Scottish Affairs Committee
Wednesday 12 February 2025
Ordered by the House of Commons to be published on 12 February 2025.
Watch the meeting
Members present: Patricia Ferguson (Chair); Maureen Burke; Stephen Flynn; Lillian Jones; Mr Angus MacDonald; Douglas McAllister; Elaine Stewart.
Questions 1 to 41
Witnesses
I: Dr Gillian Shorter, Reader in Clinical Psychology, Queen’s University Belfast; Professor Catriona Matheson, Professor in Substance Use, University of Stirling; Professor Andrew McAuley, Professor of Public Health, Glasgow Caledonian University; Professor Vittal Katikireddi, Professor of Public Health & Health Inequalities, University of Glasgow.
Witnesses: Dr Gillian Shorter, Professor Catriona Matheson, Professor Andrew McAuley and Professor Vittal Katikireddi.
Q1 Chair: Welcome to the Scottish Affairs Committee. We are delighted that you are able to come and give evidence to us this morning. We know that our predecessor Committees have looked into this issue—or at least the issue of problem drug use—in some detail, so we are very interested to find out a little bit more about the ideas behind the safe drug consumption room in Glasgow, and, eventually, to see how that works out in practice.
I know that some of you have been to the Committee before, but, for those of you who have not, we are broadcasting now. Otherwise, the Committee is a very relaxed place. If there is anything that you do not understand, or if we are not making ourselves clear, please do not hesitate to ask us. I would just ask that all questions and answers are directed through the Chair.
We will now begin, and I will kick off. I wondered if you could give us an idea of what you think the root causes and structural drivers are of problem drug use. I am sure that we all have our own thoughts and ideas about that, but it would be really interesting to hear your views, as people working in the field.
Dr Shorter: There is a lot to consider here specifically from the Scottish perspective, but there are more general points to think through. There are structural drivers such as poverty and deprivation. We have high levels of trauma, and not always the available mental health support to deal with it. There is trauma through the life course as well for individuals. There are a range of wider factors, not just at the individual level, that drive substance use particularly.
Professor Matheson: We could add to that some layers from a Scottish perspective, which I am happy to do, and I am sure that Andy will have some thoughts on that too. Gillian mentioned deprivation and poverty. Particularly in Scotland, it stems from a period of deindustrialisation in the 1970s and 1980s, when heroin got into or penetrated our more deprived communities, and we are seeing the legacy of that now.
It does mean that, in these deprived communities, as you will appreciate, there are more problems with mental health, housing and welfare benefits. That then creates communities where children are more vulnerable.
Another factor to think about in relation to children and the intergenerational aspect of drug use in Scotland is that more children were removed from their families and their parents in Scotland in particular, in comparison with other parts of the country. Adverse childhood experiences play a role, and they certainly play a role in how this has gone through the generations.
One other structural factor that I might mention is around funding and support for the services that you would hope would wrap around people in these communities and provide the support needed to help them through. Funding has been challenging. Funding for drug services in particular was reduced around 2015, which was just at that critical point where various other factors were coming together, and we were starting to see that really sharp spike in drug use. There was a bit of a perfect storm of factors around 2015, which really increased our drug deaths, unfortunately, very considerably.
Q2 Chair: Can I just follow up on one of the points that you made there, which was about, if I understood it correctly, children being taken away from their parents more often in Glasgow, perhaps, than in other places? I am struggling to think what the reasons for that would be.
Professor Matheson: It is a Scottish feature, and is not just about Glasgow, where there was drug use in families. It probably comes down to some legislation around protecting children that prioritised looking after children rather than supporting the family unit where there was problem drug or alcohol use in that family.
Professor McAuley: I support the points that have been made. A lot has been made about the beginning of the onset of the main issue through deindustrialisation in the late 1970s and early 1980s, but that population has been sustained for quite a long period now. It is not just that period that has helped sustain it. We have come through a recent period of austerity for 10 or more years, and so other, wider socioeconomic policies have helped sustain the size of the population of problem drug use in Scotland.
What we see in Scotland is that our prevalence of risk from all of these harms, including things such as drug-related deaths, is much higher per head than you see in other countries, not just in the UK but in the rest of Europe. The evidence is quite clear that, when you have a large population of people at risk of drug-related problems, you will get high counts of things such as drug-related deaths and other drug-related harms.
Q3 Chair: What would the profile be of someone who had problem drug use? Do we cover all age ranges and societal conditions?
Professor Matheson: I can give you the profile of people who are dying and are at the most harm from a Scottish perspective, and Andy can probably fill in a wee bit more from a Glasgow perspective, where there are particular features.
Just for a bit of background explanation, I do some detailed death reviews in Aberdeen city, as well as doing my job at Stirling University. The profile of people who are most at risk of death from a drug-related harm is people who have been in drug use for at least 20 years, so a long history of substance use, and all of the trauma and the experiences that go along with that. Their physical health is not so good, because they age prematurely, and they are using several substances. The areas of deprivation have 15 times more deaths in Scotland compared to the least deprived areas, so it is concentrated in areas of deprivation.
Having said that, you get drug use across all social groups and all parts of the country, so we should never forget that. There are also higher-profile risk features in men, which I did not mention. Men are about twice as likely as women to die.
Professor McAuley: Just thinking about the profile, and even going beyond the deaths, as Catriona said, it generally tends to be men who fall into that problematic side. It is generally about 70/30, which has held pretty firm for a long time. We talked about this older or ageing drug user cohort, which largely stemmed from the 1980s. That has probably been wrongly attributed as being the main catalyst for all of the problems. It is one of the reasons, but not the only one, because we do see harms across the age groups now.
Catriona mentioned poly-drug use, which is a key thing and is quite unique to the Scottish situation in terms of the volume of poly-drug use that we see in Scotland, particularly compared to other countries in the UK. The profile of that poly-drug use has changed a lot in the last 10 to 15 years. It was very stable in the past—generally heroin, benzodiazepines and alcohol, a combination of so-called downer drugs—but we have seen a lot of new drugs come into that mix now and be much more available and affordable.
Cocaine, for example, has radically changed the whole landscape in Scotland, moving from more of a so-called recreational drug and much more into the street drug scene, and being injected by huge amounts of people. People who would traditionally be using opioids such as heroin have largely shifted towards that cocaine market. The landscape has fundamentally changed.
In terms of the profile of users, as well as that older group, we now have what we call opioid-naive users, where younger people using drugs problematically, who have not entered that heroin or other opioid market, are now coming straight into that cocaine market. It is a very complex environment now—much more so than it has probably ever been—and certainly much more complex than it was 10 to 15 years ago.
Catriona mentioned poverty and inequality. The deprivation component is very strong here. As Catriona said, drug use is across all of society, but, in those most deprived communities, there is limited agency to deal with all of the other things that come with that, such as welfare, training and employment, that help people cope with the circumstances surrounding drug use, which makes them more vulnerable to addiction and dependence.
Q4 Chair: Trauma was also mentioned. Is that trauma related to living in that environment, or is it specific traumas around other issues that might occur, or both?
Professor Matheson: It is both. There is certainly trauma from the environment, and being a drug user brings with it trauma such as assaults, involvement in criminal activity, and witnessing overdoses and drug deaths. Adverse childhood experience and childhood trauma is also something that Gillian knows about. There is that combination of factors.
