Section 1: Developing an IEP programme
There are injecting populations in every part of Scotland, including rural and very remote communities. 3 Local authorities, Health Boards and Community Health (and Care) Partnerships ( CH(C)Ps) have a duty to respond to the needs of these populations, not only to reduce the significant risks of injecting to injectors themselves, but also to prevent the transmission of HCV and other BBVs within the general population.
Access to sterile injecting equipment should be available to whoever needs it, regardless of whether that individual's residence is rural or urban; island or mainland; or whether they are detained in prison or in police custody.
However, findings from the National Needle Exchange Survey have shown that, in many areas, there is far from sufficient distribution of needles to injecting drug users. In 2005, the Survey found that there were just 188 IEP services across the whole of Scotland, serving an estimated 19,000 injectors. 19
There needs to be a significant increase in the overall provision of injecting equipment across Scotland. This increase in provision can come, both by providing more services on the ground, and also by making existing services more accessible (through, for example, expanded opening hours).
However, the expansion of IEP services in local areas needs to be done in a strategic way, giving full consideration to prevalence data and to evidence about the best way of meeting the needs of diverse, and often hidden, injecting populations.
These guidelines are intended to provide a framework for the planning and delivery of IEP services across Scotland. Many of the recommendations made in the following pages focus on whatIEP services do and how they do it.
However, it is clear that, to implement these guidelines, services will need the support and commitment of colleagues who are responsible for service planning and commissioning activities. Before an IEP service can even open its doors to customers, decisions have to be taken about where and when the service will be delivered, what form the service will take, and who will staff it. These decisions will have a major impact on the accessibility and quality of services - and ultimately, the ability of services to meet the needs they were set up to meet.
Therefore, this section makes recommendations related to the process of planning and developing IEP services. These recommendations will be most relevant to those who have a strategic role in the planning and commissioning of services in their area, as well as those involved in managing and developing local IEP programmes.
The aim of the recommendations in this section is to increase the overall provision of injecting equipment and make that provision more accessible. Recommendations made later in this document will address ways that existing services can be improved.
Recommendation 1: Planning and developing IEP services
In planning and developing services that provide injecting equipment, NHS Boards, together with local partners, should undertake a number of tasks to ensure that services are able to meet the needs of their clients effectively. These include:
- Needs assessment
- Stakeholder consultation and engagement
- Staff training
- Advertising the service
- Monitoring and evaluation
Needs assessment is a strategic process that involves identifying the extent and nature of the needs of a particular population so that services can be effectively planned and delivered to meet those needs. The outcome of needs assessment will be greater capacity within services and better access for service users, as well as improvements in the quality and range of service provision.
Needs assessment is not a one-off activity. Injecting populations, and their needs, may change over time, and so it is important to review needs assessment annually, and link the process of needs assessment to on-going monitoring and evaluation (described below).
Needs assessment is a complex task. However, there are a number of good practical guides which can assist with the process. Two of these are:
Stakeholder consultation and engagement
Planners and commissioners of IEP services need to take time to develop support among the diverse groups that will be affected by IEP services. These include: injecting drug users, treatment services, the police, public health, primary care and mental health services, and community representatives. One way of developing support is by establishing an advisory group comprising relevant stakeholders.
BBV Prevention Groups currently exist throughout Scotland, and generally these include representatives from agencies responsible for the commissioning and delivery of IEP services. To be truly effective, however, the planning of IEP services also needs to take into account the views of service users and community representatives. Local community drugs forums may provide one means of communicating with, and receiving input from, these groups.
In Scotland, planning regulations require formal public consultation prior to establishing a fixed-site IEP service. This is not required if the service is delivered within a pharmacy or other existing service, or as an outreach, mobile or home-delivery service. However, even where formal public consultation is not required, future difficulties can be avoided if community representatives are actively involved in, and understand the benefits to the community, of IEP services. IEP services can often be victims of a "not-in-my-backyard" attitude. NHS Boards should be prepared to actively promote the benefits of IEP programmes to counter adverse media publicity and local opposition based on misinformation.
