - an annual allocation made by the Scottish Executive 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 ( i.e., Grampian, Lothian and Tayside).
• There is a lack of robust systems for monitoring needle exchange activity at a DAT / NHS Board level across Scotland. Many services routinely collected data; however the systems for collating and reporting data were inadequate. This finding suggests that there was little information available to inform planning and commissioning of needle exchange.
• Systems for monitoring discarded sharps and needle stick injuries to the public appeared to be largely absent across Scotland. The majority of DATs either did not have such systems, or were unaware of how to access them.
• The organisations which were responsible for commissioning needle exchange services varied across Scotland, and included among others: the DAT joint commissioning group, the primary care trust, the local NHS Board, the local BBV prevention group, and the local Addictions Partnership.
• In general, pharmacy needle exchange in Scotland is delivered on the basis of formal contracts or service-level agreements. Only a few areas in Scotland did not have such agreements.
• In most areas of Scotland, pharmacists were paid for providing needle exchange through a combination of an annual retainer fee and a payment per transaction. At the time of this study, payments varied considerably from one NHS Board area to another.
• Many areas in Scotland have attempted to respond to the challenges of accessibility through providing outreach services and expanding pharmacy needle exchange schemes.
• Few DATs reported targeting specific populations of injectors through the allocation of specific resources or dedicated workers. Homeless injectors and injectors in rural areas were targeted by more than half of DATs, but only a handful targeted other groups such as female injectors, sex workers, stimulant or steroid injectors.

This chapter focuses on the co-ordination, planning and commissioning of needle exchange services in Scotland. Issues of data collection, the targeting of particular population groups, and funding for needle exchange will also be discussed. These findings are based primarily on responses to the DAT questionnaires. This data is supplemented, where appropriate, with findings from focus group discussions.

Co-ordination of needle exchange

Throughout Scotland, needle exchange activity 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 where the boundaries of NHS Boards were not co-terminus with DAT boundaries ( i.e., Grampian, Lothian and Tayside), since DATs, rather than NHS Boards, are responsible for the planning and commissioning of services to drug users.

DATs were asked whether there was a specific individual responsible for co-ordinating specialist needle exchange activity in their area. Of those responding (n=18), 12 reported that there was a local co-ordinator of specialist needle exchange services. All DATs (n=19) had individuals who were responsible for co-ordinating pharmacy needle exchange in their area, although as mentioned above, in all cases that individual was responsible for co-ordinating pharmacy exchange across an entire NHS Board area. In 10 DATs, the same person co-ordinated both specialist and pharmacy services.

Data collection and monitoring

This study found a general lack of robust systems for monitoring needle exchange activity at a DAT level across Scotland. This first became evident during the process of surveying DATs. It was particularly intended that the DAT questionnaire be completed by those who had responsibility for commissioning needle exchange services. However, very few of the DAT questionnaires were actually completed by commissioners or others working within a joint commissioning partnership. The questionnaires were often passed to other professionals - usually needle exchange service providers or needle exchange co-ordinators - for completion.

This suggests that there was no centrally-held data on needle exchange which could be used to inform planning and commissioning. The aim of the DAT questionnaire was to investigate issues at a strategic level. However, it appeared that, in many areas, work on needle exchange at this strategic level was absent or limited.

A certain level of frustration was expressed on the subject of data collection in the focus group discussions. Respondents suggested that even within a particular DAT area, different data collection systems were often used by pharmacy and non-pharmacy exchanges. In some services, SMR24 forms were completed for each new needle exchange client, ¹⁰ while in others, only basic demographic information was recorded about the client the first time he / she accessed the service. It was suggested that voluntary sector services often had the most comprehensive monitoring systems because of a need to measure their activity to justify continued funding.

When DAT representatives were asked what information should be collected, they felt that specialist services should collect more detailed data than pharmacy services, and they appeared to be more interested in data on service activity ( e.g., number of needles out, number returned, number of clients, services received). Service providers, on the other hand, felt it would be more useful to also collect data on client characteristics ( e.g., drugs injected, sharing behaviour, whether the client is collecting needles for others). It was pointed out that certain data had to be collected in pharmacies, since in most areas, payments to pharmacists were based on the number of transactions or contacts.

In many areas, data collection was done using paper forms, which were completed at each transaction and sent back to a central office for collation. Unfortunately, in several areas, there wasn't sufficient funding to pay for data entry and analysis. Pharmacy co-ordinators particularly expressed frustration at this situation, and suggested that getting regular reports of their own needle exchange activity might actually be an incentive for some pharmacists to continue offering a service.

Minimum data set

None of the focus group participants voiced strong views about whether it would be useful to introduce a nationally agreed minimum data set, although there was a general feeling that more standardisation would be welcome - particularly withinDAT areas. In addition, service providers felt that DATs should make better use of the data that was already being collected for the purposes of on-going needs assessment.

