Responding to Drug Use - President, Health and Social Services - Transcript - 30 July 2004

SENATOR STUART SYVRET, PRESIDENT, HEALTH AND SOCIAL SERVICES

Accompanied by Mr. M. Pollard, Chief Executive

1. Failure to implement recommendation of Imperial College School of Medicine (ICSM) report for pilot study through disconnected anonymised testing to establish extent of HIV and Hep C prevalence.

1. Senator Syvret (SS) agreed that this was a serious omission. At risk groups are already screened but this doesn't give an adequate picture of the extent of STI in the community. SS was determined that this research would now take place following a period of appropriate public consultation.
2. The issue of funding for this purpose had not previously been brought to his Committee' attention but had been dealt with at officer level. This was oneof several competing bids for funding.
3. Funding for Hep C nurse would also now be found.
4. SS said that it was a common feature of large complex departments that the politicians didn't always get the full picture of what was happening at the coalface. He had now issued a directive through the Chief Executive that such issues, which might involve difficult decisions over funding priorities, should in future be reported to the Committee.
5. SS agreed that the cost of not addressing the medical complications arising from infections such as HIV and Hep C were likely to be greater in the long term if they were ignored in the short term. However, it was sadly a feature of public administration generally that expenditure of this nature was given low importance against short term spending priorities. The Fundamental Spending Review process contributed to this short term focus.
6. SS also accepted that testing for HIV and Hep C was likely to reveal a significant future funding need to address the problem. A similar situation had arisen in the past with regard to the establishment of a renal unit with the result that far more people were now receiving treatment.
7. Mike Pollard (MP) said that it was important to work through the implications of a screening programme in business terms, including how this would be conducted. It would be senseless to have a screening programme without appropriate planning for meeting the consequences. The budgetary implication, in a worst case scenario, could be significant.

2. What Priority is given to Alcohol and Drug issues on Committee agenda?

1. SS said the Health and Social Services Committee had discussed alcohol and drugs strategy on a number of occasions over the last three years but had not discussed the ICSM recommendations specifically.

2. While he accepted that the recommendations of the ICSM report in general had not been as fully implemented as possible - due to competing demands on budget and resource, such as Family Nursing and Home Care or ACET, to quote recent examples - he believed that the Alcohol and Drugs Service (ADS) and the Island's harm reduction programmes compared favourably with services in the United Kingdom.
3. Clearly there is room for improvement. Some steps have already been taken and the Scrutiny process has added further impetus. For example, while there has been co- ordination of statutory provision of addiction services, it is fair to say that there has not been enough communication with voluntary agencies, such as Silkworth. This is now improving through Ian Dyer. ADS are working in a more co-operative way with other agencies. This will be reinforced by the Committee.
4. SS has requested new Chief Executive to look at whole area of community fora and the involvement of stakeholders from the voluntary sector. In general terms, he said, it was essential for public administration to get a better handle on the interface with voluntary agencies, forging new professional relationships through the development of Service Level Agreements in return for good valued service.
5. The Health and Social Services Committee regards substance misuse, with its ongoing health considerations, as a very significant area and is taking steps to convince the community that there is a really serious problem around substance misuse. The general public may tend to disregard services like ADS in favour of more worthy projects but the Committee must take a responsible, rather than simply a populist, view of its priorities.
6. It is recognised that the client group of substance misusers is difficult to reach. They often feel that their voice is not heard. This is exacerbated by the climate of fear of authority which surrounds an illegal activity. One solution is to extend the range of outreach work available in the community.
7. A word of caution: The States is seeking to save £29 million each year from its expenditure over the next five years - this will inevitably increase pressure on Health and Social Services budget including grant aid to independent agencies.

3. Integrated Care Pathway

1. The Panel has heard a great deal of criticism from clients of ADS about lack of response to appeals for help, delays in appointments, the ineffectiveness of community detox, lack of after care. It has also been told of the lack of referrals to Silkworth Lodge (SL).
2. MP said that there were currently groups of well intentioned people working in silos. The way to cut through this was to develop a rigorous system of co-ordination, a clear line from presentation through to intermediate care and specialised services, where professional roles were clearly understood.
3. The key was the development ofan integrated care pathway. This was now in preparation in consultation with other agencies, under the direction of Ian Dyer.
4. Access to the care pathway would be through many routes, including Accident and

Emergency, GPs, Criminal Justice system. The care pathway should be a rigorous regime for

practitioners but a flexible service for the client.

