Medication Assisted Treatment Standards

– in the Scottish Parliament on 23rd June 2022.

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Photo of Annabelle Ewing Annabelle Ewing Scottish National Party

The next item of business is a statement by Angela Constance on medication assisted treatment standards. The minister will take questions at the end of her statement, so there should be no interventions or interruptions.

Photo of Angela Constance Angela Constance Scottish National Party

Every life that is lost to drugs is as tragic as it is unacceptable. I offer my condolences to everyone who has felt such a loss, and I offer my determination to turn the tide of this public health emergency.

Families and people with life experience of drug and alcohol problems tell me that there must be a commitment to change and accountability at the very heart of our national mission, and at all levels from the front line to national leaders. I agree, which is why Public Health Scotland has published today’s comprehensive “National benchmarking report on implementation of the Medication Assisted Treatment (MAT) standards 2021/22”.

I will spend but little time on the areas in which progress has been made, welcome though that progress is. I want to make it clear to Parliament that the overall pace and scale of change is neither good enough nor quick enough.

The medication assisted treatment standards, which were published in May 2021, are designed to give clear criteria and principles to help care providers, and those who will benefit from services, to understand what must be on offer to support people in their MAT and in recovery. The standards should not just be considered as “nice to have”. My view is unequivocal—they must be delivered.

The standards are a demonstration of our commitment to a whole-system approach to care, and are fundamental to our rights-based approach in Scotland.

In recognition of the ambitious challenge that I set local areas through our national mission, we are providing more than £10 million per year in funding for local areas to implement the standards, and we established the MAT implementation support team to provide consistent support across the country. We are providing more practical and financial support than ever before.

The Public Health Scotland report gives us, for the first time, an area-by-area breakdown of where each alcohol and drug partnership is on implementing the standards, with particular in-depth focus on key standards 1 to 5. They are the standards on same-day treatment, informed choice of treatment, assertive outreach, harm reduction support alongside treatment, and making sure that treatment lasts for as long as people want it.

The report also summarises progress on MAT standards 6 to 10. Less data is available on those standards, which rely more on experiential feedback from people who are in services.

Of the 145 indicators; 26 have not been implemented, 25 have been implemented in full, and 94 are partially implemented. That shows that standards are being embedded and implemented on the ground, particularly in relation to informed choice, proactive identification of those who are at risk, harm reduction and keeping people in treatment. In many cases, the service standards are in place within an area, but are not consistent across the whole area for all people.

I am most concerned about the lack of progress against MAT standard 1. All the standards are crucially important and connected, but access to same-day treatment is life saving. In that regard, the Borders, where I visited recently, stands out as a beacon of what can be achieved, so my challenge to other areas is simple: “If the Borders can do it, why can’t you?”

The report includes eight detailed recommendations and some actions that are already being taken. As well as achieving implementation of the original standards themselves, we cannot stand still. The standards will also have to be developed to make them more bespoke for young people, for women and for custodial settings. The recommendations call for immediate improvement plans to set out how each local area will achieve full implementation. Those plans are being developed with ADPs and will be published in August.

I cannot stress enough how vital it is that ADPs fully implement the MAT standards—in particular, standard 1, which is on same-day treatment. We all want people to have the right to treatment, but that right will be for nothing if services are not in place. That is why I am, today, using powers of direction that are available to Scottish ministers under the Public Bodies (Joint Working) (Scotland) Act 2014 to compel local partners to implement the standards.

The ministerial direction has been issued to all health boards, integration authorities and local authorities. It spells out what must be achieved and the oversight arrangements that I am putting in place to hold local leaders to account for implementing the MAT standards fully. The Scottish Government, the Parliament and, most important, communities require a whole-system response across those three partners, and oversight of that will now be done through the following measures.

Improvement plans for implementing the standards will be required in all areas. We will require that they be signed by all chief executives and chief officers. The plans will be informed by the local assessments that are being published in August to supplement the benchmarking report.