Dr Shorter: Moving to the safer consumption side of things, the age profile of people who would use that is around 30 to 35. There are a lot of males, with a very high trauma history there as well. Probably quite a few people are also very vulnerably housed, maybe in unsafe housing, or houses of multiple occupancy. By unsafe, I mean things such mould, a lack of safety, not ideal landlords, and those kinds of things.
For some people who maybe are not housed, the stress of everyday living is beyond what I can even imagine. It is about even things such as finding somewhere to go to the bathroom. When you are housed, you could nip into a wee coffee shop, but people who are unhoused are often not even allowed to use those public facilities. It is everything from, “Where do I sleep? How do I stay safe? How do I get a night’s sleep in the cold?” It has been very cold here in London overnight, and even just that very daily trying to work out how to get through the day can be really quite substantial from a trauma perspective.
From a behavioural science point of view, if we are ever thinking about behaviour change and about helping people make more healthful choices for themselves, we need three things, which are capability, opportunity, and motivation. If we do not have all of those three things intersecting, we really are struggling to try to help people make those healthful changes. Capability is about the individual, their physical resources, whether they can move around, and their psychological wellbeing. If you are preoccupied with how to stay alive, you just do not have the headspace to even entertain possibilities of work or your relationships. It is really difficult.
For some of the supports that can be provided, opportunity is the real key part. This is about our social resource. This is about the physical resources. Centres such as safe consumption sites can do things such as even just providing space, or a place to be that is not on the street, perhaps using drugs. It builds people up and helps move that motivation forward.
Q5 Stephen Flynn: Good morning to you all. Just to take a step back, if we may, you have talked about the economic factors and the legacy impact of those through deindustrialisation. Scotland, of course, was not unique in these isles or across Europe in that context.
You referred to the growing use of poly-drugs and their impact. Would you say that there is a heightened concern about young men in particular and their ability to use the likes of cocaine readily, and that leading to the consistency in terms of drug deaths in the future as opposed to a reduction? I am very conscious of the fact that deindustrialisation was 50 or 60 years ago, so I am trying to better understand why we are still in the situation that we are in, when we are so far away from that period.
Professor Matheson: There are two parts to that. Deindustrialisation started things in communities, and now we are seeing the generational effects of that. That is the point where we are now. As you are rightly alluding to, other drugs are very widely available now across society. Cocaine is a classic example. It is much cheaper and much more available.
When you are asking about young men and cocaine, cocaine comes in two forms and is used in two different ways, but there is very prevalent cocaine use in Aberdeen. That is one area where we have particularly high problems with cocaine use across society. You see it in young men, but also in communities where there are long-term poly-drug users who are using crack cocaine alongside other drugs.
You also have young men who are using cocaine with alcohol. There are different subgroups, so I am not sure if that is quite what you are asking about in terms of that group of young men and whether they are at risk of getting more involved in poly-substance use.
We are at that stage where we are observing what is going to happen to some extent, because the other drugs that are being used by that group are things such as ketamine. There is this move away from heroin-type substances, but ketamine and cocaine are being used by a slightly different, broader demographic. That is what we are seeing locally in Aberdeen, and I have picked up that it does happen in other parts of Scotland as well. Intervention with that group to prevent them getting into more entrenched drug use is something that is being considered and very much being thought about.
Q6 Elaine Stewart: You said that there was reduced funding in 2015, but the Scottish Government have targeted areas of deprivation with the drug deaths taskforce fund. Is that working, given that drug deaths have gone up? That funding went in around 2020 or 2021.
Professor Matheson: That did not target specifically areas of deprivation. I do not know if you mean the taskforce fund or the national mission fund.
Elaine Stewart: I mean the peer project.
Professor Matheson: You might be referring to the peer naloxone project.
Q7 Elaine Stewart: It is a project that has been funded through Scottish Government to support people with lived experience to support their peers within local communities that have very high drug deaths. Is that working, considering that drug deaths have gone up?
Professor Matheson: I understand what you are alluding to now. There are so many strands to different projects that were started. The aim of the peer project was to develop that living experience community, so that there is a feedback mechanism for people to be able to feed into the development of services and things that can meet their needs. That is targeted where there are areas of highest drug use.
As for whether it is working, we would not necessarily expect to see that in itself having a big impact on drug deaths. It is several components and initiatives put together. That is where we would like to see drug deaths starting to come down. It is difficult to pick out the impact of one initiative such as that, but it is certainly an important initiative to make sure that any responses that are taken are meeting the needs of those most at risk.
Q8 Elaine Stewart: Could you outline the key differences between the criminal justice system and the health-based approach to problem drug use?
Professor Katikireddi: A criminal-justice-based approach is focused on really trying to punish and address drug use per se, whereas a public health approach is focused on trying to address the health-related consequences and make sure that people’s health improves.
Generally speaking, I would say that a criminal-justice-focused approach has not been that successful. The Committee noted in its last report that most countries that have tried to tackle drug-related harms purely through criminal justice have not made particular progress.
Generally, a public-health-based approach has had more of a successful track record in reducing health-related harms, but the purpose is somewhat different. The purpose of a public health approach is very much about reducing the drug-related harms that people experience, whereas criminal justice is more focused on trying to punish drug use.
Q9 Elaine Stewart: Given that the report published that, do they work hand in hand, or is there any future of them working hand in hand?
Professor McAuley: A public health approach is what we would advocate for and what has been advocated in the previous report. A public health report does not completely reject criminal justice elements. It is about balance, so shifting towards a public health approach puts the focus on the individual and on communities, and treating health as the number one priority, not enforcement, as Vittal has mentioned. That is not to say that enforcement is not still part of a public health approach. It is just that the enforcement angle has moved much higher up the chain. The enforcement is not on the streets to the individual user in relation to that.
When people are engaged in relation to their drug use, they are signposted to treatment, for example, or other forms of support, rather than being marched down to the police station as a first point of contact and ending up in the prison system. There is a rebalancing of how you would look at that, and certainly some countries that have pursued that approach, Switzerland being probably the best example of how you rebalance your system, have achieved good results in relation to their drug-related harm indicators.
It is not about rejecting a criminalisation approach in favour of a public health reports approach, but about rebalancing the focus to that, while still maintaining an element of enforcement, but perhaps moving that up more towards the supply side of things.
Dr Shorter: These things can work together. We know, from looking at the global policy picture, that the United Nations global drug policy does not prohibit harm reduction services. It recognises that intersection between policing and the criminal justice system, and health. It does not necessarily go against the convention, so long as the purposes of facilities for harm reduction are, indeed, health-focused.
Also thinking a bit more about the policing perspective, through my work I have spoken to quite a few forces across the UK and in Scotland about some of the frustrations that they see in dealing with possession-related offences—how much time it takes for officers and how many times they see people repeatedly for things such as possession. There is sometimes more of a decriminalisation approach, where you are speaking with people and maybe taking more of a health-led approach in that respect, with some good examples of pilot work here in Durham and Thames Valley, as well as in other places around the UK.
