Drug Deaths Taskforce response: cross government approach

6. No wrong door and holistic support

Taskforce Recommendation: Local and national leadership should ensure that the principle of no wrong door is at the heart of a new whole-systems approach. This means that individuals are never turned away, or passed from service to service, or told that their treatment is conditional on another treatment. It should be the responsibility of services to join up support, not the individual to develop and navigate their own care plan.

In 2017, 76% of people were in contact with a service with the potential to address their problematic drug use or deliver harm reduction interventions in the six months before death (2018: 67%)^[35]. This includes police custody, being discharged from hospital, prison, social work, housing and/or drug treatment services.

The Taskforce highlighted the need for national leadership to "ensure that the principle of no wrong door is at the heart of a new whole-systems approach^[36]." In addition to ensuring that people who use drugs can access the support they need, when they need it, we also know that people with problem drug use often have complex needs requiring joined up care plans.

This section therefore focuses on the action we are taking across government to support people who are currently using drugs, to ensure they can access the support they need and are entitled to, and to support their families.

This action is underpinned by the Scottish Government's introduction of the Fairer Scotland Duty, set out in Part 1 of the Equality Act 2010, which came into force in Scotland from 1 April 2018. It places a legal responsibility on particular public bodies in Scotland, including Scottish Ministers, to actively consider ('pay due regard'to) how they can reduce inequalities of outcome caused by socio-economic disadvantage, when making strategic decisions.

Evaluating the socioeconomic duties in both Scotland and Wales in 2021, found that they encouraged public bodies to review and formalise their consideration of socio-economic disadvantage within strategic decision-making processes.^[37] The Equality and Human Rights Commission found that most public bodies in Scotland felt the Duty already ensured, or would ensure in the future, that inequalities of outcome resulting from socio-economic disadvantage are considered as part of strategic decision-making; while some reported that the Duty had begun to influence and change the outcomes of decisions. Therefore, the Duty plays an important role in ensuring socio-economic equalities are given due consideration in decision making.

6.1 Getting it Right for Everyone: Ensuring person centred care and joined up multi-agency support for those who require it.

Getting it Right for Everyone (GIRFE): Too often, adults and their families are excluded from assessment and support processes by complex bureaucracy. GIRFE is about providing a more personalised way to access help and support when it is needed, placing the person at the centre of decisions that affect them to achieve the best outcomes, with a joined-up, coherent and consistent multi-agency approach regardless of the support needed at any stage of life.

Key actions

• People accessing addiction services have been identified as one of five key themes for the Getting it Right for Everyone (GIRFE) pathfinders which will test this new approach using a co-design method to support a national practice model. Other pathfinders include People in Prisons, Families with multiple and complex needs, older people and frailty and people registered at Deep End GP practices. Together these pathfinders will help provide a holistic understanding of how we can best support people with complex needs – including people who use drugs. Pathfinders are taking place in 11 locations, with East Ayrshire, Angus and Argyll and Bute pathfinders having a specific focus on addictions services as well as prisons and families with multiple complex needs. Pathfinders in these areas and Edinburgh and South Ayrshire will also work on the theme of deep end GP practices.
• A GIRFE Pathfinder Design School will be established from December 2022 to April 2023 to help local teams come together, get ready for co-design work, and engage people with lived experience to understand the current situation and work collaboratively to interpret and implement GIRFE.
• The pathfinders are currently being developed and are due to begin in Spring 2023. Full implementation of GIRFE is expected to be complete in Summer 2025.

6.2 Removing the barriers experienced by people who use drugs to accessing employment

People who use drugs face a number of barriers to gaining and maintaining employment and many of these barriers not only persist as people journey through recovery but can also act as a barrier to recovery.

Barriers identified include poor self-confidence and mental health problems, physical health problems, a lack of education, training and skills, ongoing drug use, receiving treatment whilst working and, importantly, stigmatisation.^[38]

Employment Support: No One Left Behind is the Scottish Government's approach to simplifying the employability system. It has a crucial role in achieving our vision for economic transformation and tackling child poverty; and aims to deliver a system that is more tailored and responsive to the needs of people of all ages who want help and support on their journey towards and into work, including people who use drugs. Through No One Left Behind, participants receive support from an Employability Key Worker who will work with them to develop an individual plan specific to their circumstances and barriers, to help them achieve their goals.

This year (2022/23) the Scottish Government is investing over £59 million in No One Left Behind, providing person-centred support to those further from the labour market as they move towards, into and progress within work. In addition, the Scottish Government is investing £23.5 million in Fair Start Scotland delivery, providing intensive and personalised pre-employment and in-work support for unemployed disabled people, and those with health conditions or other barriers to progressing into work.