Monitoring drug litter

Also in relation to the issue of data collection and monitoring, DATs were asked whether there were local systems in place for monitoring discarded sharps and needle stick injuries to the public. Only six out of 19 DAT respondents said they systems for monitoring discarded sharps (Aberdeen City, Borders, Glasgow, Highland, Perth & Kinross and West Lothian). However, only four of these were able to provide figures on discarded needles for the period April 2004 - March 2005. Only two DATs (Borders and Highland) said they had routine systems in place to monitor needle stick injuries to the public. In the remaining DAT areas, there either were no systems for monitoring, or the DAT respondent was unaware them.

Budgets and funding

As already mentioned, funding for needle exchange mainly comes from annual ring-fenced funding to NHS Boards for BBV prevention. However, some DATs indicated that other sources of funding for needle exchange also included:

• The local primary care trust (n=7)
• Pooled or DAT treatment budget (n=6) ¹¹
• Pharmaceutical funding negotiated at a local level (n=1)
• Lottery / charitable foundations (n=1).

DATs were asked whether "in real terms (accounting for inflation)", the budget for needle exchange in their area had increased, decreased or remained the same over the last three years. The majority of respondents (n=12) indicated that overall, the budget for needle exchange in their area had increased in the last three years, even when taking inflation into account. However, when asked about the budgets for specialist and pharmacy exchanges, some interesting differences emerged. Only 8 DATs reported that the budget for specialist services had increased in the last three years, whereas 10 reported increased budgets for pharmacy services.

Interestingly, very few DATs reported that budgets for needle exchange services had decreased in recent years. However, a sizeable proportion indicated that these budgets had remained static. And as will be seen in Chapter 12, lack of sufficient funding was seen as one of the main impediments to good practice in providing needle exchange. As one DAT survey respondent wrote:

Our actual needle exchange budget has remained the same. However, our overspend has increased by 74.5% over three years.

Commissioning and purchasing needle exchange services

DATs were asked which organisations are responsible for commissioning needle exchange services in their area. Responses included: the DAT joint commissioning group / manager (n=7) and the primary care trust (n=5). However, it was clear from the responses that in many DATs, one or more multi-agency groups were responsible for commissioning needle exchange services. These included:

• The local BBV prevention group
• The local NHS Board, in partnership with the local DAT
• The BBV strategy group in co-ordination with the needle exchange working group
• The integrated Addictions Partnership
• The DAT in partnership with local Joint Future groups

Commissioning pharmacy needle exchange services

Additional information on the commissioning of pharmacy services was sought from pharmacy co-ordinators. Namely, pharmacy co-ordinators were asked whether the pharmacies in their local needle exchange scheme had formal contracts, service-level agreements or other written agreements regarding the provision of their services. Eight out of 10 co-ordinators said they did. Only Orkney and Highland did not have such agreements.

Pharmacy co-ordinators were also asked for details about the payments made to pharmacies for needle exchange services. Most respondents indicated that their pharmacies were paid through a combination of an annual retainer fee and a payment per transaction (contact). As Table 9.1 shows, these payments varied considerably.

Annual retainer fees ranged from £120 to £1342 per year, while payments per transaction ranged from £1.60 to £2.25.

Pharmacy co-ordinators felt that existing arrangements were inequitable and suggested that this unfairness was having an impact on pharmacists' willingness to participate in needle exchange schemes. However, they expressed hope that the new national pharmacy contract (currently under negotiation) would resolve a number of problems.

Table 9.1: Arrangements for payments for pharmacy needle exchange services

Making services more accessible

The issue of accessibility was discussed in each of the Scottish focus group discussions. Respondents indicated that they had attempted to respond to the challenges of accessibility through:

• providing outreach services,
• encouraging secondary distribution of needles and syringes, and
• expanding pharmacy exchange schemes.

Service providers suggested that outreach services, in particular, were often more successful in reaching a wider range of service users, or indeed, a completely different client group than fixed site services. In Highland, the backpacking service was reported to have a much higher proportion of female clients than the pharmacies in Inverness did. It was thought that this was due not only to a lack of public transport - making it difficult for women from rural areas to travel into Inverness for services - but also a lack of affordable childcare. There was a feeling that female injectors were very unwilling to access local pharmacy needle exchanges with a young child in tow.

Outreach methods were also seen to be more effective in reaching certain populations that traditional drug services have found it difficult to engage with, for example, homeless injectors and sex workers.

Targeting special populations

DATs were asked in the survey whether they specifically targeted certain populations of injectors - for example, women, sex workers, the homeless or those who inject steroids or stimulants. Targeting could occur through the allocation of specific resources or dedicated workers to meet the needs of those populations, and would indicate the recognition of an identified need in an area.

Few DATs reported targeting specific populations. See Table 9.2. Homeless injectors and injectors in rural areas were targeted by more than half of DATs. But only a handful targeted other population groups. Interventions included among other things: a drop-in centre for homeless people; needle exchange in hostels for the homeless; a needle exchange clinic in a local Women's Aid service; a separate clinic for steroid users with specialist advice and support; and back-packing to injectors in rural areas.

Table 9.2: Number of DATs targeting specific populations

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