Renfrewshire Council

In setting out its findings and recommendations, the Commission must firstly recognise the evidence heard from Renfrewshire Health and Social Care Partnership in relation to the independent review of alcohol and drugs services. It was clear that the review had generated a number of appropriate recommendations to improve the services that were provided by the HSCP, in order to ensure that they were recovery focused and person centred going forward. 

Whilst evidence was presented that the recommendations of this review were being progressed, this was at an early stage in some areas and some changes were not yet visible in many cases to service users and families.

The Commission therefore acknowledges the work planned by the HSCP to date, however urges the HSCP to progress this work at pace and in partnership with local stakeholders including service users and families. It is important the service review is also cognisant of the wider findings of this Commission as well as national developments such as the emerging recommendations of the national Drug Deaths TaskForce.

Levels of harm are concerning in Renfrewshire

It is important to note that whilst the Commission was asked by the Community Planning Partnership to consider the impact of drug and alcohol use in  Renfrewshire, data was much more readily available on drug rather than alcohol related harm at both a local and national level. This could often skew discussion towards drug related issues, which was recognised on several occasions by Commission members. The value of the engagement sessions undertaken by the Commission became very important here, as it allowed Commission members to hear about these issues with a human rather than statistical lens.

It was clear from the evidence heard, that there are high levels of drug and alcohol related harm impacting individuals and communities in Renfrewshire. In terms of some of the data the Commission considered, Renfrewshire's levels of harm were not out of kilter with other local authorities within NHS Greater Glasgow and Clyde or with Scotland, but they remained unacceptably high as detailed in subsequent sections of this report.

People often have very complex needs that they need help with

It was recognised by Commission members that there was a high level of complexity in terms of the support that individuals and families needed, and a real jigsaw of services that had to be assembled to provide different levels of support at different times to people. This was a key focus of some of the discussions that Commission members had with staff across partner organisations and with service users and their families.

The Commission heard that there was often a perception that services are not always flexible and at times can be difficult to access. Both people using services and their families and frontline staff, told the Commission that a whole systems approach to supporting people who use drugs and alcohol and also their families, would be hugely beneficial.

Wrapping support around people as partners and communities in a radical and person-centred way, was viewed as one of the most important things that could be done to improve outcomes for people using drugs and alcohol, their families and communities overall.

Support for mental health issues is perceived as being difficult to access or not there at all

There was a fundamental disconnect between what service users, families and frontline staff told the Commission about access and availability of mental health services in Renfrewshire, compared to the views of senior managers in the HSCP. Service users and families told us how stressful it was to wait to see a psychologist or mental health service, and that the trauma or depression they were experiencing was a particular barrier to them making the next steps in their recovery.

Family members spoke of very dark times and situations, where they had to call in first responders such as the police, as they felt there was a risk to life. A common theme was that often service users or families just wanted to speak to someone and to talk about some of the trauma that they were dealing with in their lives. Many would have benefited from just one person (like a key worker, navigator or mentor) to help them navigate their way through and advocate on their behalf.

Commission members were particularly concerned about the impact of poor mental health on young people. Whilst high quality services like the RADAR service existed for young people with issues relating to alcohol and drug use, it was clear that mental health services for young people must be made available to support people with all different levels of needs. There was evidence of counselling and peer support in schools, but it was clear that a whole systems approach is required to ensure that young people do not fall between the cracks and experience poorer life outcomes as a result of mental health issues.

Hidden harm is all around us 

The engagement that the Commission undertook also indicated that there was a significant amount of harm that was being experienced which didn't necessarily mean that a person or family would contact a support organisation or service - whether informal or statutory. Identifying hidden harm and understanding the changing nature of harms are essential to connect people to the right support at the earliest stage.

In practice this means partners need to think about strengthening community-based supports which can reach or help people in different ways to formal services.

Alcohol and drugs surround people whether they want it to or not

The impact of alcohol and drug use on young people was a particular focus of the Commission's work and engagement programme. Young people made a short film about their experiences, and about how easy it was to get access to alcohol and drugs and the negative impact it had on themselves, their families, friends and communities.

