We have discussed a range of changes in this report, from legislative shifts to nurturing a person-centred whole system of care. We have also explored the necessary culture changes and key drivers that will coordinate this change.
We are clear that if Scotland is to deliver the change we have outlined – the change that is needed – the sector must be appropriately resourced. More importantly, the resource must be targeted where it is needed most and where it will have the greatest impact.
4.8.1 Overall funding
The March 2022 Audit Scotland update (46) outlined how the funding position has changed over the last decade. It states that “Overall funding to alcohol and drug partnerships reduced over several years but by April 2021 it returned to around the level it was six years ago in cash terms, but with no real terms increase in funding.”
The reduction in funding in 2016/17 has had serious consequences, as many warned it would (54).
In 2016, 867 drug-related deaths were reported by NRS (55). In 2020, the number had risen to 1,339 – a 54% increase.
When the decision to reduce funding for alcohol and drug services was made, the 2014 drug-related death statistics had reported a 16% increase on the previous year and were 72% higher than in 2004. In the months after, the 2015 statistics reported a further 15% increase.
Audit Scotland (46) goes on to explain that “the recent additional funding announcements by the Scottish Government mean the real terms increases in funding from 2014/15 were a 16 per cent increase in 2020/21 (total funding was £98.2 million) and a 67 per cent increase in 2021/22 (total funding was £140.7 million)”.
We welcome this real-terms increase. If meaningful change is to be realised, however, significant additional funding will be required.
What needs to change
The significant treatment and recovery system changes we have outlined in this report will require adequate resourcing if they are to be fully implemented. Aspects of the whole system of care are expensive to deliver and do not currently have any funding attributed to them. Stabilisation, for example, has been estimated to cost between £9 million and £12 million per year.
Too often in the drug and alcohol sector, limited funding has resulted in competition, pitting services or approaches against each other in a battle for finance. This competition perpetuates the limitation of choice, hampers partnership working and most importantly negatively impacts on those who need support.
The total £140.7m funding for alcohol and drugs represented 0.8% of the health and sport budget in 2021/22 (56). The most recent prevalence rate for those with problem drug use is 1.62% of the population (57), although this figure focuses solely on problem opioid and benzodiazepine use and does not capture the prevalence of other drug types.
The £140.7 million funding is for alcohol and drugs. The prevalence of possible dependence on alcohol is significantly higher. It is clear, therefore, that demand for services far outstrips the supply of funding.
It is for this reason that we have concluded that the current level of funding is woefully inadequate for this level of public health emergency.
Dame Carol also stated in part two of her report that “currently each £1 spent on treatment will save £4 from reduced demands on health, prison, law enforcement and emergency services” (47). It is clear therefore, that increased funding in this space represents the ultimate spend to save.
As part of its response to this report, the Scottish Government should outline how it will fund the implementation of our recommendations and actions. It needs to set out a fully funded strategic plan that commits to fully resourcing the demand for services.
We believe more funding is required to deliver the pace and scale of change required. We recognise, however, that the current financial picture is challenging. A re-evaluation of resources under the National Mission may therefore also be necessary.
The First Minster has publicly recognised that her Government “took their eye of the ball”. The question now is whether the Government will provide targeted funding to enable services to deliver transformational change – not a return to the funding of the past, but an ambitious and radical commitment to making people’s lives better.
Action 133. The Scottish Government must publish a fully funded plan for the National Mission by the end of this year. This should deliver on all elements of the evidence-based strategic plan outlined in this report. It should commit to increasing funding to meet demand and appropriately resource each aspect of the whole system of care to ensure people can access the support they need when they need it.
Many services, in particular those run by third-sector partners, have highlighted the challenge of recruiting and retaining staff for short-term contracts. The outlined funding should therefore commit to sustained investment over the medium- to long-term and across financial years to ensure that partners can recruit the best candidates, retaining and developing them over time.
Funding should be fair and transparent. The right funding should be in place for the right organisations, be these statutory, third-sector or peer-led (like recovery communities).