The police are also important stakeholders in relation to IEP services, and the drugs strategy of the Association of Chief Police Officers in Scotland ( ACPOS) supports the principles of injecting equipment provision. Links to the police can be made through local community safety partnerships, and discussions with the police should take place before setting up any new service since police support can help to allay fears and combat local opposition. It may be helpful, in some circumstances, to establish a protocol with the police (and / or shop security staff), so that clients are not harassed when entering or leaving an IEP service, as this can discourage clients from attending. 26 Current good practice guidance from the UK Department of Environment, Food and Rural Affairs ( DEFRA) suggests that such a protocol may also be helpful to avoid clients inappropriately discarding injecting equipment, since injectors may fear that if they are found by the police in possession of needles, they will be arrested and the needles used as evidence against them. 54
While it is crucial to engage with stakeholders in the early stages of setting up a new IEP service, it is also important to maintain that engagement over time, so that services can identify and respond to any issues that arise, and promote successes, for example, in reducing street-based injecting or drug litter.
It is the responsibility of services to ensure that their staff are properly trained prior to delivering an IEP service. However, it is the responsibility of service planners and commissioners to ensure that suitable training is made available, and that staff are given all necessary support to be able to attend. In the case of pharmacy IEP services, this may involve providing locum costs. Recommendation 9 in Section 3 provides further information about the skills and knowledge that should be expected of all staff involved in the delivery of IEP services.
"Advertising" the service
Information about IEP services should, as much as possible, be targeted specifically at injecting drug users and agencies that work with them, not at the general population. This sort of communication strategy reduces the potential for inappropriate exposure that could lead to negative attention from the community and result in stigmatisation of clients attending services and practical difficulties for the service provider delivering the service.
Monitoring and evaluation
As discussed above, the process of needs assessment involves gathering information about the needs of a particular population. In many cases, a needs assessment exercise will result in change - either in the way existing services are provided, or in the introduction of new services or interventions. It is important to check that these changes are having the intended effect. For that reason monitoring and evaluation should be integral components of the process of needs assessment.
Monitoring is an ongoing process that involves the continuous or regular collection of key information to allow regular checks on whether an intervention is going to plan. However, monitoring does not provide information about the changes that could be made to improve outcomes for service users. For this latter task, evaluation is needed. The process of evaluation involves looking back to find out what difference an intervention has made. Evaluation can also be used to explore how and why something is working or not working.
Recommendation 2: Choosing appropriate models of delivery
NHS Boards and other service commissioners should ensure that a range of IEP services are provided using models of delivery appropriate to their local injecting populations and the geography in their locality, based on an assessment of local needs.
In addition, it is recommended that:
- All clients should be able to access in-depth advice and information from a specialist IEP service.
- In large towns and cities (defined by the Scottish Government's urban-rural classification as settlements of 10,000 or more), there should be a balance between the use of specialist, enhanced and general services.
- Fixed-site services should be located in areas where there are clusters of injecting drug users.
- All NHS Board areas should have at least one fixed-site service.
- Fixed-site services should be located on, or within five minutes walk of, a public transportation route.
- When injectors live in areas where they cannot easily access a fixed-site service on foot or by public transportation, other models of distribution (for example, through outreach) should be used in preference.
Chapter 3 of this document discussed the strengths and limitations of different models of IEP services. It is clear from the range of evidence presented that no one model of an IEP service can be considered betterthan another. Rather, the evidence suggests that some approaches may be more successful than others in reaching certain injecting populations, and that service users themselves may prefer, for a variety of reasons, to use one type of service over another. Therefore, IEP programmes delivered through a combination of models - with services at different venues tailored to meet the needs of different injecting populations - will be better than those delivered through a single model.