I am not sure whether there has been one in Scotland, and my apologies if I did not know that, but there is a way for these things to co-exist and to protect communities, which also includes people who use drugs, and the police officers who work in those communities.
Q10 Stephen Flynn: Just to build on that, could you perhaps illustrate to us the differences in approaches that exist within Scotland and elsewhere in the UK, be that England, Wales or Northern Ireland, and perhaps go a little bit further and explain where there have been successes but also learnings that could be had?
Professor McAuley: Is that specific to the public health approach?
Stephen Flynn: And criminal justice.
Professor McAuley: An obvious example of a public health approach versus an enforcement approach, and a good place to start, is the Police Scotland naloxone programme. Effectively, that is a public health approach to policing. It brings in a public health intervention to a workforce who are traditionally used to enforcing the law, and has been a hugely successful endeavour. It was initially piloted, a bit like the consumption room, and has now become part of national policy through effective evaluation and then implementation. Seeing the police carrying a naloxone kit as part of their routine daily equipment is probably something that we could not have imagined happening 10 years ago.
As Gillian mentioned, cannabis legislation is another area where, not just in Scotland but the rest of the UK, we now see that there is no longer the same enforcement with respect to low-level cannabis offences. There is perhaps a pseudo decriminalisation approach to that, where people are not punished but diverted in different ways. Although we do not have decriminalisation in the UK, or in any of the devolved nations, there are aspects of that, either where we are getting the police involved in public health approaches, or where specific offences are being managed in a different way, with a different approach to that.
Q11 Douglas McAllister: Do you still see value in relation to the criminal justice approach? One argument for that would be that Scotland, and Glasgow in particular, specialises in relation to quite ground-breaking treatment of those who are prosecuted, as well as drug treatment and testing orders, which are Scotland-wide. Glasgow in particular has the specialist drugs court, which, to my mind, is unique. It has been running now for several years and has achieved major success in relation to tackling the drug problem in Scotland. What is your view on that?
Professor Matheson: Even in the development of that service across the country, there has been a public health element brought into it. It has been successful, although it probably is due some more evaluation, because the evaluation of it is quite old. It is generally considered to be a useful tool that is open to criminal justice services to use. They do build in more of a public health way of delivering that, which is important, and they are considering the individual and their health in how that is delivered.
You see it at a local level, where you have someone on a DDTO. They may have a lot of support from a criminal justice social worker that they might not otherwise have had. That level of individual support, not just from a health aspect but in terms of those broader issues that we have already alluded to around housing and welfare, et cetera, can really be quite useful for some individuals. There is value there.
Q12 Douglas McAllister: Effectively, it offers that wraparound engagement with broader services in relation to housing support, mental health support and welfare support. Is that something that you can see the safe drug consumption rooms developing and offering? Rather than just being a service to facilitate safe drug use, are there the complementary services around it?
Professor Matheson: Yes, absolutely. Others can talk about that in terms of the Glasgow service and evidence from other services elsewhere. If I can broaden it a wee bit before I hand over to colleagues, anywhere where there is that kind of wraparound support is crucial. Our drug treatment services really need to be able to provide that, and they are not, because they are under-resourced to do so. That is crucial. Criminal justice can at the moment through DDTOs. The safe consumption site is planning to and will be doing that, but we also need to be able to do that within our general treatment services to a greater extent than we are able to currently.
Professor McAuley: Just as a point of information, it is important to recognise that the safe consumption room is not planning to do that. It already offers that wraparound service, so it is already on site. Whether there is uptake of that, we will have to wait and see. That will need to be found out as things play out, but that wraparound care is available on site. It is not simply a facility for people to go and inject. There is a whole host of other services there that are available to people, should they choose to engage in them, so it is very much part of the original framework.
Dr Shorter: If we are thinking about and exploring wider facilities across Scotland, there tend to be four types. You have a standalone service or an integrated service. The standalone would just be the consumption space, and there would be some aspects on site, but others would be by referral to other partners. There are also mobile sites, if you have quite a dispersed population, so you will be wanting them to go around and bring those services to the people in the community.
The other one is temporary, which we do not really want to talk about, because people will engage with the services and then disappear and peter off into nowhere. The whole point of this is to really connect people to welfare and health care services. It is really about building up trust, social inclusion and safety, and creating that space where that can happen.
I have been very fortunate to speak to the managers at Glasgow and, if somebody says that they are ready for treatment or for some kind of intervention, the wheels just come straight on and everybody heads towards helping that person get to where they want to go. The second that somebody says that they are ready for something, we want those services to be ready and raring to go.
Q13 Chair: Just following up on my colleague’s point there, this may be something that you do not feel is in your remit to comment on, but we have had, as Douglas says, the drug court in Glasgow for quite some time now. Do we need to roll that out to other parts of the country? Would that help the situation? Feel free to say, “That is not for us”, if you do not think that it is.
Professor Matheson: There are DTOs in other parts of the country. The drug court is a bit different, so I would let somebody else answer that.
Chair: That is okay. We do not have to have an answer to that one. I realise that it is not quite in your remit.
Q14 Maureen Burke: How do safer drug consumption facilities seek to reduce drug-related harm? As a caveat to that, what services are often provided within such facilities internationally?
Professor McAuley: I am happy to take the first bit and then maybe move to Gillian. The concept of safer drug consumption facilities is fairly basic. It is that you have an identified problem, which is people using—and particularly injecting—drugs in public. You are aiming to move that public drug use indoors, away from the communities in which it is happening.
Public drug use is bad for the individuals who are engaged in it. It is unhygienic. It is dangerous. It is also bad for the communities where it occurs, because of things such as drug-related litter and worries about public nuisance that go alongside that.
By moving that issue indoors, first of all, you can treat the danger to the individual themselves. You can give them a safe, sterile environment where they can engage in their drug use, and particularly their injecting drug use. You can provide on-site support in case they get into any particular harm, and particularly overdose-related harm.
You can also provide on-site treatment and care to deal with complications that come with public drug use, such as skin and soft tissue infections, and, potentially, mental health support. As other people have said, should people be willing at any point to engage with a wider array of services, such as recovery services or treatment and care services, there is a pathway for people to engage in that through the service itself.
For the wider community, in theory, that public drug use moving inside should reduce the amount of drug-related litter that people are exposed to on a daily basis, and reduce the amount of people who they see using drugs in public on a daily basis, whether they live or work in that area, which is difficult for people living in those areas.
It addresses both the individual needs and the community needs in relation to the problem that is occurring in that area, and that is why they are most effective if they are located within the hotspot, really, of where that public drug use is occurring.
Dr Shorter: Just to come in on that, I have a few extra little points. We talked earlier about some of the issues around marginalisation. Some of the facilities would also have things such as tea and coffee, some food, and places where people can do laundry. If you are vulnerably housed, you could be wearing the same pair of socks for three or four weeks, so there is also fresh clothing, and those kinds of things.
There is also a public health surveillance function. We do not talk about that as much, but it gives wider interest holders—policing, public health professionals or local treatment services—a bit of an idea of what is going on in the population and how they can respond.
The other part in terms of communities is either that they tend to have no influence on crime rates compared to control areas, or there is usually a slight decrease. That is based on evidence from Australia and Canada, as well as some emerging evidence coming out of the USA. There is a wide range of community and individual-level benefits there from these services.
