National Mission on Drugs: annual report

5. Outcomes 3 & 4: People at most risk have access to treatment and recovery & people receive high quality treatment and recovery services

5.1 Overview

Treatment is a protective factor against drug-related deaths and harms^[6]. It is vital that treatment is high quality, evidence-based and promotes a recovery-orientated system of care to get more people into the treatment they need. This includes the wide range of treatment provision available, both community based and residential. All 10 MAT Standards are key elements in delivering these outcomes.

5.2 Progress in 2023-24

5.2.1 MAT Standards

In 2023-24, all local areas have continued to report good progress against their implementation plans following on from the Ministerial Letter of Direction issued in June 2022, for the MAT standards, on either a monthly or quarterly basis.

The PHS MAT Standards Implementation Support team (MIST) have been supporting areas to not only implement the standards, but also to set up processes to provide the numerical and experiential evidence to demonstrate implementation. The third PHS National Benchmarking Report was published by PHS on 9 July 2024. In 2024, for MAT standards 1–5, 90% have been assessed as fully implemented (RAGB blue and green). For MAT standards 6–10, the programme did not have enough evidence to show full implementation but 91% were assessed as RAGB provisional green (evidence that implementation is beginning).

PHS presents data over consecutive years, however there has been a fundamental change in how a key metric has been built since last year – meaning it is not possible to make direct comparisons with previous years. Analyst view is that the 2023/24 report should be taken as a reflection of a snapshot in time only as opposed to a comparative progress report.

5.2.2 Long-acting Injectable Buprenorphine

Long acting injectable buprenorphine (also referred to as the brand name Buvidal) is now on all Health Board formularies, and prescribing data shows that it is being made available nationally as per MAT standard 2. As reported in the 2023-2024 Benchmarking Report, published in July 2024, this standard was assessed as fully implemented in 28 out of 29 ADP areas. This was based on evidence of clear process documentation; that all pharmacological options, as set out in the agreed criteria, were available and numerical evidence demonstrated that there was uptake.

5.2.3 Benzodiazepines

In 2023-24 the Scottish Government drew together responses to its consultation on potential changes to prescribing guidelines on z-type drugs and benzodiazepines. The Scottish guidelines are scheduled for publication in 2024-25.

In February 2024, the University of Stirling published the findings on research we funded into the practices and views of addiction prescribers in Scotland on the management of benzodiazepine dependence. It is intended that this research will help inform future prescribing practice as part of the National Mission.

In 2023-24 Public Health Scotland published the MAT standards guidance on benzo harm reduction which it drafted with the Drug Deaths Taskforce. The findings of its Short-Life Working Group were presented to the Clinical Advisory Group for the National Mission, to consider how clinicians can be encouraged to adopt the harm reduction guidelines as part of the implementation of MAT standards.

In 2023-24, the University of Stirling led a consortium of academics from across the UK to apply to a call for research launched by National Institute to Health and Social Care Research into the comparative outcomes of people at risk of drug harm who have either been maintained on benzo prescriptions or been tapered off illicit benzos.

5.2.4 Primary Care

Primary Care support is a vital strand in delivering the National Mission. MAT standard 7 seeks to ensure that MAT is delivered alongside primary care. The 2023-2024 Benchmarking Report provides a snapshot of performance against the Standards. The process evidence submitted demonstrates that most ADP areas are exploring various models to implement MAT 7 and have agreed pathways and protocols. From the 29 ADP areas, a total of 22 areas were assessed as RAGB provisional green, three amber and four provisional amber.

Public Health Scotland led a Rapid Evidence Review of integrated models of drug treatment in Primary Care, which was published in April 2024. It describes different models of care when Primary Care and specialist services interface to support people who use drugs.

Community Pharmacies play an important role in the dispensing of opioid assisted treatment and other medicines, and increasingly work more closely with general practice on healthcare including on substance use. In 2023-24, Healthcare Improvement Scotland surveyed how community pharmacies could be more involved with delivering MAT standards, and a final MAT Standards Pharmacy Impact Report, with recommendations for improvement in their role, was published in April 2024.

5.2.5 Substance Use Treatment Target

In March 2022, the former Minister for Drugs Policy announced a new target to increase the numbers of people in community-based Opioid Substitution Therapy (OST) by around 9 per cent to 32,000 people.

PHS are conducting research into the underlying drivers of treatment uptake, which will help us to better understand whether the OST Treatment Target is providing effective incentive to local service delivery leadership to improve treatment uptake, and we expect the first results to be made available from that work later in 2024.

Whilst new data, evidence, and insights into the dynamic trends in drug use show us that there is increasing stimulant and benzodiazepine uptake, it also continues to show that opiates are implicated in the majority of drug deaths.^[7] However, the crisis is multi-factorial including a reported increase in the incidence in injecting drug use-related wounds, linked to an increase in reported injection of powder cocaine.^[8] There is a wealth of evidence that OST is protective against drug-related mortality, and appropriate provision of, and ready access to, this form of treatment remains a key pillar of our National Mission.