The chief executives and chief officers will have shared and visible responsibility for delivering the MAT standards, and they will identify one senior leader to take responsibility for driving the necessary changes and reporting on progress. Most will be expected to deliver quarterly reports on progress. However, for areas that are of particular concern, where drug death rates are particularly high—today’s report shows that MAT standard 1, on same-day treatment, has not been delivered—those reports will be monthly.

The new oversight arrangements that I am putting in place will also strengthen accountability to communities, through the involvement of lived and living experience in the quarterly or monthly reporting that is now required. If necessary, we may also consider further powers to intervene through implementation of the national care service, which will introduce a more formal single framework of accountability. I will provide Parliament with regular updates on progress on implementation of the new arrangements and oversight of implementation.

I do not want to give the impression that no progress has been made. It is clear that some areas are on that journey, including East Ayrshire, South Ayrshire and North Ayrshire. In West Lothian, which I visited today, the Change Grow Live recovery service in Bathgate, which is part of the West Lothian Drug and Alcohol Service, offers same-day treatment, so it has implemented MAT standard 1. I know that that change has made a huge difference to the people who are being supported there. The challenge that lies ahead for West Lothian and other areas is to scale up the level of service across the whole council area.

ADPs and local partnerships are taking forward innovations to help to address drug deaths. One innovation that I know is of interest to Parliament is potential use of safer drug-consumption facilities. I have previously made it clear that we would support work to make such facilities available within the constraints and limits of the law on drugs, which is currently reserved.

Glasgow City Health and Social Care Partnership has been developing such a proposal for some time. It has engaged extensively, and I thank it for its work. Following detailed partnership working between the Scottish Government, the health and social care partnership, Police Scotland and the Crown Office and Procurator Fiscal Service, details of a new service specification have been developed and shared with the COPFS. The specification, which seeks to meet the parameters that were set out in the Lord Advocate’s statement on 3 November, will now be considered by the COPFS. If appropriate, it will then be referred to the Lord Advocate for consideration of any related statement of prosecution policy.

To improve services and embed standards, we need to have the necessary workforce in place. That is why the majority of the £10 million per year funding is targeted at recruiting more than 100 additional staff who will be able to offer services that meet the MAT standards. That increase in staffing is part of our national mission planning for further workforce recruitment and development. I intend to return to Parliament in the autumn to set out our plan to expand and upskill the workforce. Over this summer, we will draw on the experience of people who are at the heart of workforce policy, as part of the expert group, to help to develop and implement the necessary planning.

The standards are not optional extras; they are essential to getting more people into the protection of life-saving treatment more quickly. I pay tribute to local leaders, families, people with lived and living experience, and members of the voluntary sector, who have worked together to deliver demonstrable change on the ground, where it matters most. I thank the MAT standards implementation team for its continuing hands-on support, which it works alongside local areas to provide, and I thank Public Health Scotland for its vital report.

MAT standards are about delivering faster and more responsive services, but they are also about changing hearts and minds, and tackling stigma and discrimination. MAT standards are empowering people to demand the treatment that they deserve. There is no going back—we can now only go forward.

We all need to dig deep to do the hard miles ahead. All senior leaders within and outside Government must pick up the pace and deliver a public health response to this public health emergency, and they must do it now.

The Deputy Presiding Officer:

The minister will now take questions on issues that were raised in her statement. I intend to allow around 20 minutes for questions, after which we will move to the next item of business. It would be helpful if members who wish to ask a question would press their request-to-speak buttons now.

Photo of Sue Webber Sue Webber Conservative

I thank the minister for advance sight of her statement, and I acknowledge the challenging comments that she has made today about progress on the standards.

The statement has laid bare the damning truth that a critical target has been missed. Drug-related deaths are Scotland’s national shame, yet this Government’s actions have once again fallen short and families continue to be let down. Although a target was set last year to ensure that the MAT standards would be fully embedded across the country by April 2022, the report shows that that target was nothing more than a pipe dream. Only 17 per cent of the standards have been fully implemented and, shamefully, MAT standard 1 has been implemented in only one ADP area—the Borders. That is a 97 per cent failure rate.