For young people experiencing more complex needs, it was disturbing to hear that most young people felt that nothing could have prevented their drug or alcohol use, and that they were always destined to be this way. The value and strength of their relationships with support workers however shone through and there was real hope for the future expressed by young people and their support worker.

Over and above the impact on young people, it was clear that the availability and presence of drugs and alcohol was an issue for people across all age groups.

There is strength in local communities to support recovery

All of the people the Commission engaged with discussed ways to reduce the harms of alcohol and drugs, including supporting community based recovery and tackling some of the stigma and relationship issues which alcohol and drug can lead to. This is an area of significant opportunity at a Renfrewshire level given the ambition of local recovery organisations, the strength of existing partnership working and the capacity for change within local communities.

The key findings of the Commission are explored further in the following sections. These have been grouped under a number of themes which help us to explain the Commission's findings in the easiest way.

Findings - Risk of Harm

Through its work, the Commission has explored the risk of harm and impact of alcohol and drugs on individuals, families and communities. Through a public health lens, Commission members firstly considered why levels of drug and alcohol use were so concerning in Renfrewshire, and in Scotland more widely.

As noted within the introductory sections of this report, the area of Renfrewshire was badly impacted by the decline of traditional industries. Post-industrial decline is often cited as one of the reasons for the West of Scotland's (including Renfrewshire's) poor health profile.

In terms of the relationship between the population and alcohol, it is clear that levels of alcohol consumption have increased over many decades as the population adapted to significant levels of social disruption and change. It is well documented that in the 50s and 60s, alcohol consumption was generally very low and confined largely to men drinking within pubs. Illicit drug use was considered uncommon.

From the 1970s onwards, de-industrialisation in Renfrewshire and across the West of Scotland changed the alcohol culture and heralded the onset of a new and evolving drugs culture. De-industrialisation deprived many communities of jobs, a sense of purpose and social solidarity. The gap between those on higher and lower incomes widened.

Alcohol became cheaper, more widely available and was consumed in much larger quantities by a much wider range of age, gender and social groups. Similarly, drugs became increasingly available and affordable. Looking back at the way in which the country's relationship with alcohol and drugs has changed over time, and considering the reasons for this, is an important first step in terms of identifying what needs to change in the future.

Profile of harm

During the early stages of the Commission's work, a detailed profile of drug and alcohol related harm was developed. The Commission initially identified that there was a gap in some of the data specifically relating to alcohol harms. Some of the data considered by the Commission members is highlighted in section 4 of this report.

The profile highlighted a significant level of complexity in Renfrewshire with large numbers of individuals accessing multiple public services including addictions services, mental health services; criminal justice, children's services; and housing services etc. This was also reflected in the caseloads of frontline staff.

Approximately 2,100 people are in contact with local alcohol and drug services in Renfrewshire. Waiting times are broadly in line with Local Delivery Place Standards which require that at least 90% of people should wait no more than 3 weeks to access drug and alcohol services and exceeds the Scottish Government target. Whilst this is in many ways positive, Commission members felt that waiting times in many ways could be seen as an arbitrary way to view access to services and that there was an opportunity to implement some of the emerging findings of the national Drug Deaths Taskforce around rapid access to treatment through for example "same day prescribing" of opiate replacement therapies.

Drugs

Based on data presented to the Commission, there is growing evidence of a shift in the demographic profile of people who use drugs, with an increasing number of people aged over 40 years. This suggest that people who have been using drugs for many years are living longer and are more likely to have complex health issues as a result.

It is well documented that the number of drug-related deaths in Scotland increased by 27% between 2017 and 2018. Similarly, in Renfrewshire, the level of drug-related deaths reached 50 in 2018 which is the highest number recorded in the past decade and an increase of 17% since 2017. This was also the 7th highest number of drug deaths across Scotland's local authorities. The Commission found this deeply concerning.

Based on the data available, it was found that most drug related deaths were attributed to individuals consuming more than one drug (poly-drug use,) with Etizolam (also known as street Valium) contributing to 68% of deaths. Etizolam is highly addictive, inexpensive, dangerous and illicit class C drug which is relatively easy to purchase. Etizolam was described as "the story of Renfrewshire's drug-related deaths". Each one of these deaths was noted with sadness, recognising that every person who had died was a son or daughter and family member or friend. A significant number of people who had died were also
parents.