Q15 Mr MacDonald: That leads perfectly on to my question. The international experience is clearly something that everybody is looking at. Has there been a very noted improvement in areas where they have drug rooms around the world?
Dr Shorter: We completed a very large evidence review back in 2023, which summarised the evidence from around the world, including summaries of 35 reviews on different topics. It certainly would be the case that we are seeing some major improvements to communities. That is not to say that, when these services open, there are no teething issues and that things do not evolve over time.
I am not going to pretend that it is all rosy in the garden, because it definitely is not, but it is really about partnership working. Police are key partners, as are public health, health professionals and the people running the service. You need to speak to the community that you are hoping will come to your service. That is a really important partnership.
When all of those things are in place, such as the legal protections and that partnership with the police—and you were talking about the criminal justice and health intersection there—it does seem to be effective. That is not to say that sites do not close. There are often political shifts in the wind, if I could politely put it that way, which can mean that services close despite evidence. Sometimes, services close because there is no longer a need for them to be open; the issue that led to it being open in the first place no longer exists. There are around 200 facilities in 19 countries—the numbers always vary, so it is a rough estimate—including the UK and Ireland now.
Q16 Lillian Jones: Just on the back of that, Gillian, you said that, in some cases, services close because it may be that there is no need for them anymore. That would suggest that they are successful. Can you give me some examples of areas where the services have closed for those reasons?
Dr Shorter: Services sometimes evolve into different spaces. In terms of public drug use, people sometimes move on to things such as smoking, so it can be a shift in facility. It is no longer dealing with an injecting drug use problem, but with a different kind of problem. I cannot think of the countries off the top of my head, but I can contact Lulu with more details, if you do not mind.
Lillian Jones: That would be helpful.
Dr Shorter: It is quite rare that that happens, just so that you know, if you have this idea that we are going to open these services and then everything changes. The evolution of a service has to be very much part of services such as that in Sydney, which has been open for 24 years now. That is not the same service as it was when it opened its doors. It has had to evolve to the changing needs of the population.
Sometimes they will go mobile. I mentioned previously the need to move around the place and perhaps be less in that fixed place. Maybe the mobile sites will have to go out and serve the community in that way. It is not designed to stop drug use. That is not the purpose. It is designed as a harm reduction intervention.
Q17 Lillian Jones: Are international services 24-hour facilities? I understand that the Glasgow facility is open from 9 until 9. I have a background in the NHS, and my experience of addicts is that they have very chaotic lifestyles. They will not stop injecting after 9 at night. I am just trying to find out what the view is in other countries in terms of opening hours and service provision. Is it more tailored around the lifestyles of people who are addicted to drugs and need the vital service that it provides?
Dr Shorter: That is a very good question. It very much varies. It tends to be the unsanctioned, temporary sites that are open 24 hours. I can think of maybe only one or two off the top of my head. The other services that are sanctioned tend to be open as a function of capacity to pay for staffing and to properly resource these sites, because one of the key aspects is observing the consumption event. You need to make sure that people are there. There need to be enough people, if there was an overdose, to deal with that and to support the others who are there. It quite often comes down to a situation of resources.
We were talking earlier about the closing and evolution of sites. A good example of that would be in Zürich, Switzerland, where there are three or four sites across the city that open at slightly different times. This is a bit unusual, because there are quite decent transport links, so people can move around the city and afford to do so, and there is that opportunity that people have for behaviour change.
Again, it is really about evolving the model to the resources that are there to the needs of the people, and trying to serve the community as best as you can with the resources that you have. There are very few 24-hour facilities, and, of course, we would then have risks with people overdosing afterwards at home or in the streets and so on.
We talked previously about wraparound care and thinking through different aspects, and it is really about looking at housing provision and even digital solutions such as watches that can detect overdose response and things like that these days as well.
Professor McAuley: I was just going to add that the key thing is that the consumption room is not the only service. It is not a magic bullet for the individuals who it serves. You rightly highlighted that people might be engaged in these behaviours beyond the opening and closing hours of the facility. As Gillian has rightly said, it is one part of a whole system, which involves not just the consumption room. It involves needle and syringe exchange. It involves the treatment and care system. It involves the naloxone intervention. It is one part of a whole system that is designed to reduce harm among these individuals, and opening times are often a pragmatic decision based on funding and capacity.
A key point that I would like to make is that it is a pilot. Once the service starts to establish itself, it will quickly become clear what the busy or the main utilisation points of that service are. There is potential for the service to evolve and adapt how it mainly operates. That is not to say that it is going to be from 9 until 9 forever. It might change in relation to that, based on, like you say, when people are most likely to use it and you get the most efficient use of the service. It is important to bear in mind that it is a pilot, and there is potential for change or flexibility there.
Q18 Stephen Flynn: Just going back to those international comparators, in terms of harm reduction as a benefit of the safe drug consumption facility, I am very conscious that the facility in Glasgow has been open only for a matter of weeks. What sort of timescale was it internationally with our comparators in terms of being able to assess whether there had been a significant harm reduction as a result of the facility being there, or otherwise?
Professor Katikireddi: This may be a good time for me to mention the plans for an evaluation, and when results might be available for Glasgow specifically, and then I can pass back to Gillian in terms of the timelines more generally.
It is possible to find out, relatively early from the point of view of research, whether the service is being implemented as intended, whether people are engaging with the service, and whether it is reaching the right type of people. Often, the people that the facility is really trying to reach are those who are not engaging with current services, so we can get a sense of some of these process measures fairly quickly.
In terms of tracking things such as the amounts of overdoses, ambulance call-outs, and these types of measures that you might view as harder health outcomes, that can often take some time and depends a bit on how big the service is, how many overdoses normally occur and so forth, in terms of having the amount of numbers to conduct reliable statistical analysis. It will probably take more in the order of two or three years to be able to develop that type of evidence, but potentially even longer than that, in terms of it then going through peer review and being published, and so forth.
You can get early indications of success in terms of things on the pathway to improvements within a couple of years, but, in terms of demonstrating real reductions in drug-related harms, it is probably more in the order of three or four years, or thereabouts.
Q19 Stephen Flynn: Does that fit with what we have seen elsewhere?
Dr Shorter: Yes, very much so. One of the things to recognise about this population is that they are quite often not engaged with services at present. There are quite a lot of issues of trust, and sometimes of the police and of health care services. We have heard of stories around individuals who have been to hospital and then been denied swift access to things such as opioid substitution therapy, which discourages them from going, so they may have that mistrust of the NHS, unfortunately.
It takes time to build those relationships to get that harm reduction to happen. The mechanism by which safe consumption sites work is through safety, trust, inclusion, and building those relationships with the health care staff, and the staff on site. We are really looking at engaging high-risk substance users, but not people who want to inject perhaps for the first time. That is not the target population. These are people maybe with long career histories, and the more we can engage them and the more they attend, that tends to be where we see the big harm reduction benefits.
The early piece is really about understanding how they are perceiving it, and what we can do to change the service. Again, we have talked about evolving the service a couple of times here. The more we get people to attend, that is really where the magic happens.