The new recommendation from Public Health Scotland is to push the target back by a year and water it down; it is that only half the standards are to be implemented by April 2023, with only partial implementation for the others.

Across Scotland, there has been unwarranted variation in implementation of the standards. There can be no clearer illustration of that than the statistics on drug-related deaths that were released last week, which show welcome declines in Glasgow but mask increases in deaths in Edinburgh, Fife, and Dumfries and Galloway. What urgent steps is the Government taking to end that postcode lottery? What support will the minister offer to the ADPs that have fallen so far behind?

Photo of Angela Constance Angela Constance Scottish National Party

The report by Public Health Scotland does not pull its punches or mince its words, and nor will I. I say again that progress is not good enough or fast enough.

There are, obviously, responsibilities within Government, but some responsibilities lie on the shoulders of people outwith Government. I have today announced immediate action on issuing letters of ministerial direction, which are not just asking. I have also announced the important improvement plans and the reporting oversight arrangements that will now be in place. In some instances, reports will be required monthly. That is all about driving faster and more consistent progress.

The Public Health Scotland report shows that some areas have—despite the challenging environment that everyone is working in—been successful in implementing changes, or are well along on that journey. We must pick up the pace, because people across Scotland deserve consistent services.

I am well aware of the commitments that I have made as a Government minister, and of what I have said should have happened regarding those statements. I will continue to set the very highest standards, based on the highest expectations, and I will continue to provide both financial and practical support. I will continue to be accountable to Parliament and to do everything that I can to overcome every challenge and difficulty that gets in our way, because we have a national mission that is about saving and improving lives. Some of our people are dying, and we must remember every day that those deaths are preventable.

Photo of Claire Baker Claire Baker Labour

The number of drug deaths in Scotland remains too high: in the past 14 years, more than 11,000 people have died preventable deaths.

Today’s publication of the benchmarking report is welcome, but its content is not: it is a disaster. A year ago, the minister talked about embedding and implementing the MAT standards within a year, and the First Minister said 18 months ago that there would be rapid implementation. Those claims are now in tatters. A year later, we see abject lack of delivery of what was promised, and a flagship policy that is now in disarray. It is appalling that, after all the promises that were made, only one ADP is fully delivering same-day prescribing, while almost 60 per cent are making no progress.

Although the minister talks of powers to compel delivery, she must take responsibility for the difficulties that are still being identified by the sector. ADPs are concerned about insufficient funding for delivery, a burned-out workforce and a lack of staff.

Can we really have confidence that standards 1 to 5 will be implemented by next June, when progress in the past year has been so slow? How can the minister give an implementation date of 2025 for standards 6 to 10? That is unacceptable.

Photo of Angela Constance Angela Constance Scottish National Party

The level of detail in this first benchmarking report means that there is no hiding place for either national leaders or local leaders. That is why we will continue to invest £10 million per annum, most of which is going to support the workforce.

The recommendations in the report are recommendations that Public Health Scotland published prior to my announcement today on the immediate action that we are taking in and around ministerial direction. I, for one, want to see much quicker progress being made. I will, of course, be reporting back to Parliament and making sure that we follow the investment—investment that has increased by 67 per cent, according to Audit Scotland—that has been secured since 2014-15 as a result of the national mission.

Public Health Scotland is very clear about the role of leadership, and not just at the national level. I am not asking people to do something that I will not do myself. However, it is very clear that we need a whole-system approach and leadership right across the public sector—from national health service boards, from local authorities and from integration authorities, in particular. Each and every one of us now has to step up to the plate.

I have announced immediate action that will take place, and once we have seen the improvement assessments and improvement plans, I will certainly come back to Parliament later in the year to provide further updates.