We will continue to use all intelligence at our disposal as part of our efforts to actively expand and review the Treatment Target, to ensure that we are responding to the full range of known and emerging harms.

5.2.6 Residential Rehabilitation

The National Mission includes a commitment to significantly increase the funding available for residential rehab and associated aftercare over this parliamentary term.

We have committed to increase the number of statutory funded placements in Residential Rehabilitation by 300% and increasing the number of beds available by 50% so that by 2026 there are at least 650 beds and 1,000 people are publicly funded for their placement each year.

There are three key parts to our national approach to achieving improvements in treatment options and recovery pathways: improving pathways into and from rehabilitation services, in particular for those with multiple complex needs; investing in a significant increase in the capacity of residential rehab services; and developing a standardised approach to commissioning residential rehab services.

In 2023-24, the aim was to continue to build on the achievements from previous years, specifically around the utilisation of the additional capacity added via the Residential Rehabilitation Rapid Capacity Programme (RRRCP). Progress is reported in the Interim Monitoring Reports on statutory funded residential rehab placements published by PHS.

In 2023-24, Lothians and Edinburgh Abstinence Programme (LEAP) expanded their service as the only statutory provider of residential rehab in Scotland. As a result of the changing landscape of drug use and in line with the objectives of the grant, LEAP have improved access to residential rehab by revising referral criteria, including changing thresholds for prescribed medication, and creating a pathway for illicit benzodiazepine use and complex polysubstance use.

Additionally, because of this funding, LEAP have established a Midlothian Aftercare Group, which provides graduates from the programme located in Midlothian continuing aftercare for as long as they would like, supporting the growth of the recovery community within Midlothian.

Harper House, the new National Specialist Families Service run by Phoenix Futures, located in Saltcoats, has approved placements for 32 families^[9] this year alone, and has developed relationships with North Ayrshire Health visiting team and Education North Ayrshire to support children up until Primary School age across all Scotland.

The children’s charity Aberlour opened their first Mother and Child House, Cowan Grove, in Dundee in December 2022 and in their first year enquiries for admission to the service outstripped demand, highlighting how crucial services such as this are. Alongside this we have been supporting Aberlour with the development of their second house which is due to open in 2024-25 in Falkirk. We have supported Aberlour to open this second house in a manner that allows them to build on the learning from the Dundee house, and learn from the best practices that saw them achieve industry-leading Care Inspectorate scores.

In addition to the RRRCP round 1 projects, we have continued to support the recipients of the RRRCP round 2 projects as they move towards opening. Phoenix Futures have secured the site for their new facility in Aberdeenshire. Approximately £11m was made available to Phoenix Futures for an ambitious project that will deliver 27 units of CI registered residential rehab alongside up to 50 units of Housing and Therapeutic Community Dayhab in an innovative model across the North Eastern region of Scotland, resulting in up to 200 placements per year. We expect this to open in early 2025 alongside the expansion to CrossReach’s Beechwood House in Inverness, with the expansion to the Maxie Richards Foundation to open in Autumn 2024.

The Residential Rehabilitation Development Working Group (RRDWG) has continued to be a source of constructive challenge and support to the Residential Rehabilitation Programme. The expert group is comprised of academics, referrers, clinicians, and crucially those with lived experience, and supports the Scottish Government with scrutiny of the programme, including oversight of any externally commissioned projects. It is an important resource that the Scottish Government is grateful to be able to utilise to support policy development and implementation.

As highlighted in the 2022-23 annual report, in order to further support ADPs to increase the number of residential rehab placements we commissioned Scotland Excel to complete engagement work with ADPs, as well as providers, on the current provision of rehabilitation in Scotland. The report recommended that a National Commissioning Framework (NCF) should be established. The tendering process for the NCF invited services across Scotland to bid and, once operational, successful providers will sign contracts that set out minimum quality requirements and a service specification for a set price per provider. This framework launched officially on 1 April 2024 and we are continuing to support providers and ADPs towards a successful implementation via a series of engagement events.

One of the key recommendations made to the Scottish Government in December 2020 by the Residential Rehabilitation Working Group (RRWG) report was to develop a national directory of residential rehab services. Since then, several focus groups and consultations with key audiences, including those with lived experience and families of those with lived experience, helped to inform the design and content of the site. The Gate Worldwide was procured and contracted in May 2023 to design and manage the directory on the Scottish Government’s behalf. The directory passed through a series of design, testing and user acceptance stages in the latter half of 2023, and internal governance requirements were completed in early 2024 with a view to launching in mid-2024.

Monitoring data from Public Health Scotland indicates that we are on track to meet our commitment of 1,000 people receiving public funding for Residential Rehab. The most recent data, published on 18 July 2024, reported that in the financial year 2023-24 a total of 938 placements were approved, the highest since PHS started reporting on this.