The Commission heard about the work that Police Scotland were doing to disrupt the production and supply of Etizolam in Renfrewshire. Managers from the HSCP also updated the Commission on work being done locally to inform people using services and their families, about the dangers of Etizolam. There was some indication that some of the people who had suffered a drug-related death where Etizolam was a factor, were known to services and had been considered reasonably stable in their treatment or use of drugs prior to their death.

An important consideration for the Commission was the reach of services, in order to ascertain whether access to services was appropriate, and importantly whether people were receiving the support they needed. The Commission reviewed data in relation to the scale or prevalence of drug use in Renfrewshire and found that that the number of people in contact with local drug services didn't correlate as expected. The Commission heard that in the views of some experts, treatment and care services would typically be in contact with in the region of 60% of people experiencing problem drug use, and in Renfrewshire this was below 50%.

In trying to understand this, the Commission discussed levels of caseload and whether services in Renfrewshire were supporting people with much higher levels of need than in other local authority areas. Both complexity and caseloads were felt to be high and Commission members were strongly of the view that local drug services needed to both change the model of service delivery, and boost capacity to increase the reach and number of people that could be supported in Renfrewshire.

The Commission noted some of the work being undertaken by We Are With You (formerly Addaction), whereby a Scotland wide survey using social media channels found that significant numbers of people were assessed as being at high risk of harm from alcohol or drug use, but were unlikely to be or were not in contact with formal services. Several hundred people were identified in Renfrewshire through this survey, indicating that there is potentially a significant population that don't currently access local drug or alcohol services. It is important to gain a better understanding of this 'hidden' population in order to support them better going forward.

The Commission agreed that an assertive outreach model should be developed in Renfrewshire to reach those most at risk of serious harm, including people who may not be known to or engaging with services currently, in relation to their drug or alcohol use. This would ensure services engage with people at the earliest stage possible and reduce serious risk of harm to individuals.

Blood borne viruses

People using certain types of drugs can be at high risk of harm from blood borne viruses such as HIV and Hepatitis C. The Scottish Government has been, and remains, committed to eliminating Hepatitis C within Scotland's population. Alcohol and drug services play a critical role in supporting this objective and are required to ensure that 90% of service users have received at least one test for Hepatitis C, and to ensure 80% are tested on annual basis. In terms of HIV, it is recommended that alcohol and drug services ensure that those with highest levels of risk are supported to receive tests every 3 months.

Testing levels in Renfrewshire have continued to improve, however these remain below the targets set. Low testing levels are of particular concern in light of increasing levels of HIV among those who inject drugs. In the Glasgow City area, there have been significant outbreaks of HIV over the course of the last couple of years, with a small number of cases also identified this year in Renfrewshire. It is critical that local services continue to support testing, particularly for those with higher levels of risk.

Naloxone

Naloxone is a medicine which can temporarily reverse the effects of an overdose caused by opiates and opioids such as heroin, methadone or morphine. The Commission recognises that naloxone saves lives and is an effective antidote for opiate overdose and directly heard local examples of its critical impact. Within Renfrewshire and across NHS GGC, there are two types of supply route for naloxone. Individuals at risk of opioid overdose, friends and family members of individuals at risk of opioid overdose and individuals likely to witness opioid overdose, can all receive a brief intervention on overdose prevention and how to identify and respond to an opioid overdose. Individuals are then provided with a physical naloxone kit or a kit can be prescribed on a prescription. The acute addiction liaison team offer and provide naloxone, with provision additionally via RAH.

There are a number of opportunities to further promote the roll out of naloxone within Renfrewshire, with potential to train staff and volunteers across the Community Planning Partnership and community anchor organisations. Family members supported this approach and went further to suggest that naloxone should be more widely accessible. These include:

• Encourage more non-drug treatment centres such as housing support, supported accommodations, homelessness organisations, mental health organisations and criminal justice organisations who provide services to individuals at risk of opioid overdose to consider participation
• Development of Peer Supply Model
• Promotion of naloxone provision in Shared Care practices and GP practices
• Development of provision via family services.