Young Person's Guarantee: The Scottish Government established the Young Person's Guarantee in November 2020. It aims to connect every 16 to 24 year old in Scotland to an opportunity. This could be a job, apprenticeship, further or higher education, training or volunteering. It could also be an enterprise opportunity as a means of addressing the potential impact of the Covid-19 pandemic on young people. It continues to play an important role in supporting our economic recovery and improving outcomes for young people. Through the Guarantee, which is delivered through No One Left Behind, we have allocated over £4 million of funding to third sector organisations in financial year 2022-23 to support those young people who have additional barriers to engagement. As we start to mainstream elements of the Guarantee, there will be a renewed focus on disadvantaged young people who face the greatest barriers to accessing the labour market. We will continue to work with partners in the third sector to develop a whole system approach to supporting all young people, work to eliminate discrimination and ensure that no one is left behind.

Key actions

• Maximising the impact of our existing investment in employability services through No One Left Behind and Fair Start Scotland, providing people who use drugs with the support that they need to move towards, into and to sustain work.
• We are working across each local authority area to explore support and referral mechanisms for accessing employability support for individuals with a history of drug dependency. This will provide a pan-Scotland perspective of current connectivity between employability and drugs support agencies at local levels, to enable us to collectively identify how connections can be strengthened to ensure the right support is available to the individual at the right time.
• Through our funded employability provision, service providers and delivery partners continue to work with the NHS and other specialist organisations to support participants with a history of using drugs, through mentoring, group support and other activities that help with personal recovery.
• Work is continuing with all delivery partners to share good practice in terms of effective working with employers to support individuals with a history of drug use.
• We will seek to improve current service delivery by working with service providers to learn from the range of interventions already in place, including outreach at recovery cafes and projects.

As part of the National Strategy for Economic Transformation we are working to eradicate structural barriers to employment through the further development of No One Left Behind. We will work with partners and those with lived experience to ensure that our approach to employability in Scotland best supports the National Mission on Drugs.

• Lived experience remains at the heart of the design and development of No One Left Behind. We will consider how best to ensure that further development of the No One Left Behind approach is informed by the lived experience of people who use drugs.
• We know that employability support must be embedded within a broader range of support services such as housing, health, justice and advice services to ensure that individuals can access the holistic packages of support that they need to move towards, into and to sustain employment. We will consider how we can ensure that "Every Contact Counts" is signposting people who use drugs towards employability support.
• We are due to publish the next No One Left Behind Strategic Plan in early 2023 and will ensure that this plan considers how best our future employability services can support the National Mission on Drugs.
• We are currently refreshing our national workforce policies in partnership with NHS Scotland employers and trade unions to provide single, standardised policies to be used consistently and seamlessly across the NHS in Scotland as part of the 'Once for Scotland' Workforce Policies Development Programme. The Managing Health at Work suite of policies that includes guidance on alcohol, tobacco and other substances, will be reviewed as part of this programme of work.
• Creating sustainable career pathways for people entering the drugs and alcohol sector is a clear focus of workforce development plans. Work is already underway to develop these pathways with a focus on ensuring that those with lived and living experience have the right support to enter the sector and play a more active role in the design and delivery of drug services. We are working in collaboration with experts across the sector to develop guidance for employing and supporting staff with lived and living experience.
• We are exploring opportunities to enhance data collection to better differentiate between types of substance use and understand how well our service support their progression towards work.
• We are identifying potential routes for better connectivity between employability and drugs support agencies with the aim of providing, at Community Planning Partnership level, more integrated support via local Alcohol and Drugs Partnerships, Community Justice Partnerships and Local Employability Partnerships.

Promoting take-up of benefits: Ensuring that people can access all of the Social Security Benefits to which they are entitled is a moral duty and fundamental priority of the Scottish Government. Our second Benefit Take-up Strategy^[39] sets out how we are working to ensure that people from all walks of life can access the support they are eligible for.

Ensuring that support reaches those in need is of paramount importance and will be critical in delivering on our national mission to tackle child poverty, in our journey of Covid recovery and most recently to help mitigate the devastating impacts of the Cost of Living crisis. The Scottish Government is committed to increasing the take-up of our devolved benefits and reaching those that are in the most need of support. We are doing this in several ways, including the launch of our £20.4m Social Security Advocacy Service in January 2022, and expanding our Welfare Advice and Health Partnerships with an investment of £3.5 million over three years which places welfare rights advisors in up to 180 GP practices in Scotland's most deprived areas.