Q20 Stephen Flynn: In terms of drawing conclusions, I guess you would be wary of politicians of any ilk seeking to draw conclusions as to the success or otherwise, for a considerable period of time, in order to let the pilot expand and meet the needs of the people who are using the facility, effectively.
Professor McAuley: One of the core elements of the Lord Advocate’s permission for the facility to operate is that there was an independent evaluation to take place. That is where politicians, members of the public and other key stakeholders should be looking to the findings from that, alongside other evidence, to see what impact the service has had, once that independent evaluation has concluded its business.
Q21 Chair: The Lord Advocate is a key stakeholder in all of this, and there are others. I understand some of what you are saying about the evaluation, which, clearly, will be incredibly important. I presume that they have given you a clear idea of what they are looking for in terms of the independence of the evaluation. Have they set that out very clearly?
Professor Katikireddi: From an evaluation point of view, there is a research team that is planning an independent evaluation, and that team involves researchers at the University of Glasgow, Glasgow Caledonian University and others.
The team is engaged with a broad range of stakeholders to identify what the suite of indicators of success might look like. It is not going to be a single metric, but an assessment of the range of potential benefits, and trying to quantify those, including things such as whether the service is engaging people who have not been engaging in services, as well as some of the harder reduction in drug-related harms—for example, overdoses and so forth. It will also be looking at evidence of whether there are potential adverse impacts on the local community, where community members have raised specific concerns that are being investigated.
We have not directly contacted the Lord Advocate, partly to try to ensure that we remain independent, but we have been seeking input from a broad range of stakeholders, including the local health board, the police and so forth, to identify what key indicators people would want to see evidence around.
Q22 Elaine Stewart: Andrew, how can the safer drug consumption facility combat the spread of blood-borne viruses?
Professor McAuley: Another important point to remember is that the proposal for the safer drug consumption facility often gets confused as being a response to Scotland’s drug death public health emergency, but the proposal predates that by a number of years. The proposal for the safer drug consumption facility was partly in response to the HIV outbreak among people who inject drugs in Glasgow city.
A needs assessment was carried out in relation to public injecting, and various proposals were made on the back of that—the heroin assisted treatment service and enhanced IEP provision, et cetera—but the drug consumption facility was part of that proposal.
HIV was being transmitted as a blood-borne virus between people who inject drugs in the city through the sharing of contaminated injecting equipment, so it was a proposal directly in response to that blood-borne virus outbreak, and it is important to remember that.
Thankfully, that outbreak is now under control. It took many years for that to be officially announced, but there is still a huge risk within the city, because, although many of the people involved in that are now engaged in treatment, and their viral load is under control, there is still a risk. The reservoir of infection, as we would call it, is still very high in the city. Should individual circumstances change, transmission events occur, so we need to bear that in mind. The importance of that incident is still relevant to the service.
As I said in answer to Maureen’s earlier question, by moving that consumption indoors, you immediately remove one of the key risks for blood-borne virus transmission, which is the sharing of contaminated injecting equipment, because there is no permitted sharing of equipment or drugs on site. People are immediately engaged in safe, sterile injecting drug use.
You also remove a lot of the other factors that make public injecting risky to the individual. Like I said, people are often rushing when they are doing it, for fear of being caught by the police or a member of the public, and they are in very unhygienic circumstances.
There is also the opportunity for people, when they are in the service, should they wish, to be tested for blood-borne viruses. They can be tested for HIV, hepatitis C and hepatitis B within the service. One of the huge successes of the response to the HIV outbreak was a huge upsurge in blood-borne virus testing within Glasgow city. It was probably at the bottom of the national average before the outbreak, and has now risen to probably nearer the highest levels in Scotland for blood-borne virus testing among that at-risk population. The service should definitely make inroads into blood-borne virus prevention, provided it is utilised to a sufficient level.
Q23 Elaine Stewart: Will that be reported in your independent report?
Professor Katikireddi: Yes.
Professor McAuley: That is absolutely one of the indicators that would be included as part of that.
Q24 Lillian Jones: That leads very nicely into my next question, which is about whether safer drug consumption facilities offer value for money, when considering the impact that they have in addressing problem drug use—for example, in terms of cost savings for the treatment of BBVs such as HIV and hep C. I imagine that the NHS and health and social care partnerships have had discussions on what they are hoping to save in terms of treatment, because treatment for HIV and hep C is quite costly, in addition to the demands and the pressures on the national health service.
What are the hoped-for cost savings and value for money that the drug consumption facilities can offer versus the cost of operating the facility annually? I am hoping and guessing that they are huge, but has there been some work on that or any numbers that you can share with us?
Professor Katikireddi: A key element of the planned evaluation is to look at the costs and benefits, and to try not only to quantify the short-term costs, but to think about the longer-term potential savings, both to the NHS and also more broadly in terms of broader public sector services, including things such as criminal justice and housing.
One challenge within the broader existing evidence base is that a lot of the evaluations of costs and benefits have been based on quite a limited number of locations, and it is unclear how those costs and benefits will apply to the UK setting. It is difficult for us to give you an estimate for the Glasgow facility specifically at this point. We will need to do some of the research to figure out what the costs of the facility overall are, and what the benefits are.
Q25 Lillian Jones: I appreciate that it is still early days. What about in terms of your research from international studies?
Dr Shorter: The research in this area is quite diverse. Again, we are looking more at Canada, the USA and Australia for estimates. I am not a health economist. This is a figure that I have brought together, based on my reading, so take it with a big pinch of salt here, because there are lots of ways in which you can calculate this, and I am not fully across all of them.
Broadly speaking, in terms of US dollars, where I have converted things from Canadian dollars and taken into account the mad differences that you have in currency fluctuations, somewhere between two US dollars and seven or eight US dollars are saved for every one US dollar spent.
This depends on a lot of things. It depends on how much the facility costs to run. Medical-led services are more expensive than nurse-led, peer-led or drug worker-led services. It depends on the services that are provided there. Things such as HIV and hepatitis prevention, treatment and support are very expensive to the taxpayer, so we need to see if we can change anything on that. Overdose deaths are very expensive too, as is emergency healthcare, and those tend to be the things that they are counting.
What they are not counting is what you brought up: this idea of prevention. It is one of the things that we see is not really part of the numeric figures. Maybe we and the health economists need to come together a bit more in terms of some of these more delicate aspects. For example, when wounds are starting to look like they are getting infected, you do not want them to get to the point where you have something really costly such as sepsis or amputation. You do not want people going in for long-term stays. You want to try to prevent that, if you can.
It is a very ballpark figure, but, in nearly all of the facilities that I have had sight over in terms of the health economics, it is saving more than it is costing. There was a review by Behrens et al in 2024, which looked at services. There was one that was fairly cost-neutral. I do not have the details of that at hand, but I can connect with the team about that. It is quite rare that that is the case. In a well-run service with good, high-quality standard operating procedures, which is the kind of thing that I have been seeing through my conversations with the Glasgow team, there should be some savings to be had.
One last thing is just to note that, in terms of Canadian and US figures, they very much have fentanyl in the drug supply, so it may be that their numbers are a bit higher in terms of the cost savings as a function of that. Although we are seeing synthetic opioids such nitazenes coming in here, and they are a great concern for everyone here on the panel and for anyone working in the sector, I just want to temper your expectations in terms of what we might find, and this evidence will be really useful to model.