In considering which models to use, the aims must be:
- To maximise the distribution of sterile injecting equipment and remove barriers to access (discussed further in Section 2)
- To ensure that clients receive in-depth, user-friendly advice and education about how to reduce injecting-related risks (discussed further in Section 3)
- To offer clients access to a range of other services through IEP services (discussed further in Section 4)
Increasing pharmacy provision is one way of improving the accessibility of injecting equipment. At the same time, too much reliance on community pharmacy IEP services alone is problematic because of some of the limitations of pharmacy services discussed in Chapter 3 above. The National Needle Exchange Survey found that in some areas of Scotland, IEP service provision is almost exclusively through community pharmacies, 19 which, at the time of the survey were mainly offering general IEP services. Therefore, it is recommended that in these areas, there should be a better balance between specialist, enhanced and general services. In addition, these different types of services should not all be provided in the same location; they should be separate services, to give service users a range of options in how and where they access sterile injecting equipment. (For example, it may be useful to deliver a specialist service through outreach on the premises of an enhanced or general pharmacy service. However, this should not be the only route of access to a specialist service.)
To expand the distribution of sterile injecting equipment, both in remote and rural areas, and in built-up areas, there are some good arguments in favour of a greater use of outreach models. These services can be targeted to the needs of specific populations, can provide greater privacy and confidentiality, and can offer in-depth advice and education from a specialist harm reduction worker. However, there is a lack of evidence about the cost benefits of different forms of outreach. In remote and rural areas, peer distribution models may also be useful, and services should take sufficient time to educate peer distributors in safer injecting practices which they can pass on to others in their own social networks.
Service commissioners may also wish to give consideration to making injecting equipment more widely available through health centres, as this might also improve injectors' access to primary and secondary care. However, if the IEP service is only provided a few hours each week, there is a risk that clients will miss the service if they are unable to attend.
Although the use of dispensing machines is controversial, service commissioners may wish to consider the possible benefits of offering their injecting population 24-hour access to injecting equipment in this way.
In making the important decisions about where to locate a service, commissioners should take into account evidence which indicates that an injector's proximity to an IEP service can lead to greater utilisation of IEP services, and result in reduced syringe sharing. 6 In addition, there is evidence from a number of studies to suggest that convenience (specifically opening hours, location and queues) of IEP services can influence decisions on whether to obtain injecting equipment from services, or from street sellers or through secondary distribution. 32 Moreover, there is evidence to suggest that the immediate availability of injecting equipment is more important to injecting drug users than perceptions of risk associated with injecting behaviour. 16, 32
Recommendation 3: Meeting the needs of sub-populations of injectors
In deciding which models of service provision to use, service commissioners and service providers should give special consideration to the specific needs of the following sub-populations of injectors, where these populations exist in their area:
- New injectors
- Sex workers
- Homeless injectors
- Users of performance and image-enhancing drugs ( PIEDs)
- Minority ethnic groups
- People receiving opiate substitution therapy, or who have recently relapsed following treatment
- People in custody (both prison and police custody) or recently released from custody or court.
People who inject drugs are not a homogenous group. Within the drug-injecting population, there are different cultures, and different groups with different needs. The groups listed above are often unwilling or unable, for a variety of reasons, to attend IEP services. Because of this, these groups are at high risk of acquiring HCV and other BBVs, and are at risk of other injecting-related harms resulting from unsafe injecting practices.
- New injectors: There is evidence from modelling studies to indicate that injectors are at greatest risk of being infected with HCV (and HBV) in their first year of injecting. 55 Experts are of the view that recent-onset injectors often do not use existing IEP services because they feel uncomfortable about disclosing their behaviour to individuals whom they perceive to be disapproving of them.
- Women: A review of qualitative evidence carried out by NICE has shown that female injectors are more vulnerable than men to unsafe injecting practices, due to incorrect beliefs about the risks of sharing equipment with a sexual partner, and increased fear of exposure. Women are also more likely to have negative feelings about using pharmacy-based IEP services and to obtain equipment by secondary distribution. 32
- Sex workers: A survey of health service use among female prostitutes found that sex workers are likely to have chaotic high-risk drug use and have multiple sexual partners. They are also likely to have poor use of health services, including IEP services. 56
- Homeless injectors: A review undertaken for NICE found evidence to suggest that homeless injectors have lower levels of syringe coverage than those who are not homeless. 6 This is likely to put homeless injectors at greater risk of sharing and reusing injecting equipment. Homeless injectors are also more likely to report abscesses, open sores or wounds at an injecting site, and to be infected with HCV. 4
- Users of Performance and Image-enhancing drugs ( PIEDs): The nature of PIEDs and the way they are injected requires different injecting equipment (including larger barrels for syringes) and therefore a different form of safer injecting advice. IEP staff need additional training to be able to provide good-quality advice. Experts report that PIEDs users do not identify themselves with other injecting drug users, and as a result this group is often reluctant to access IEP schemes. At the same time, PIEDs users are often unaware of the risk of BBV transmission from sharing needles. In planning services for PIEDs users, it should be noted that this group is often in employment and so may require evening services.