Photo of Stuart McMillan Stuart McMillan Scottish National Party

The MAT standards emphasise a multipronged approach to treatment and residential rehabilitation as one potential course for support. In the work to ensure that the MAT standards are met, will there also be oversight of ADPs’ efforts to increase access to residential rehab?

Photo of Angela Constance Angela Constance Scottish National Party

Yes. There is already oversight from the Government, through an evaluation and monitoring programme, of our investment in residential rehab. There has been an uplift to ADPs of £20 million, and a portion of that is specifically identified for residential rehab placements and, crucially, aftercare.

When I reported to Parliament two statements ago, I think, I confirmed that 326 placements had been funded through ADPs in the first nine months of last year. Figures on this are available area by area, and Mr McMillan will be able to check on the progress that is being made in Inverclyde. One of the purposes of our gathering and publishing more data than ever before is to enable members of this Parliament to scrutinise what is happening in their areas, as well as to scrutinise the Government.

Our overall target is that, over the next five years—over this parliamentary session—we want to see at least 1,000 people being publicly funded for their residential rehabilitation placements.

Photo of Sandesh Gulhane Sandesh Gulhane Conservative

Overall, nearly three quarters of alcohol and drug partnerships were unable to provide documented policies, guidelines and standard operating procedures that were sufficient to demonstrate full and consistent implementation of the MAT standards. Shockingly, no data was provided for 14 per cent of standards. I quote directly from the report:

“There is a risk that, as a result of systems to collect numerical and experiential information not being set up, data for improvement work is not available and the improvement cannot take place.”

Over a year after the standards were drafted, it is shocking that there is still no standardised method of data collection and that improvement work cannot take place because those systems have not been set up. Why is that the case? As the minister knows, standardisation of data collection is key to knowing what is going on across Scotland. Did we not know—

The Deputy Presiding Officer:

Dr Gulhane, are you coming to the end of your question for the minister?

Photo of Sandesh Gulhane Sandesh Gulhane Conservative

Absolutely. What work is the Government undertaking to correct those identified flaws?

Photo of Angela Constance Angela Constance Scottish National Party

The point that Mr Gulhane makes about data is certainly not lost on me—I assure him of that. Nonetheless, despite the difficulties or the frustrations that Public Health Scotland has faced in relation to data, it has for the first time produced a benchmarking report that, to be blunt, is a warts-and-all assessment of what is happening in every ADP, local authority and health board area.

I make the point that data is important, as we are not relying solely on self-reporting, therefore a range of work is on-going, both within and outwith Government, to strengthen the data. That is partly through the drug and alcohol information system—DAISy—and partly through the measures that I announced at the end of last year on the national drug-related deaths database and data linkages. Other studies are taking place in emergency departments, to help us with quicker warning systems about what is happening on the ground.

The point in the report that really strikes me is that, in many areas, people still need to get with the programme on the role and importance of experiential data. We can collect people’s operational policies, which are important, and we can collect numbers and data, which are also important. However, what else is important is the experience of folk on the ground. Local areas need to speak to local people about their experience of which services are, or are not, meeting their needs.

The Deputy Presiding Officer:

Before I call the next member, I point out that eight members wish to ask questions. I would like to take all of those, but to do so we must have shorter questions and answers.

Photo of Audrey Nicoll Audrey Nicoll Scottish National Party

The creation of a national care service might provide opportunities to give greater statutory oversight of ADPs in the delivery of MAT standards. Now that the National Care Service (Scotland) Bill has been introduced, will the minister outline what steps will be taken to determine whether greater statutory powers are needed in this area?

Photo of Angela Constance Angela Constance Scottish National Party

There is a bit of a twin-track approach here. First, there is the work that is going on around the national care service. I am a proponent of having such a service. I also want drug and alcohol services to be covered by the national care service, because it is important that we have a single framework of accountability. The national care service could be a really important vehicle for delivery of person-centred care and the provision of joined-up services. It is not good enough that folk are bouncing about between services, whether they be for addiction or mental health issues.

