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Chapter 7: Needle exchange policies and procedures
Headlines from this chapter
- There was variation across Scotland in policies and practices related to syringe distribution. The majority of non-pharmacy services (28 out of 45) said there was a maximum number of syringes that their service would give out at any one time. However, in nearly a third of these services, the maximum levels reported bore no relationship to official guidance from Scotland's Lord Advocate.
- A number said that the maximum number of syringes they would give out to a client at any one time was dependent on certain circumstances such as whether the client was known to the service, the number of syringes returned, etc. There appeared to be similar variation in pharmacy schemes.
- Regarding policies on returns, there was less variation among non-pharmacy services. The majority said that their policy was to "encourage the return of used equipment, but this was not a condition for accessing sterile equipment."
- Secondary distribution (also known as peer distribution) was highlighted in Scottish focus group discussions as a possible way of improving the accessibility of needle exchange services in rural areas. However, the practice did not appear to be common in Scotland.
- Three-fifths of services (26 out of 45) said that they did not supply injecting equipment to young people under 16. However, 18 reported that they would supply to under-16s in certain circumstances.
- Three-quarters of services (34 out of 45) said they would supply sterile injecting equipment to young people aged 16-17. Many said that over-16s were treated in the same way as adults, but others said that they only supplied this group under certain circumstances, which were similar to those for under-16s.
- Just over a third of non-pharmacy services had a written policy or protocol on the provision of injecting equipment to young people. Only three of these had agreed their policies with the local area Child Protection Committee.
This section presents information about formal policies and procedures related to needle exchange in Scotland. The data is taken mainly from responses to the Services and Pharmacy Co-ordinator surveys.
Policies on the number of syringes distributed
Both non-pharmacy and pharmacy services were asked whether there was a limit on the number of syringes and / or packs that they would give out at any one time. This question was included in the Scottish questionnaires partly to allow comparison with other parts of the UK, and partly to investigate whether services had policies in addition to the official national policy established by Scotland's Lord Advocate.
Interestingly 8 (out of 45) non-pharmacy services, and two (out of 10) pharmacy co-ordinators, said there was no limit on the number of syringes that their service or pharmacy scheme would give out to a client in any one transaction.
The majority of non-pharmacy services (28 out of 45) said there was a maximum number of syringes that their service would give out at any one time. However, when asked to state what this was, nearly a third of these entered figures which bore no relationship at all to the Lord Advocate's guidance:
- Four services said that the maximum number of syringes they would give out in any one transaction would be five or less. Three of these were police custody suite exchanges, and one was a hospital-based service. Police custody suites tend to operate needle-replacement schemes, and so this finding is not surprising in relation to these services.
- One service stated that their maximum limit was 45.
- Two said the limit was 30.
- One service indicated that clients were permitted five syringes for their first visit, 10 for their second visit, and 15 for their third and subsequent visits, unless they were from a rural area, in which case they were permitted a maximum of 30 syringes.
- The remaining services said that the maximum number of syringes they give out would be 60 at any one time, and 120 in exceptional circumstances, in accordance with the Lord Advocate's guidance.
Eleven services said that the maximum number of syringes they would give out to a client at any one time was dependent on certain circumstances. These included:
- Whether the client was known to the service - those who are not known to the service were given fewer syringes.
- The number of syringes returned - those who returned only a few or no used syringes were given only a few clean syringes.
- Where the client lived - those in rural areas were given more.
- Whether the service had concerns about the health of the client - fewer syringes were given to those with abscesses to encourage more frequent contact.
- Holidays - clients were given more syringes prior to holidays or when the service was going to be closed.
Responses from pharmacy co-ordinators were similar. As mentioned above, two pharmacy co-ordinators said there was no limit on the number of syringes that their pharmacies would give out at any one time. However, the majority (6 out of 10) said that there was a limit, but only one of these entered a number which bore no relationship to the Lord Advocate's guidance (30). The remaining five said the maximum was either 60 or 120, in accordance with the Lord Advocate's Guidance, although one of these also indicated that the maximum might be less if the client consistently returned little or no syringes. Two pharmacy co-ordinators said that the maximum depended on circumstances. One said the client would be given a maximum of 60 syringes, unless he / she had no returns, in which case, the client would only be given 20. Another said that pharmacies would follow the Lord Advocate's guidance for clients who were known to the service, but if they were not, they would only be given one pack of 5 syringes.
These findings clearly indicate a great deal of variation across Scotland in policy and practice related to syringe distribution.