Action 134. The Scottish Government and statutory services should commit to providing sustainable medium-/long-term funding across financial years to provide security for services and the workforce.
4.8.2 Protected budgets
We have stressed throughout this report, but particularly in Chapter 2, that people who use drugs experience stigma and discrimination on a daily basis. Much of this stigma is institutionalised.
People who use drugs are often seen as being less important than the non-drugusing population. They are dismissed as being hard to reach, when in fact it is services that are hard to reach.
We have argued that drug dependency should be treated as a health problem and its treatments should have parity with those for other health conditions. This is not as straightforward, however, as simply absorbing alcohol and drug treatment and support into the health system.
Given the existing stigma and discrimination, there is a need for positive action to create equity, not simply equality.
Funding for drug and alcohol treatment is protected and separately managed. It is important that these protected budgets remain. Even if developments such as the NCS absorb services, budgets must remain protected so alcohol and drug services can continue to target the effects of the ongoing drugs crisis.
Protected budgets for this vulnerable group are accepted within health and social care as the norm. In other areas that have significant interaction with people who use drugs, such as justice, housing and social security, protected budgets are less common.
What needs to change
We believe the only way to tackle drug dependency is to see individuals as people with multiple complex needs and address the underlying causes of their dependency. Tackling the underlying causes needs to be a priority across Government, with ring-fenced funding to improve services, support individuals and facilitate meaningful change.
The assumption should be that every portfolio under the National Mission will have ring-fenced funding. Not having this funding should be the exception, rather than the rule.
Action 135. The Scottish Government should commit to providing ring-fenced budgets for alcohol and drug services, even if services are absorbed into the NCS, so there is no reduction in their budgets.
Action 136. Portfolios across the Scottish Government should agree ring-fenced funding to support people who use drugs to improve their lives through better access to services and holistic support.
4.8.3 Joint commissioning
As part of the shift towards a whole-Government response to the drug-deaths crisis, areas should look for ways to combine budgets and work together to address intersectional challenges. This would maximise opportunities for quality improvement.
What needs to change
Scottish Government policy areas should proactively explore opportunities for joint working, in particular making links to address multiple complex needs and severe and multiple disadvantage.
Action 137. As part of the National Mission, Scottish Government portfolios should commit to a programme of joint commissioning and joint working. Projects should work towards supporting holistic care pathways and system integration, with a focus on multiple complex needs.
Partners at local level should look to integrate services and provide joint provision wherever possible to improve individuals’ experience of services and reduce costs.
Statutory services should work towards joint commissioning to support integrated care pathways and improved accessibility. ADPs should act as a central coordination point for joint commissioning between partners, ensuring that agreements further the outcomes in their strategic plan and outcomes framework.
Action 138. Local partners, coordinated by ADPs, should commit to joint commissioning and joint working to deliver key improvements and support local outcomes frameworks.
4.8.4 National commissioning
We outlined in Chapter 3 that the funding of residential services such as stabilisation, detoxification and residential rehabilitation remains challenging. Local areas have told us of a gap in the provision of residential care, particularly stabilisation.
The Scottish Government has committed £100 million for residential rehabilitation over the course of the Parliament. This commitment has in some cases been extended to cover detoxification services but does not include stabilisation.
These services are expensive to deliver. It often is not possible for local areas to operate their own residential services.
What needs to change
Dame Carol Black recommended “a regional or sub-regional approach to commissioning these services to ensure national coverage” (6). Organisations that deliver residential services told us that the services should be nationally commissioned with regional delivery.
Dame Carol in her review recommended “review by the end of 2021 to 2022 the commissioning and funding mechanisms for high-cost but low-volume services such as inpatient detoxification and residential rehabilitation.” We support this recommendation in Scotland, but wish to incorporate a focus on crisis and stabilisation. This should be included as part of the recommendation for a fully funded plan.
Action 139. The Scottish Government should nationally commission residential services, ensuring adequate funding is available to meet the demand for crisis and stabilisation, detoxification and residential rehabilitation. Placements should be free at the point of need and should be available without lengthy delays.
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