The work that we are doing on MAT in relation to local assessments of needed improvements, which will be published in August, and the quarterly or monthly reporting cycles that are now required of all agencies will certainly feed into our work on building a national care service to ensure that we end the postcode lottery and can deliver consistency of care to people afflicted by drug and alcohol problems.

Photo of Paul Sweeney Paul Sweeney Labour

I welcome the news that there has been progress on the work that is being done on overdose prevention centres. The minister and I whole-heartedly agree that those centres are desperately needed, particularly in a city like Glasgow. My proposed member’s bill on drug deaths prevention is out for consultation at present.

However, what Glasgow also needs is full implementation of the MAT standards to which the Government has committed.

I find it appalling that Glasgow—the city with the highest drug death rate in Scotland—has not fully implemented a single MAT standard by the target date. I accept that the minister has said that that is not good enough, but what exactly are she and the Scottish Government doing to turn it around? Every time that we miss the target, more people are dying. No amount of warm words will fix that.

Photo of Angela Constance Angela Constance Scottish National Party

I would have thought that I had demonstrated to Mr Sweeney that I am prepared to do the hard miles when it comes to issues such as safer drug consumption rooms. We have worked steadfastly on those, and our work will now be scrutinised and a decision will be taken elsewhere.

I think that I have also demonstrated in my statement today not just warm words, but tough words of action. We will dig deep and do the hard miles. When it comes to implementing MAT standards, I am not asking and I am not taking no for an answer.

Photo of Joe FitzPatrick Joe FitzPatrick Scottish National Party

I know that the minister will be disappointed that she has had to take the measures announced in her statement. However, we should not lose sight of the excellent work that is taking place across Scotland. Just last week, I visited the Lochee hub, in my constituency. It is supported by significant Scottish Government funding, via the Corra Foundation, to deliver the five-tier recovery programme that is aligned with the MAT standards. I invite the minister to join me in a visit to the hub. Will she provide an update on the range of support that is being provided to Dundee to fully implement the MAT standards? Can she say anything about discussions on the potential provision of drug checking and heroin-assisted treatment in the city?

Photo of Angela Constance Angela Constance Scottish National Party

There is a lot in that question, but I say to Joe FitzPatrick that I am no stranger to the good city of Dundee and I very much look forward to an invitation to visit the Lochee community hub or, indeed, anywhere that members would like to invite me to.

I have engaged with the Dundee drugs commission and the Dundee ADP—my officials continue to be in discussion with the partnership. Through the medication assisted treatment implementation support team—MIST—we have provided programme management support to assist the implementation of MAT standards. We are funding work in primary care that relates to MAT standard 7 and, of course, we have been in discussion with Dundee and other areas of Scotland in and around the provision of heroin-assisted treatment. Of course, we need to turn interest into commitments with regard to some of those initiatives and others, but I very much look forward to continuing to support the good city of Dundee. I know that work is also under way to establish a pilot drug-checking facility.

Photo of Alex Cole-Hamilton Alex Cole-Hamilton Liberal Democrat

The minister knows that she and I share a lot of common ground on this issue and that I want her to succeed. However, I am disappointed by today’s statement and by the explanations that have been given. I say that because she is doing exactly what she has criticised others for in the past, which is blaming staff. I also say that because, yesterday, a whistleblower approached my party to say that the reason why many of the MAT standards have not been delivered or data accurately collated is that the Scottish Government made money available to achieve them only very recently. Can the minister tell Parliament right now when that money was released?

Photo of Angela Constance Angela Constance Scottish National Party

I have come to the chamber a number of times to outline action on a range of issues, and I have also, a number of times—verbally, in and outwith the chamber, and in writing—given the assurance that, as I have continuity of funding, that continuity of funding is also passed on to ADPs and front-line services. In addition, we have delivered five-year or multiyear funding opportunities for the voluntary sector. I assure Alex Cole-Hamilton that, where there are blockages in the system, I will get in about it and unblock them. I am sure that people have received funding, because I certainly recall signing letters confirming funding. People should have received those funds. If they have not, I will check what is happening.

