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Chapter 12: Problems and impediments

Headlines from this chapter

Problems in relation to commissioning and delivery of needle exchange included:

• Problems of funding and budget shortfalls
• Lack of consistency and inability to implement recognised good practice in paraphernalia distribution
• Negative public attitudes towards harm reduction interventions
• Negative attitudes among pharmacy (and police custody suite) staff in some areas
• Staff shortages

Survey respondents were given an opportunity to describe some of the problems that affected the provision of needle exchange in their area in the last 12 months. This was done through an open-ended question at the end of the questionnaire and through the three focus group discussions. In addition, there was also one question in each of the three surveys which asked whether there had been any difficulties in relation to a specific list of problems. The findings in relation to this question are shown in Table 12.1 below.

These findings suggest that the main problems facing commissioners and providers of needle exchange services across Scotland are: (i) budget shortfalls affecting the provision of injecting paraphernalia; (ii) complaints from local residents and businesses; and (iii) difficulties in recruiting or keeping pharmacies in the scheme.

In relation to the latter issue, focus group and survey respondents suggested that the problems were mainly due to lack of interest among pharmacists in joining the scheme and, once joined, difficulties in retaining them. In addition, one DAT respondent reported that they had recently had to ask a rural pharmacy to leave their scheme because of the negative and punitive attitudes of staff towards injecting drug users.

Table 12.1: Problems affecting needle exchange provision in the last 12 months

The remainder of this chapter summarises respondents' written and verbal comments on the difficulties or impediments to good practice in relation to commissioning and providing needle exchange services.

Problems of funding and finance

The problems of funding and finance seemed to touch on every aspect of needle exchange service provision. Focus group participants expressed serious concerns about the chronic shortage of funding for these services, and felt that this was undoubtedly affecting the health and safety not only of injecting drug users, but of the public.

National funding allocations for blood-borne virus prevention were seen to be insufficient. In most areas of Scotland, needle exchange is funded by NHS Boards with monies allocated and ring-fenced by the Scottish Executive for the prevention of blood-borne viruses. One DAT focus group participant suggested that too much of this scarce BBV prevention money was spent on sexual health interventions that were completely unrelated to BBVs - for example, interventions to prevent sexually transmitted infections such as chlamydia. Other DATs said that their local budget for needle exchange was overspent every year, but so far they had been successful in "borrowing" the necessary funding from other budgets. However, there was a recognition that this situation was rather precarious. ¹²

In some areas, voluntary sector needle exchange services had been successful in bidding for funds for the distribution of injecting paraphernalia. Concerns were voiced about what would happen when this funding had run out. Services were faced with having to withdraw items of paraphernalia they had previously provided for free.

In the view of many respondents, insufficient funding not only prevented the distribution of paraphernalia, but it also disallowed the expansion and development of services more generally. Added to this, was a belief by many service providers that needle exchange was simply not seen as a priority. Participants expressed the view that, at both a national and local level, needle exchange was a "Cinderella service". As one service provider said: "Needle exchange is under-resourced and under-valued." Priorities for funding and service development focused mainly on structured treatment services (in particular, maintenance prescribing), and in some areas, local decision-making made it impossible to use treatment funds for needle exchange. Some DATs had attempted to pool a variety of local budgets for needle exchange, but again, persuading local partners to contribute was sometimes difficult given their other competing priorities.

Paraphernalia distribution

Problems related to the provision of paraphernalia clearly impacted on many services. As already mentioned, the root of many of these problems was the lack of sufficient funding. However, this was not always the case. A comment from an individual who provided a service in an NHS Board that does not currently fund paraphernalia distribution suggested that she had not been permitted to sell citric acid to her service users:

I am (and have been) trying very hard to be allowed to sell citric acid or ascorbic acid to the clients. This one problem creates a huge difficulty for clients who cannot buy citric elsewhere. They commonly resort to lemon juice, baby paraphernalia sterilising products and industrial strength citric - the last two being extremely corrosive. (Non-pharmacy service provider)

Throughout Scotland, the distribution of paraphernalia was seen as a balancing act - with difficult decisions having to be taken. Service providers expressed concern that these decisions were too often taken on the basis of funding, rather than best practice.

Negative public attitudes

All focus groups participants felt that work needed to be done to change public attitudes towards harm reduction interventions. In many areas, the public have a "not-in-my-backyard" attitude to needle exchange.

A zero-tolerance community response makes it difficult for individuals to seek support or information. A harm reduction policy is seen by many as colluding with drug use. This limits how open the service can be about its activities. (Non-pharmacy rural service provider)

Several respondents had spoken about fierce resistance in their areas to plans for locating sharps boxes in public places.

Negative public (and political) attitudes towards harm reduction interventions were seen to be fuelled by the tabloid press. Adopting a positive, pro-active relationship with the local press was seen to be one of the solutions to this problem, but it was also recognised that more needed to be done to educate the public and local politicians about the importance of needle exchange to public health.

Negative staff attitudes

All focus group participants considered that "having the right attitude" was an essential requirement for staff in a needle exchange service. And there was a view that "attitude problems" tended to be found more in pharmacies than specialist needle exchange services. Several respondents mentioned problems with pharmacists refusing to give service users sterile needles if they had no returns.

However, focus group participants also had experience of pharmacy staff attitudes becoming more positive when they were given regular training and good on-going local support. Focus group participants pointed out that training has to be provided not only for the pharmacist but also for counter staff. Moreover, because of the high turnover of counter staff, the delivery of training had to be an on-going process, not just a once-a-year event. Unfortunately, current training of pharmacy staff often has to take place in the evening to avoid the cost of paying for locums. Therefore it happens infrequently.

Attitude problems were not only seen in pharmacy staff. One police custody suite respondent wrote:

At present, the scheme is viewed [by staff] with some trepidation and unease. This attitude requires to be changed so it [the service] can run more efficiently. (Custody suite exchange provider)

Staff shortages

Staff shortages in needle exchange services were apparently widespread. One service provider reported that staff sickness and absence created particular difficulties for outreach services. In addition, in some rural areas, outreach workers may be responsible for providing a number of services. In one area, clients stopped using the needle exchange service because the outreach worker responsible for delivering it was also responsible for supervised methadone dispensing.

Other problems affecting needle exchange

Other problems mentioned less frequently by survey respondents and focus group participants included:

• Separate management structures in some areas for pharmacy and non-pharmacy exchanges
• Poor communication between the NHS agencies in control of BBV prevention funding and the local DAT
• Problems in accessing suitable accommodation for the service
• Concerns about the practice of secondary distribution
• A perception that national research undertaken on this topic is only ever based in Glasgow - and so is not representative of Scotland as a whole.

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