Professor McAuley: You can be reassured that Glasgow is fairly strong and well placed to evaluate the economics of it. Vittal has highlighted the gaps and limitations in the evidence base. Glasgow is well placed to address a lot of those gaps, because of the infrastructure, not just with the service, but with the data as well.
Q26 Douglas McAllister: In preparing for this morning’s evidence session, I picked up that we were currently going through a 30-year high in Glasgow in relation to an outbreak of HIV attributed to those injecting drugs. In your evidence earlier this morning, you were advising us that perhaps that is slightly outdated, and that those figures that I was looking at may be from 2021-22. Are we seeing those numbers coming down? If they came down before the safer drug consumption facility was made available to Glasgow, is that because of the provision of clean needles, for instance?
Some will ask, “Is Glasgow still the right place at the right time?” Do you see your safer drug consumption facility effectively making further inroads into that and building on that reduction? Is it also not just in relation to blood-borne viruses, but also about the safe levels of the drug being injected by the user at your facility as opposed to on the streets?
Professor McAuley: In relation to your point about the 30-year high, that is still a fact. The Glasgow HIV outbreak among people who inject drugs was the largest that the UK had seen since the 1980s, when Edinburgh and Dundee were the biggest focal points for us in Scotland, but also elsewhere in the UK, including here in London.
In terms of the prevalence that we reached in Glasgow, which was about 11% at that time, we had not seen anything like that in that population. That was a re-emergence of an old infection for that population, through a range of factors that created the scenario for that to re-emerge, such as homelessness and the surge in cocaine injecting and public injecting.
As I mentioned earlier, that outbreak was declared formally under control within the past few months, and that is because the number of new infections attached to that outbreak had largely reduced to either zero or one over the last few years. There was an assessment made by the incident management team that the outbreak was now fully under control.
There have also been a huge number of evaluations looking into not just the drivers but also the response to that outbreak. A couple of the main factors that came out as being mainly responsible for bringing the outbreak under control were the increase in blood-borne virus testing—and getting the testing up to a sufficient level made a huge difference—and, specifically, the repurposing of the HIV treatment model.
HIV treatment was moved away from Gartnavel hospital, where HIV treatment in Glasgow was generally delivered, to a more community-facing model within Glasgow city. HIV treatment was taken to the pharmacies and other services that people who inject drugs in the city engage with. That very quickly increased treatment engagement numbers overnight, from a very low to a very high percentage. That combination of blood-borne virus testing, prevention and the enhanced IEP, but particularly that treatment model, was successful in getting that outbreak under control.
Your question was whether the drug consumption facility has come too late because that outbreak is under control. What I was trying to highlight earlier is that HIV is just one of a number of issues facing that population in the city. HIV was one of the most recent and high-profile, but they also have very high levels of hepatitis C and of skin and soft tissue infections, because of this public injecting that they are engaged with.
Glasgow city has the highest overdose rate in Scotland. There is sometimes what we in academia call a “syndemic”, with multiple epidemics happening at one time within a very specific population. There is a syndemic of drug-related harms affecting people who inject drugs in Glasgow city, and very particularly affecting people who inject drugs in public places. Those levels of drug-related harm have not gone away, so the case for the facility is still as strong now as it has ever been. There still has to be an enhanced response for that group.
Q27 Mr MacDonald: I wonder how the local community were perceiving the impact of antisocial behaviour as a result of this opening. Do we have any feedback from the international experience on antisocial behaviour within an area of drug rooms?
Professor Katikireddi: I can maybe say something about the local community in Glasgow. Inevitably, the response will probably be quite varied between people. There certainly has been an extensive amount of work done by the local health board in running community events to listen to people living in the area and hear their concerns, and to think about how best to address them.
There seems to be a relatively small proportion of people who have expressed a concern about the facility being opened. As part of the evaluation, we are going to look at what happens to people’s experiences of the local community and whether they find that those concerns are borne out over time, and compare what is happening in the area around the facility to other comparable areas of Glasgow.
In terms of the broader international evidence, I will let Gillian add flesh to the bones, but my impression is that, generally, communities have found that the local environment tends to improve. There is often a reduction in drug-related litter and those types of things, and concerns around crime and so forth tend not to be borne out. Of course, different contexts might experience different things. Because this is the first facility in the UK, it is still important that we look at that as an independent research team.
The broader international evidence so far seems reassuring in terms of that not happening elsewhere, but it has probably been a bit less studied than, say, the impacts on the people who use the facility.
Q28 Douglas McAllister: The obvious question is about how we prevent it from becoming a magnet for drug dealers and drug suppliers. This is not a crime exclusion zone that we are introducing, is it?
Professor McAuley: An important thing to remember is that there is already drug dealing and public drug use happening in that area at quite an extensive level. Anybody who has been in and around that area would recognise that. That is one of the reasons why people who live and work there have, and have raised, concerns about this. It is already happening, so we would not be importing something into an area where this is not already happening.
That is one of the reasons why the location has to be within that hotspot area. You have to have it in an area that people do not have to travel large distances to get to it, because the likelihood is that people will not travel large distances to access a facility such as this. It has to be a short walk from where this behaviour is already happening. The location is in an area where that is happening, so it addresses that point.
What you are suggesting, I suppose, is the so-called honeypot effect: will it bring more people to the area? That is a genuine question to ask, and something that the evaluation will consider as to whether more people come to that area.
Certainly, Gillian might want to reflect on the international evidence. My understanding of it is that there is not a huge body of evidence to suggest that people come from further afield to access a drug consumption room in another area, because people who use drugs tend to stick to their localities. It is unlikely that people in Govan or other parts of the city are going to make long-distance journeys there, because they probably have a drug scene in their own area, which they are already accessing.
Professor Matheson: In a way, this is not entirely new. We already have pockets where drug users congregate and are known to congregate, and which could attract drug dealers. These include community pharmacies that have very high levels of service providing replacement treatment and supervision. There are pharmacies seeing over 100 people a day, as well as needle exchanges and drug treatment services. It is not a completely unique area around this facility, and we do already have potential hotspots that can and do, to some extent, attract drug dealing.
Q29 Chair: I will perhaps come in on the back of that and just ask, being devil’s advocate slightly, whether you would have a concern that such a facility would encourage drug use.
Professor Matheson: There is no evidence at all that that is the case.
Dr Shorter: Typically, centres would have a plan for somebody coming in to initiate drug use for the first time, in that they would provide them with health support, rather than going down the line of facilitating that. It is very much people who are entrenched in substance use over a long period of time that that tends to be.
May I answer the other international question?
Chair: Yes, of course.
Dr Shorter: Douglas, you were talking about people travelling. Typically, across the world, sites tend to be within one mile of an open drug scene, because people just do not have the physical health or financial resources to get around much more than that, whether that is getting on buses or physically walking to the spaces, as Andrew has suggested. There is one exception, to the best of my knowledge, which is some travel between Denmark and Sweden, but that is the only instance of that that I know of, and it seems to be very localised and unique.