I say to Alex Cole-Hamilton that I am not taking a dig at staff or front-line workers. The Public Health Scotland report says:

“Commitment and senior leadership from Health and Social Care Partnerships will be necessary to allocate the resource that is required for successful implementation.”

I know what money I am putting out the door, and I am determined to follow that money to ensure that it gets to the front line and does not sit in reserves anywhere. There is no point in putting money away for a rainy day if you do not use it when there is a rainy day. The present circumstance is more than a rainy day, and money that is allocated by this Government needs to be committed and spent.

The Deputy Presiding Officer:

Four more members wish to ask a question. I will not get all of them in unless we now have succinct questions and answers.

Photo of Jenni Minto Jenni Minto Scottish National Party

Will the minister outline the next steps that she understands the Crown Office and the Lord Advocate will take to consider the proposals for a safer consumption facility?

Photo of Angela Constance Angela Constance Scottish National Party

I will be brief. If Jenni Minto wants further information, I will be happy to discuss the issue further with her.

Those proposals are now with the Crown Office, and it is for the Crown Office to submit them to the Lord Advocate. It would be somewhat inappropriate for me to comment any further than that, other than to thank partners including Police Scotland, the Glasgow city ADP and, indeed, my officials and the Crown Office officials, who worked hard to get a specification together and meet what was required, which was outlined when the Lord Advocate attended the Criminal Justice Committee on 3 November 2021.

Photo of Gillian Mackay Gillian Mackay Green

The Scottish Drugs Forum has highlighted that stigma is still acting as a barrier to people accessing MAT. It causes people to present later for treatment and means that they are often not as fully supported as they might be. What action will the minister take to tackle that and ensure that nobody is prevented from accessing MAT due to stigma? Will she consider requiring mandatory stigma training for all staff who work in ADPs?

Photo of Angela Constance Angela Constance Scottish National Party

I know that an organisation called Reach Advocacy Scotland has provided training to 15 ADPs on taking a human rights approach, applying MAT standards and tackling stigma.

Ms Mackay is absolutely correct to say that stigma is a barrier to treatment. Some of the work that is required to implement MAT standards in full, particularly standards 1 to 5, is crucial in tackling discriminatory attitudes and stigma. Ms Mackay will be aware of the work that the Government has done, to date, in and around our stigma campaign, some of which will figure in the workforce plans that we will bring forward in the months ahead.

Photo of Tess White Tess White Conservative

Presiding Officer and minister, I apologise for my lateness today.

Will the minister outline what urgent action the Scottish Government is taking to address workforce shortages among ADPs?

Photo of Angela Constance Angela Constance Scottish National Party

Ms White raises a very important point. A few months ago, we published the first-ever survey of the drug and alcohol workforce, which reveals the size and shape of the workforce—there are about 3,500 full-time equivalents. It also begins to unpick some of the issues in and around recruitment, training and retention, and it will inform the work that we need to do to support the welfare of staff.

As I intimated in my statement, I will come back to the chamber with more detail on the plans for what is to be undertaken. It is important to note that much of the £10 million per annum that is going towards the implementation of MAT standards is for recruiting staff.

The Deputy Presiding Officer:

That concludes the statement.

Photo of Stuart McMillan Stuart McMillan Scottish National Party

On a point of order, Presiding Officer. I apologise to you and to members in the chamber, as I should have, once again, made everyone aware that I am a board member of Moving On Inverclyde, a local addiction service.

The Deputy Presiding Officer:

Thank you, Mr McMillan. That is duly noted.

I apologise to the one member whom I was not able to call for a question on the statement; what I had feared would come to pass did come to pass. We have a very busy afternoon ahead, and we have to try to keep to time as far as possible.