In light of the current pandemic, prescribing supply rights have been extended to non-drug treatment services staff (for example, residential housing services) to allow them to not only hold a stock of naloxone to use in an emergency, but also to make supplies to their service users. Relevant services in Renfrewshire can use this exemption to extend supplies of naloxone to at risk individuals and those likely to witness an opiate overdose.

Alcohol

The Commission found that the data available in relation to alcohol was significantly less comprehensive than that available for drugs. This was disappointing and suggested that fundamental improvements need to be made to enhance the level of information available on alcohol related harm at a Renfrewshire level. Without this information, it will be impossible for partners to assess the scale of the issue over time, and what needs to be done to address this collectively.

The Commission also recognises the impact of the implementation of Minimum Unit Pricing (MUP) for alcohol which has been enshrined in legislation in Scotland in recent years. A minimum price for alcohol sets the lowest price an alcoholic drink can be sold for. In Scotland, the minimum price per unit of alcohol was set at 50p per unit of alcohol, from 1 May 2018. Prior to this:

• Alcohol was 60% more affordable than 30 years ago
• 52% sold at less than 50p per unit.

Public Health Scotland is undertaking an evaluation to look at the impact of MUP and its report will be published in 2023. Studies on the short-term impact of MUP have indicated high levels of compliance, reduced consumption rates and limited impact on the alcohol industry.

In terms of local data, in a health and wellbeing survey undertaken by Renfrewshire HSCP for the period 2017/18, 48% of participants said they never drank alcohol. One in ten (10%) drank alcohol at least twice per week. People living in Renfrewshire were less likely to drink alcohol than those across NHS GGC (52% Renfrewshire; 65% NHSGGC).

Those who drank alcohol were asked how often they had drunk above the levels set for men and woman (6 or more units if female, or 8 or more if male) on a single occasion in the last year. In total, 47% of drinkers had drunk alcohol at this level in the last year - 1% had done so daily/almost daily, 12% weekly, 12% monthly, and 22% less than monthly.

Since 1981/82, there was a steep and sustained increase in general acute alcohol-related hospital admissions until 2007/08 reaching a rate of 855 admissions per 100,000 population; this has now fallen to 669 per 100,000 population. There were 1,136 alcohol-specific deaths in Scotland in 2018 (where alcohol was the underlying cause of death) - an increase of 16 (1.4%) more than in the previous year. In Renfrewshire, alcohol specific deaths were the 7th highest in Scotland and alcohol related hospital stays were 6th highest at 1130 stays for 996 patients.

The Commission found that data and intelligence was more readily available for drugs than for alcohol. It considered that improvements could be made to ensure that alcohol information and intelligence was made available to Community Planning partners to help inform future policy making and to assess the impact of decision-making, including through the production of an annual profile. It is recognised that Alcohol and Drug Partnerships are likely to be required to undertake local reviews of alcohol related deaths in the future. Given concerns in relation to data in this area, it is strongly recommended that local partners in Renfrewshire implement this now.

Harm to families

The impact that parental alcohol and drug use has on children is well documented. In terms of alcohol specifically, it must be recognised that the impact of alcohol consumption is not limited to the health of the drinker. Alcohol can have a serious impact on family life with 26% of current (October 2020) child protection cases in Renfrewshire related to alcohol. Even in less extreme cases, children report feeling unsafe, worried or left out by adults drinking.

The impact on families is not limited to children and young people being impacted by parental alcohol or drug use. The Commission also heard evidence of the negative impact that alcohol and drug use has on spouses, parents, siblings and other family members. Family members reported having to care for and support adult relatives and were very frank about the significant impact that this had on them and the wider family. There were also examples of elderly parents having to support grown up children. Many of those in recovery who the Commission spoke to were also keen to highlight the impact of their previous alcohol / drug use on their families and that they felt that family members did not always have access to support needed.