- Minority ethnic groups: Experts believe that this group of injectors, because of cultural differences, may not identify with other injecting drug users, and so may be reluctant to attend IEP services. There may also be language barriers in some cases.
- People receiving opiate substitution therapy, or who have recently relapsed following treatment: In the experience of experts, people on a methadone or other opiate substitution programme may face, or perceive barriers in accessing an IEP service, particularly if they are accessing needles through a pharmacy where they also are receiving methadone. This view was strongly confirmed by service user groups who were consulted on these guidelines. Both IEP services and treatment services should avoid punitive responses to injectors in this situation. Services should instead seek to discuss with the client whether changes need to be made in their prescription medication or dose, or whether other types of support are required, including the provision of injecting equipment.
- People in or recently released from custody or court: The most recent series of Hepatitis C prevalence studies in Scotland's prisons were undertaken in the mid-1990s. Overall, HCV prevalence was found to be 20.3%, which is substantially higher than HCV prevalence in the general population. 57 The high prevalence of HCV, combined with the illicit sharing of injecting equipment, make prisons a high-risk environment for the transmission of HCV.
In relation to police custody provision, a number of police custody suites in Scotland currently provide injecting equipment to people released from custody through needle replacement schemes, and there is tentative evidence that this model of IEP may be reaching people who are not otherwise in contact with IEP services. 40 Local areas may wish to consider the options for extending this type of service to people who are released directly from court after being held for a period in police custody.
The particular needs of these groups should be taken into consideration when deciding on the models and locations for IEP services and setting opening times. Some of these groups may require novel models of service delivery. In some cases, outreach models may be appropriate; in others, it may be enough to provide longer opening hours or night-time drop-in services.
Recommendation 4: Opening times
IEP services should operate at times when injecting drug users are likely to need access to injecting equipment. There should be out-of-hours and weekend access within each NHS Board area corresponding to the needs of local injecting populations.
As mentioned above in relation to Recommendation 2, convenience (specifically, opening hours, location and queues) of IEP services are very important to injectors and there is evidence that such factors can and do influence decisions on whether to obtain equipment from IEP services or from street sellers or secondary distribution. 32
IEP service commissioners and providers need to consider ways of improving access to sterile injecting equipment. One way of doing this is by making services available out of hours. Out-of-hours provision includes evenings, weekends and 24/7 provision.
Where resources are limited, there is some evidence to show that having access to injecting equipment at the weekend is rated more highly than having access in the evening 58 and injectors often consider community pharmacy IEP services to be more accessible than drug agency-based services for that reason. 32 Consultation with service user groups in Scotland indicated that some community pharmacies may restrict access to injecting equipment to certain hours of the day. NHS Boards should ensure that these restrictions are removed and that injectors have access to sterile injecting equipment at any time during the pharmacy's opening hours.
Where local injecting populations include certain hard-to-reach groups (as described in the previous recommendation), there may also be a need for some form of service in the evenings which is directly targeted at those groups.
The need for injectors to have 24-hr access to sterile injecting equipment should also be considered This can be done either through increasing the number of 24/7 services, by making injecting equipment available through existing 24/7 services (e.g., hospitals), and / or by making sterile equipment available through other means, such as dispensing machines.
Finally, NHS Boards should ensure that accurate information is made available to service users about the locations and opening hours of all local IEP services. This can be done through a leaflet, or by printing the information on the bag that is given to service users to hold their injecting equipment. This information should be updated as necessary when opening hours are temporarily changed such as, during holiday periods for example.