Key actions

• We will learn from and respond to the Social Security Experience Panel's "Seldom Heard Voices" research programme which brings the voices of groups who need to be treated with particular sensitivity into the design of the new Social Security system in Scotland. Some research participants from vulnerable groups who had or have experiences of drug addiction and substance use have shared the challenges and barriers they experience with the benefit system, in particular with DWP. The final findings of this research will be published in early 2023.

6.3 Supporting people with co-occurring mental health and substance use needs

While substance use is a mental health condition, as defined by WHO guidelines, co-occurring mental health problems are also very common. Many people with dependent drug use are using drugs to self-medicate from pain and trauma.

Mental Health & Wellbeing Strategy: The Scottish Government will publish a new Mental Health and Wellbeing Strategy in the coming year. The new strategy will allow us to look ahead to make sure we are doing the right things to meet changing Mental Health needs over the coming years; and will set out a clear vision for future population mental health, wellbeing and care and our priorities to help us get there. We will ensure that our future strategy is evidence-based, informed by lived experience, and underpinned by equality and human rights. It will focus on every part of what mental health and wellbeing means; this ranges from addressing the underlying reasons behind poor mental health, helping to create the conditions for people to thrive, challenging the stigma around mental health, and providing specialist help and support for mental illness. We recognise that there are links between substance use and mental health conditions, both as a cause and consequence, and we will work closely with stakeholders to consider how the new strategy can engage with these issues.

Suicide prevention and self-harm: While the majority of drug misuse deaths are classified as accidental, suicide by poisoning also sadly occurs.^[40]The Scottish Government and COSLA published Creating Hope Together^[41], Scotland's latest Suicide Prevention Strategy, in September 2022 following wide stakeholder engagement. The strategy sets out how Government, partners and local communities can come together to help prevent future suicides. Our vision is to reduce the number of suicide deaths in Scotland, whilst tackling the inequalities which contribute to suicide, taking a whole of government and society approach. The new strategy is long-term (10 years), and outcomes focused, to bring about a step change in suicide prevention. The strategy is underpinned by a dynamic action plan (initially 3 years) and is supported by the Programme for Government commitment to double suicide prevention annual funding to £2.8 million by 2025/26. We are also working to develop a dedicated self-harm strategy and action plan which will be separate from, but connected to, our work on suicide prevention. We know that for many people, self-harm is not a route to suicide but a way of coping with their distress. While self-harm is complex and can have many causes and manifestations, previous experience of trauma is common. Some people may use both self-harm and substance use as a way of coping with trauma and distress, and for some, substance use may be a form of self-harm. Our approach is informed by lived experience, by data and evidence and insights from services, and will be published by summer 2023.

Key actions

• In November 2022 the Scottish Government published a rapid review of care for people with co-occurring mental health and substance use conditions. The review set out a number of recommendations for the system, including a call for local areas to agree a protocol for joint working between mental health and substance use services, the roll out of appropriate training to reduce stigma, and further research into why we have seen a rise in the number of mental health diagnoses prior to a drug-related death over the past decade. We are now engaging with NHS, local government, and Health and Social Care Partnerships on a plan to deliver the recommendations from the rapid review. By the end of February 2023, we will have concluded engagement and have a clear delivery plan for both these recommendations, and those from the Mental Welfare Commission's report 'Ending the Exclusion: Care, treatment and support for people with mental ill health and problem substance use in Scotland'^[42]. This will be underpinned by clear lines of accountability, reporting mechanisms and milestones. A total of £2.39 million will be invested in the implementation of these recommendations over three years.
• We commissioned Health Improvement Scotland (HIS) with £2 million to create new models of care for people with co-occurring mental health and substance use conditions by April 2024. The programme is active in five health boards and aims to understand how mental health and substance use services can be better integrated to deliver person-centred care. The findings from the programme are being shared through webinars so that all areas can benefit from the work.
• We are working with local areas to embed Medication Assisted Treatment Standards. The ten standards include an expectation that "all people with co-occurring drug use and mental health difficulties can receive mental health care at the point of MAT delivery". This work is complemented by the rapid review and HIS programme.
• We are undertaking a national review of guidelines for responding to substance use on inpatient wards to ensure that people with substance use problems receive appropriate care in mental health wards.
• We will pilot and measure the success of the new national guidelines for responding to substance use on inpatient wards before national implementation.
• We are working with partners at a national, local and sectoral level to implement Scotland's new Suicide Prevention strategy and action plan. Given the close link between substance use and suicide, the action plan includes specific actions to support this group.
• We are currently developing national quality standards for adult secondary mental health and a service specification for Psychological Services and Therapies, as part of a suite of standards and specifications covering mental health services. The aim of these standards and service specifications is to improve the quality and safety of mental health services and ensure that individuals, their families and carers know what they can expect from services. Equality and human rights considerations remain central, the standards and specifications should ensure that services provide mental health care, treatment and support that is person-centred and free from discrimination or stigma, meeting the needs of all individuals, including those that use substances.