Policies on returns of injecting equipment
Non-pharmacy services were asked about their policy on the return of used needles and syringes. The majority (34 out of 44) said that their policy was to "encourage the return of used equipment, but this is not a condition for accessing sterile equipment." Only one service had a strict one-for-one return policy; this service was a police custody suite exchange which operated a needle replacement scheme. Seven services said they always required some returns before new equipment was issued, and two - both located in hospital A&E Departments indicated that they dispensed sterile injecting equipment, but that used injecting equipment was not returned to their service.
Unfortunately, this question about policies on returns was not asked of pharmacy co-ordinators, as it was felt that any variation in practice would exist at the level of individual pharmacies, rather than at the level of an entire area scheme. However, focus group participants and survey respondents confirmed that pharmacy practices did vary.
Policies and practices on secondary / peer distribution
Services were asked about their practices in relation to the secondary distribution of sterile injecting equipment. Secondary distribution, also known as peer distribution, involves needle exchange clients in the distribution of sterile equipment to other injectors. The majority of services (31 out of 45) stated that they discouraged secondary distribution and ten others said they "neither encouraged nor discouraged it." Only four services encouraged the practice. Differences between services did not appear to be associated with either rurality or health board.
Only six services (out of 45) said they had a written policy on secondary distribution. Of these, two encouraged the practice, one discouraged it and three did neither.
The subject of secondary distribution was discussed briefly in the focus group with non-pharmacy service providers. Secondary distribution was considered to be one way of improving the accessibility of needle exchange services in rural areas. While a few areas reported some success in this, the practice did not appear to be common in Scotland.
Policies on needle exchange for young people
Non-pharmacy services were asked about their policies and practices regarding needle exchange to young people. In the first instance, services were asked whether they provided injecting equipment to (a) young people aged under 16 and (b) young people aged between 16-17.
Under 16s
Nearly three-fifths of non-pharmacy services (26 out of 45) said that they did not supply injecting equipment to young people under 16. Unfortunately, it is not clear whether services did not do this because they have a policy which prohibits it, or because they simply do not have young people of this age accessing their services. Several respondents indicated that they had never been asked to supply injecting equipment to anyone under 16.
Eighteen respondents indicated that they would supply injecting equipment to under 16s and provided details of the circumstances in which this would be done. Some of these circumstances included:
"A full assessment is required, and the young person is referred to [local drug service] for injecting advice from a nurse."
"If we can't dissuade the person from injecting, we will supply, but we ask them to return on a regular basis."
"If the client is in an active working relationship with the youth support worker."
"Two workers would be involved in undertaking a risk assessment."
Several of those who said they would supply to under 16s indicated that they would do so only if there was evidence that the young person had been injecting previously, and they were able to demonstrate that they understood what they were doing - i.e., able to give informed consent for treatment.
16- to 17-year-olds
In relation to 16- to 17-year-olds, three-quarters of non-pharmacy services (34 out of 45) said they would supply sterile injecting equipment to young people in this age group. Many respondents said that young people of this age were treated in the same way as adults.
However, others reported that they only supplied to this group in certain circumstances, often the same circumstances as for under-16s. Again, several said that they would only supply to young people aged 16 or 17 if there was clear evidence that they were already injecting. But again, it would appear that many services did not commonly see clients under the age of 18. As indicated in Chapter 5, 23 services reported only 756 contacts with under-18s in the period April 2004 - March 2005. On average, that works out to be about 2.7 contacts per service per month.
Service providers focus group participants said that when dealing with clients under 18, they tried as much as possible to ensure that the client understood what they were doing. There was a feeling that it was very important to provide specialist support for young people, and one service provider said that his service had two dedicated young people's workers, who were responsible for working with young injectors.
Service providers and pharmacists also pointed out the difficulties in knowing just how old people are when they come into the service. Most service providers said they record client date of birth, but pointed out that clients could easily give false information.
Policies on supply to young people
Just over a third (18 out of 45) non-pharmacy services reported that they had a written policy or protocol on the provision of injecting equipment to young people. Only three of these indicated that these policies had been agreed with the local area Child Protection Committee, although one other reported that discussions were currently taking place.
Standard operating procedures for pharmacies
Pharmacy co-ordinators were asked whether they required their local pharmacy exchanges to have standard operating procedures on needle exchange. Seven (out of 10) respondents said that they did, and three said they did not.
Getting the views of service users
Both pharmacy co-ordinators, and non-pharmacy service providers were asked specifically if they had mechanisms for assessing client satisfaction. One-half of non-pharmacy providers (n=23 out of 45) and two of the 10 pharmacy scheme respondents (Fife and Glasgow) reported that they did.
The methods used for assessing client satisfaction varied from one service to another, and in some services, a combination of formal and informal methods were used. These included:
- Bi-annual questionnaire surveys
- One-to-one verbal feedback
- Customer complaints forms
- Service users' comments book
- Regular service reviews
- Participation in formal research studies
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