Harm within communities

The Commission heard some, but not particularly extensive, evidence on the impact that drug and alcohol use can have on communities in terms of issues such as community safety, crime and overall quality of life. The Commission heard how alcohol and drug use can significantly undermine perceptions of community safety with approximately 75% of cases handled by Renfrewshire Council's Community Protection Team linked to alcohol or drugs in some way.

Data published by Police Scotland also evidences the link between the use of alcohol and crime, and in particular violent crime. Around half of all violent crime victims in Scotland believe the offender was under the influence of alcohol. Nearly two fifths of those serving custodial sentences in Scotland report being drunk at the time of their offence. 

Drug related crime can also impact on communities and in Renfrewshire as at January 2020, there had been an increase of 27.2% in supply crimes although there had been a decrease of 9.2% in drug crimes. This was in the context of a 24.8% increase in overall detections. Whilst it is helpful to review impact in terms of community safety and crime, it is also important to consider the link between alcohol and drug use and levels of vulnerability. People who use alcohol and drugs can also be subject to significant levels of harm from other people, in terms of violence and intimidation or in extreme cases trafficking and prostitution.

In considering the risk of harm to communities, the Commission explored the tension which is often thought to exist between balancing the economic value of the night- time economy to a local town or community, to the wider harm that alcohol use can cause within communities. This is discussed in greater depth later in this report, with specific consideration given to the role of licensing.

Availability

The Commission heard examples of how young and vulnerable people have been coerced into selling drugs in order to pay off their drug debt and agree that serious and organised criminals who are dealing in drugs are dangerous and ruthless and care nothing about the misery they inflict on individuals, families and communities.

"The availability of alcohol and drugs was explored by the Commission. Some of the evidence provided indicated that it has never been as easy or as cheap to access drugs in Renfrewshire and indeed across Scotland. Illicit benzodiazepine like etizolam or street Valium, have never been cheaper or more available."

Dr Carole Hunter, Lead Pharmacist, Alcohol and Drug Services, NHS Greater Glasgow and Clyde

The Commission heard from the Director of Public Health from NHS Greater Glasgow and Clyde and from Alcohol Focus Scotland that environmental factors such as how cheap alcohol is, how readily available it is, and how heavily and attractively it is marketed, all serve to encourage and normalise alcohol consumption.

Evidence presented by Alcohol Focus Scotland and NHS Greater Glasgow and Clyde expressed that the impact of alcohol is disproportionately felt by people living in more deprived communities. Although more people in higher income groups consume alcohol, research indicates that those in lower income groups tend to consume a greater amount.

Also, people in deprived communities are also more likely to experience other health and social issues which place them at increased risk, with people living in deprived areas being six times more likely to die from an alcohol-related disease or illness. As of November 2019, there were 439 licenced premises in Renfrewshire while 510 occasional licences were granted in 2018-19. Data presented indicated that Renfrewshire has 62 off-sales premises in the most deprived parts of Renfrewshire, compared to 11 in the least.

It is important to note that there may be many reasons for this variation, including ability or tendency to drive to supermarkets from less deprived areas, or indeed a variety of other factors which deprivation alone does not explain. Possible actions in relation to alcohol availability are outlined later in this report.

The role of trauma

Throughout our discussions with individuals and families with lived experience, frontline staff and experts in the field, trauma has been identified as being intrinsically linked with the use of alcohol and drugs. Commission members heard about the trauma faced by individuals, families and communities and from workers trying their best to support people facing complex trauma while feeling not fully equipped to do so.

The 2019 Hard Edges Scotland report commissioned by Lankelly Chase and The Robertson Trust and authored by Heriot-Watt University, highlights the significance of trauma as a route into alcohol and/or drug use. This can be due to trauma in early life or in childhood, or due to significant events that have impacted people during their life.

It was clear that the Hard Edges report findings mirrored local experience. In the conversations that Commission members had with local groups, service users and families, it was clear that there were significant issues of trauma that had been experienced by people using drugs and alcohol and their families. We heard that people often didn't feel that they were getting help to deal with their traumatic experiences. As mentioned elsewhere, this related to both young people and adults that had experienced trauma at different stages in their life.