6.4 Primary Care – Ensuring that primary care meets the wider health needs of people who use drugs.

People who use drugs are potentially more likely to have wider health needs and share everybody's common right to access healthcare to meet these needs. This can be a challenge for primary care services, which often have to be able to adapt to provide holistic care while ensuring appropriate referrals to specialist services if needed. Providing person-centred support for all their healthcare needs also contributes to tackling health inequalities in communities.

Primary care, and general practice in particular, is well placed to help address health inequalities in local areas. The Primary Care Health Inequalities Development Group was established to drive work in response to the report from the Primary Care Health Inequalities Working Group, which set out a range of far-reaching recommendations to realise the potential for primary care to tackle health inequalities. These include actions to improve access and enhance support for prevention, early intervention and proactive care for patients with unmet needs in areas of high deprivation, for all patients on a range of health matters including addictions. The Group includes national and local stakeholders, practitioners and academics and has input from drugs policy leads.

The Scottish Government also provides funding for primary care contracts and enhanced services, such as General Practice and community pharmacy. The GP enhanced services include support for specific services related to drug treatment.

Key actions

• The successful implementation of MAT Standard 7 (All people have the option of MAT shared with Primary Care^[43]) will see better joined up working between drug treatment services with broader Primary Care, to help address the wider health needs of people who use drugs, who need to benefit from better support from General Practice, Primary Care and Community Pharmacy.
• In order to accelerate the adoption of Enhanced Services for drug services across Scotland, we will ringfence £10m from the Scottish Government's Enhanced Services Allocation to NHS territorial Boards from April 2023 for this purpose. Local areas will be asked to prioritise use of this funding to improve outcomes for people who use drugs.

6.5 Dentistry

Oral health problems are among the most common comorbidities related to substance use^[44]. Literature reports that people who use drugs can self-medicate for painful medical and dental conditions. Yet many people who use drugs tend to be very apprehensive about dental care, resulting in avoiding visits to dentists. Stigma and fear of judgment (as well as dental phobia) can be barriers to accessing treatment. However, there is also evidence that the quality of life of people who use drugs can improve as their oral health improves, for example through improvements in speech, eating, raised self-esteem and reduced stigma.

For dental professionals, the perceived complexity of the oral health of patients who use drugs can present a challenge, and high-quality care needs to reflect individual circumstances. For example, pain management needs to take account of the patient's history of substance use, and there can be apprehension around supporting patients whose holistic needs are complex.

Key action

• We will develop an evidence-based programme to enable health professionals to meet the specific oral health needs of people who use drugs in Scotland.

6.6 Community Pharmacy

Pharmacists and pharmacy staff are often the people who have the most contact with individuals who are receiving MAT. They are in a strong position to detect if a person has missed their substitution treatment, putting them at risk of disengagement from treatment and overdose^[45]. Due to the amount or the level of interactions they have with patients, community pharmacies will play a key role in tackling stigma.

Key actions

• We are working on the implementation of recommendations from the Working Group on Prescription Medication Dependence and Withdrawal to ensure better advice and support to people who use drugs, carers and their families.
• In response to Taskforce action 51, and in line with MAT Standard 4, Scottish Government and Community Pharmacy Scotland (CPS) are working to establish a national core service that would require every community pharmacy to hold naloxone for use in the event of an emergency. In 2022/23, funding of £300,000 will be made available to the community pharmacy network in Scotland for the provision of emergency access Naloxone.
• We will continue to work with community pharmacies to minimise any impact from unscheduled pharmacy closures as maintaining access to substitution treatment.

6.7 Women's Health Plan

The Women's Health Plan^[47] was launched in 2021 and aims to improve health outcomes and health services for all women and girls in Scotland. The Women's Health Plan takes an intersectional approach, which recognises that many women and girls in Scotland face multiple, and often overlapping, disadvantages to accessing good healthcare. It highlights the need to respond to unjust and avoidable differences in health between specific population groups as well as across the population.

We know that women who use drugs often have poor physical and mental health and are likely to face additional barriers in accessing the support outlined in the Women's Health Plan. As we implement the current plan and develop future iterations, we will continue to explore ways of ensuring women who face additional barriers, including women who use drugs, are able to access the support they need.