5. Once this care pathway was established it would be possible to address more effectively client care issues such as those mentioned above.
6. There is currently no system of primary care in Jersey which might provide a multi- disciplinary team which could include care for addicts. The system of general practice militates against GPs being involved in the methadone programme.
7. SS said that he too had spoken with addicts and members of their families and was aware of the criticisms. He accepted that there was a need to improve the speed of response and the speed of referrals.
8. He said that there was also no denying that some people, including health care professionals, regarded addicts as a lesser kind of patient because their problems were considered as self-inflicted. This however could be said about many people in acute wards and was an unhelpful attitude. Many addiction problems were caused by deeper underlying problems.

4. Harm reduction measures

1. SS said that the original harm reduction strategy approved by the States in 1999 was far thinking. MP said that Jersey can be proud of the current Needle exchange scheme.
2. Legal issues surrounding needle exchange and supply of paraphernalia have been addressed by the Committee.
3. SS recognised that there are some problems with providing discreet or confidential areas in pharmacies for addicts to take methadone - there is ongoing work to address this. It was important however to maintain the supervised programme to avoid leakage of methadone onto a street market.
4. SS would oppose a dedicated injecting centre. He was not convinced that this is necessary in Jersey, given all the other harm reduction work going on. It would mean that the States would become resigned to the fact of illegal drug taking. The general approach taken by Health and Social Services was not to maintain substance use but to take people onto a substitution programme which was aimed at gradually getting them away from using.
5. SS said that the Arrest Referral scheme should be expanded. He felt however that the Judiciary should review its approach to sentencing. Their solution seemed to amount to little more than making more space at the prison. The Criminal Justice Policy should be more cohesive. It is plain that prison doesn't work. The focus should beon effective ways of intervening to turn people with problematic lives away from substance misuse.
6. SS agreed that there needs to be a reasonable approach to harm reduction in the prison, although he would hesitate to accept a needle exchange scheme there, for security reasons. He would favour a more rigorous security approach rather than accepting that a drug free environment is impossible to achieve. This, however, is a

Home Affairs Committee issue - politically a difficult thing to do.

7. The spread of blood born infection at the prison is a matter of concern for health - hence the importance placed on harm reduction measures, such as methadone and subutex. The Wool Report into Health Needs at the prison is being studied carefully by the Health and Social Services Committee.
8. Aftercare support for former prisoners is clearly not adequate.

5. Silkworth Lodge

1. SS said that he was in favour of making the best possible use of Silkworth, which would require additional funding up front. The Committee will need to look more closely at this kind of activity to see how people with addiction problems can be helped at places like Silkworth.
2. This would be cost effective to the States in the long term in avoiding the social problems caused by addiction, but the current Fundamental Spending Review process militates against this kind of rational approach.
3. SS was asked to explain the apparent resistance to using SL.He felt that it might be a case of a lag in accepting a new venture; or the fear by a public body of losing control; that once sharing of resources is commenced there is a danger of expenditure running away. There is a need about clarity in funding arrangements. He hoped that any early resistance would now be overcome.

6. Gathering data

1. SS said that, although ADS collected a great deal of information in its interface with clients, there was no escaping the fact that more work, such as the disconnected anonymised testing needed to be done.
2. There is still a problem with data sharing due to the multiplicity of different systems which are unable to communicate with each other. Despite the fact that Health and Social Services was the first department to produce an integrated IT strategy the funding has never been forthcoming - that's why it's so late in the roll out. The Department is getting to grips with itnow but will take two to three years to complete. The IT roll outinGP practices has largely been completed.
3. Sharing of medical information requires tough protocols to preserve adequate confidentiality. There are case handling issues where consent is required before information can be imparted.

7. Conclusion

SS said that the issues raised by the Panel, including the Care Pathways approach, the anonymised testing, the funding of a Hep C nurse would be on the Committee's agenda, although the Committee's decision and funding to all could not be guaranteed as other competing priorities would need to be balanced.

The Committee however should not simply respond to elevated public and political pressure and expectation about a particular issue brought about by the Scrutiny process.

The Health and Social Services Committee would take note of the issues raised by the Panel in its final report and would take some up even before its publication.