Of course, one aspect of these facilities is that we really do want high-risk substance users to be coming to these centres as well, if they can, because they are then connected in with health, welfare and other support services as well.
Going back to the communities part, community consultation is an essential part of opening a service. In Glasgow, there has been some essential and extensive consultation with a wide range of interest holders, including those in the communities, as well as business and tourism, and all of those really important elements of our communities. There are concerns, and we have to listen very compassionately to people’s concerns about what it is that they are worried about, to provide reassurances to people, and to respond when things come.
One of the things that I would suggest to people who are thinking of opening new services is making sure that there is a designated liaison person, so that, if there is a problem, there is somebody to contact. What usually happens is, “Hello. Police Scotland”, “There are people loitering outside my business premises”, or whatever, and it is usually the police that deal with some of those issues of moving people on.
I do not know whether there have been issues, but there will be some teething issues to start with, as everyone works out what is going on and people who may be injecting in public come into this facility, but these are usually ironed out, and we see some really lovely community partnerships. There is one statistic from Sydney that I always like, and it never leaves me. 18 months after the Sydney facility opened, half of residents and a third of businesses could not tell you where it was on the map. That is how much it blended into the background and just became part of a busy street in Kings Cross in Sydney, and that is really what you want.
There is similar evidence across Denmark and places such as that, where there are cafés and busy places where people come along, meet their friends and enjoy living in Copenhagen, very much as part of the fabric of communities.
The last thing that I just want to say is that it is really important for us always to remember that people who use drugs are also members of our communities, so consultation with them is really essential to get the right service to get people to come in, but also to iron out some of the issues as the service evolves.
Lillian Jones: On the back of Patricia’s point about the facility attracting more drug use, just for clarity let us note for the record that the facility does not provide the drugs.
Q30 Maureen Burke: There is a bit of concern that the focus on harm reduction services, such as safer drug consumption facilities, risks overshadowing the need for long-term recovery options. What are your thoughts on that?
Professor Matheson: We need to think about things as a system of care. Andy has used that phrase already, but that is where there are different entry points and things are joined up. I would see this as an access point to care and support of some sort, which we hope will encourage people to get drug treatment, which we know is protective, and we hope that that would then lead to people moving into recovery and support services.
I would see it as a continuum of care that is currently not available to encourage people into our treatment services. Those recovery services can either work alongside treatment services or be a support for people beyond. I do not think that it overshadows that. That is probably as much as I would say on the matter. It is about thinking of it as a system rather than as one or the other.
Q31 Mr MacDonald: On that same subject, this has been a big issue in Glasgow for a decade or more. Are we on a trajectory where, basically, this is not going to become the issue that it is now? This is about drug use and drug death, and all of that. So much has been put into it, and there has been so much effort to reduce it. Are there signs that we are on the right track and that this is not going to become the issue that it is now?
Professor Matheson: It depends on what metric you look at in terms of numbers. Drug deaths are levelling off, and let us hope that that continues. Drugs are going to be around and people are going to use drugs, so we need to just improve the way that we manage and support that, and give people the options to address their drug problem in a way that works for them. There is the hope that, overall, drugs will not be such a dominant issue in Scotland. It certainly should not be. As you can see, compared to other countries, it does rather dominate. The intention would be that, if we get the systems of care right, it will be less of a dominant issue going forward.
Professor Katikireddi: Just as a quick point to add to that, it is also quite challenging, though, to address the issue of drug-related harms without addressing the underlying drivers as well. It does take us back to the start of our conversation, where issues around deprivation and so forth were emphasised. We know that, within much of Scotland, and Glasgow, there are ongoing issues of deprivation and poverty. In the absence of that substantially improving, it is quite difficult to see drug-related harms really being tackled while not addressing those fundamental drivers.
Professor McAuley: Problem drug use in Scotland—and, indeed, Glasgow—is 40 years in the making. We are not going to turn around a 40-year issue in a short space of time. The consumption facility is an important additional tool in the response, but there are still a huge number of issues across the range of responses.
For example, our drug treatment engagement rates are still not at a level that we would like. There are still gaps in our drug treatment response, particularly related to the cocaine issue that we have mentioned. We still have huge issues in relation to counterfeit medicines. Benzodiazepines have been well documented, and we have the threat of other synthetic drugs coming in just now, and potentially nitazene.
We have a long way to go before we can conclude that we have a hold of this issue and are on a downward trajectory. There is still lots of work to do in this area.
Q32 Stephen Flynn: In that context, there has been significant public discourse around the potential for a further tightening of the social security network that exists. Would that be a help or a hindrance to the people who we are talking about?
Dr Shorter: Can I just ask for a point of clarification? What do you mean by “tightening”?
Stephen Flynn: A tightening of the budget.
Dr Shorter: So reducing the amount that we spend on this.
Stephen Flynn: Yes.
Douglas McAllister: Are we asking our witness to, effectively, speculate on what might be announced in the future?
Chair: I think we can accept that poverty is a major driver, and anything that contributes towards—
Stephen Flynn: It is a legitimate question.
Chair: It is speculation, because we do not know that that is necessarily the case.
Q33 Stephen Flynn: I will reword it. In the social security budgets that exist, 78% of welfare spend comes from Westminster. If there was to be a reduction in that safety net that is in place for people who are living in deprivation and have much more challenging circumstances, would that be a help or a hindrance to dealing with many of the societal issues that we are dealing with and which impact these people and potentially lead to their drug use?
Professor Katikireddi: As is hopefully clear, poverty and deprivation are really important drivers of drug-related harms, so anything that threatened addressing poverty and deprivation could have adverse effects. Hopefully, it is really clear that the importance of poverty and deprivation is a fundamental driver here.
Chair: I think we understood that from the earlier conversation, so thank you for re-emphasising it.
Q34 Lillian Jones: We have touched on wraparound services, but to what extent is the provision of these services needed to address the root drivers of problem drug use? Does Glasgow have the necessary wraparound services, and are they appropriately resourced and equipped to be as effective as possible?
Professor Matheson: I do not know the specifics of Glasgow in terms of how funding is allocated, but, in terms of the wraparound services, I just want to point out some of the key things that we have not mentioned. Housing is crucial. Stable housing for people is one of these key levers that gives them the safety and stability whereby you can then start to address other aspects of people’s problems.
Those other supports are available in Glasgow. Whether they are available on the scale and at the level of funding that is needed for the scale of the problem is another question that I cannot answer, and I do not know if my colleagues in Glasgow might be able to shed any more light on that.
Professor McAuley: All I would add is that there is a range of services available. I am not sure that any of us could answer on whether they are at the scale required. I do not think that that question has been properly evaluated yet.
There has been investment in a lot of the treatment and care infrastructure over the last few years through the national mission, for example, which Glasgow and other areas have benefited from, but the national mission itself is being evaluated at the moment to see whether that increased investment has reached the areas that it intended to, in terms of increased investment in residential rehabilitation, for example, or in the provision of medication-assisted treatment standards.
There is a process in place to evaluate whether that increased investment has reached its intention, as you asked, and it would be interesting to see how that reports in the next couple of years.