6.8 Preventing homelessness and addressing complex housing needs

A fifth of people who had ever experienced homelessness in Scotland between 2001 and 2016 had evidence of drug/alcohol interactions^[47] and around half of all homeless deaths are drug related^[48].

All those assessed as homeless by local authorities in Scotland have a right to accommodation, unlike in the rest of the UK.

Those at risk of homelessness are legally entitled to help and support, to stop people losing their home and help them find another as soon as possible. This also helps identify other contributing issues, such as debt or mental health problems and substance use, so that the right support measures can be put in place.

We know that people with complex needs, including substance use issues, require more than just a house, and that the provision of specialist support is crucial in the transition out of homelessness. Where someone requires support from a variety of services, it is our priority to get them into suitable accommodation first, which will allow them to access treatment and recovery communities from the security of their own home.

For people with substance use issues, returning to their previous communities can sometimes be problematic. Offering people choice and the empowerment to move to a different part of their local area or a different area all together, is an important factor to support people who use substances to achieve and maintain their goals in recovery.

We will introduce new duties to prevent homelessness in the forthcoming Housing Bill. The Scottish Government has recently concluded its consultation on these new duties and published an independent analysis of responses in September 2022^[49].

We know that there can often be links between homelessness and problem drug use, and that people facing these issues are likely to engage with various services before reaching out to specific homelessness organisations, often at the point of crisis. These new duties will mean a shared public responsibility for preventing homelessness.

As part of the new duties, we will build on the good practice around joint working that already exists in preventing homelessness for people with more complex needs, including substance use issues, and ensure consistency and quality of delivery, including through the use of better case co-ordination across services in more complex cases.

Key actions

• The Scottish Government is continuing to support the scaling up of Housing First across Scotland. At end of September 2022, 25 local authorities had a Housing First project and another two plan to develop this in 2022/23.
• The full evaluation of the Housing First Pathfinder (covering Aberdeen/shire, Dundee, Glasgow, Edinburgh and Stirling) was launched on 16 November and revealed that 579 people with experience of homelessness and multiple disadvantage had been allocated a new home. This pathfinder was designed to test how a housing-led approach could work in all local authority areas as a default response to complex needs and homelessness, and the findings of this pathfinder will inform our next steps in expanding Housing First across Scotland. Some Housing First projects have been developed with a particular focus on certain groups of people e.g. young people, women fleeing domestic abuse, people coming out of prison and mental health.
• Following public consultation Scottish Government are engaging with partners and stakeholders about the introduction of the new prevention of homelessness duties in the forthcoming Housing Bill and the practical implementation of them.
• The Homelessness Prevention and Strategy Group, co-chaired by the Cabinet Secretary for Social Justice, Housing and Local Government, has also established a Task and Finish Group to prepare the ground for the introduction of new duties, which first met in October 2022.
• The proposals include new duties on public bodies, including in health and justice, to 'ask and act' about housing situations to help prevent homelessness and changes to existing legislation to allow local authorities to intervene at an earlier stage to prevent homelessness.
• Justice and housing pathways will be explored by the Residential Rehabilitation Development Working Group (RRDWG) Pathways subgroup. This group will look at the provision of recovery housing in Scotland, with an aim of improving safe pathways out of residential rehabilitation for those at risk of homelessness.

6.9 Improving access and transport

The concessionary travel scheme for older and disabled people provides free travel on registered local and long-distance bus services throughout Scotland. The scheme improves access to services, facilities and social networks, promoting social inclusion. Individuals who have a mental health condition and need to travel to health or social care appointments are eligible for this scheme. Many people who experience drug dependency have co-occurring mental health or experience other health conditions which may qualify them for support through this scheme.

Physical and geographic access to services and support is often cited as a barrier to treatment and recovery. For many, specialist drug treatment services are one or more bus journey away and even accessing a local pharmacy for (sometimes daily) prescriptions can be a challenge for those in remote or rural areas. People with drug dependency are not entitled to concessionary travel under current regulations.

Key actions

• We are working to update the referral processes for this scheme, to ensure that those who are eligible for this support, access it.
• We are committed to delivering parity with other health conditions, for people with substance dependency, removing unnecessary stigma and discrimination and implementing a public health approach to substance use in everything we do. We will therefore explore the feasibility of expanding concessionary travel to people with substance dependency. In the short term, we will pilot a non-statutory support scheme, with funding provided for distribution by local services, to remove the barrier of transport costs, for people with substance dependency, when accessing treatment.