Professor Matheson: Some of these wraparound services do not come from that budget, and the national mission will not touch it. Things such as housing, which I have already mentioned, come from a separate Scottish Government budget, for example. We know that housing in Glasgow—not just in Glasgow—is undoubtedly unchallenging. That is one area that we can certainly pick up on that is not necessarily accounted for from the drugs budget or from the national mission, and would ideally be better funded to help support people.
Q35 Douglas McAllister: Following on from that, maybe it is too early to assess, but what level of users of your safer drug consumption facility are, effectively, homeless? As you have advised, we are going through a housing emergency in Scotland. A number of local authorities have declared a housing emergency, and the Scottish Government eventually declared one off the back of that, despite reducing their social housing capital budget. What level of those using it are homeless?
Professor Matheson: We do not know yet, but you will probably find that out, won’t you?
Professor Katikireddi: Yes. It is something that we will be looking at, but we do not have an answer for you at this time.
Q36 Chair: Will that be one of the metrics that feeds into the independent evaluation? Will that be one of the facts that you report on?
Professor Katikireddi: Yes, it will. I mentioned earlier this idea of assessing the reach, as it were, so which people are using the service and what their characteristics are would be one of the things we would look at.
Q37 Douglas McAllister: Drug-related death is a public health emergency. Glasgow has the highest level in Scotland, and Scotland has the highest in Europe. Despite that, I suspect that there will be some elements of the media and public who will focus on the cost of the safer drug consumption facility and the pilot scheme. What I really want to ask you is how soon we will see an impact from your pilot facility, and what success will look like.
Professor Katikireddi: We need to remember that this is one facility among a range of approaches that are needed. Part of the way in which the facility will work is through building up relationships with the clients attending the facility. Certain outcomes could change fairly quickly, such as reducing the amount of skin and soft tissue infections, but they still might take a little while for us to detect via an evaluation within a research study. By that, I am talking about three or four years, or that type of time period, to see those indicators change in a statistically meaningful way.
Other things such as blood-borne viruses are likely to change, but over much longer time periods, just because there is often a delay before those types of infections change enough to be really detectable. The adverse consequences of that would then take time to feed through as well. We will get at some of that by modelling what will happen over the longer time horizon to try to get an earlier handle on what the impacts are likely to be.
Professor McAuley: If I can address the point that you mentioned about the public health emergency of drug deaths, perhaps I was inferring that you were asking about how quickly we will know if the facility has made a difference to Scotland’s drug death emergency. It is important to clarify that the facility will address issues within the locality where it is located. It is not going to address drug deaths in Lanarkshire, in Lothian, in Fife or in Tayside. It is perhaps not even going to address drug-related deaths in the rest of Greater Glasgow and Clyde. It will address the drug death risk for the people using the facility and the people in and around the locality who use drugs in that area, and it is important to make that distinction.
Q38 Douglas McAllister: Just on that point, if there is a success in Glasgow, it is an argument to expand it across the country to tackle the nationwide problem.
Professor McAuley: Yes, but, again, as Vittal has said, it is important not to define success around a single metric such as drug deaths. There will be a number of metrics that this facility will be judged against, both at the individual level but also at the community level. If the evaluation does show, when we look at these overall, that there might be some metrics that did not play out as was intended, there might be some that did.
Once that has all been assessed, and if the conclusion is that it has been a success overall, it adds weight to the case for additional facilities, but only in areas where public injecting or public drug use is highly prevalent. There is no point in putting a drug consumption room in an area where you do not have a significant issue with that, because they are designed to deal with a very specific issue.
Q39 Chair: We are coming to the end of the session now, and we have talked a lot about evaluation. When you were speaking with my colleague Mr McAllister earlier, you were talking about the metrics that are going to be used for the evaluation and when we might see those results. If, for example, you were to recognise, at a relatively early stage, that there was a success in one very specific area, do you have the opportunity to make that known at an earlier stage to, hopefully, try to influence policy or practice, whenever that might be relevant? Would you be able to do that kind of thing?
Professor Katikireddi: Yes. There will be a period of collecting data over a fairly long time period—a good four years or so—but, as we go along, we are planning to feed back interim results to the health board, for example, but also other key stakeholders in and around the area.
We will also be reporting more formally on research findings, once we are confident in them and they have been peer-reviewed, and so forth. All of the findings will be made available publicly, in publications that anyone can access, but we will also be offering to give briefings or report verbally to key stakeholders as we have findings.
As long as we are confident enough in them, we will be reporting them as we go along, including things such as early learning about what types of things have worked well on the ground, what things staff have been finding successful in terms of engaging with clients, and some of these kinds of practical issues, as well as some of the changes to health outcomes, once we have those.
Q40 Chair: It was mentioned that the pilot is for three years, but the evaluation might take four years. I can understand why that might be—it is a lot of data to process and a lot of thinking to do around that—but, if it is clear that it is successful, is there an opportunity, all other things being considered, to continue the pilot, or to make it no longer a pilot, but rather a prolonged opportunity?
Professor Katikireddi: We anticipate publishing an interim report at around the two-and-a-half-year mark, or potentially a bit earlier, and the overall evaluation will last for four and a half years. Part of the reason for timing that interim report is to be able to provide evidence to help inform whether the service should continue.
From the point of view of being an independent evaluator, if the service seems successful, it is up to the health board and the Lord Advocate and so forth to make a decision, rather than us as independent evaluators, but it would seem to make sense that, if the evidence suggests success, that might be something appropriate to do.
Professor Matheson: This maybe slightly off, but just because I am aware that we are coming to the end of the session, there is a point that I would like to make for the Committee to consider, if it is appropriate.
The Lord Advocate has made this request for evaluation and made that a prerequisite. We welcome the opportunity to have a site and to have it evaluated, but it does not help other parts of the country where there is potentially a need for some form of facility, although not necessarily to the level and extent of funding that the facility in Glasgow has—and it is a gold standard-level service that the people of Glasgow have.
I would like to appeal to the Committee to also consider what other options are still available. We have very strong international evidence around the benefits of safe consumption facilities. Waiting for the Glasgow evaluation will be good to learn about some of the nuances of what does and does not work, but it delays potential developments in other parts of the country.
There are other levers available that could make those things happen, such as considering some reform to the Misuse of Drugs Act, which would enable other parts of the country, by which I mean the UK and not just Scotland, to be considering, and opening the door to being able to do, those types of services as well.
Q41 Chair: I am sure that that is one of the issues that will, no doubt, be considered by the Committee going forward.
Dr Shorter: Just as a very small point following Catriona’s point there, the Lord Advocate is a really essential stakeholder in the Glasgow site. Opening other sites around the UK really would be supported by perhaps a shift in the Misuse of Drugs Act regulations, particularly around the offence of possession, because, naturally, to use a substance, one must be in possession of it.
There are, of course, other aspects of the Act, and there is perhaps not time to discuss those now, but changes to the regulations at a Westminster level would make it easier to support Scotland going forward in opening further services, should there be a successful pilot around where there are areas of need in different aspects of Scotland.
Chair: Thank you very much, all of you, for your time today. We are very grateful to you for coming along. We do have other sessions planned with other professionals involved or with an interest in the service, but we wish you very well meanwhile with it. We are going to be visiting as a Committee very shortly, and we are looking forward to that enormously. Thank you again for your time. I declare this meeting closed.