Hard Edges Scotland

Hard Edges Scotland was commissioned by Lankelly Chase and the Robertson Trust and authored by Heriot-Watt University. The research highlights the complexity of the lives of people facing multiple disadvantage. In particular, the report illustrates the mismatch between the multiple disadvantages people face and the fact that services are often set up to address 'single issues'.

"My son has a diagnosis of bipolar condition and began self-medicating to the point of dependency in response to his illness before he was identified as needing psychiatric treatment. At present, he doesn't receive appropriate support for his needs from either the recognised drug services or the health services because his problems cross two disciplines. This means he can't be treated medically while he has drug problems and he can't be supported properly by drug services as his mental health issues pose difficulties. He falls through every crack there is...except when criminal justice is involved"

Family Member

Access to multiple services The Commission spent some time considering the findings of the Hard Edges report, and members were grateful to discuss this further with one of the report writers, Professor Glen Bramley. The Hard Edges report discusses the disadvantages that many people face, and the difficulties they have in accessing support in a joined up way to help them manage these complex needs. The report suggests that statutory services such as housing and criminal justice are often those which have to help people pick up the pieces in terms of crisis. This view was reinforced by some of the frontline staff and families that Commission members spoke to. A key example of this in the Hard Edges report is in relation to housing, with homeless services described as 'carrying the can' for supporting those individuals with multiple complex needs. The Hard Edges report suggests that the wraparound support provided by the Housing First model can work well for people with complex and multiple needs and highlighted the importance of peer support.

The Commission recognises that a safe and secure home is the best base for people to build their lives and enjoy good health and wellbeing. We believe that for those who are homeless, the provision of settled mainstream accommodation as early as possible, with appropriate support, is a key element in helping individuals and families affected by alcohol and drug use to rebuild their lives.

Renfrewshire was the first local authority in Scotland to fund a Housing First Service, in partnership with Turning Point Scotland. This type of housing support model is a critical part of Renfrewshire's Rapid Re-housing Transition Plan.

The Commission also acknowledges the success of the following initiatives and is keen to ensure that these continue to be supported and built upon:

• Housing First Renfrewshire
• The Resettlement Team within Homeless Services
• The Shared Tenancy Initiative which is a partnership with the Simon Community which supports single people to share the tenancy of a property
• Make it Your Own, where homeless people are supported to make recondition furnishings to help turn their new house into a home.

Access to drug and alcohol services

During the engagement undertaken by the Commission with service users, families and frontline staff, it was clear that most people who engaged in the process were not yet aware of the changes to the model of service delivery that the HSCP had agreed to implement following the independent review of drug and alcohol services. This was understandable in some respects, as it had only recently finished, however it does mean that the views expressed by service users are current and need to be addressed in the Commission's findings:

The Commission heard:

Concerns about the location and environment of building based alcohol and drug services at Back Sneddon Street and to a lesser extent Dykebar. Individuals highlighted the following barriers:

• public transport availability and cost
• paisley centric service provision
• personal safety in and around the building at Back Sneddon Street
• stigma associated with accessing drug and alcohol services at both Back Sneddon and Dykebar Hospital
• encountering individuals who service users would otherwise avoid for fear of relapse.

That people had experienced issues with waiting times for services, including for mental health support and services which were impacting their ability to cope.  The Commission heard that people needed to know how to access other forms of support whilst they were waiting on these services. Evidence provided to the Commission also highlighted the fact that perhaps people may not need mental health services if other forms of support were available and accessible.

That service users and families felt more services could be commissioned to support them and the issues they were facing as a result of a family member's drug or alcohol use. Community based services were felt to be good but could be developed and funded differently so that people didn't always have to use statutory services.

That it would be beneficial to see more workers and volunteers with lived experience who can provide peer support. It was widely recognised that people with lived experience play an important role in promoting recovery, reducing stigma and improving services, using personal experience to support others. It was felt that this will allow individuals to see that recovery is an empowering, accessible and achievable treatment goal.

That service users and families felt that there are some gaps in service provision in Renfrewshire. On a number of occasions, Commission members heard that provision would improve if it included access to residential rehabilitation services.

Families told the Commission that sometimes they struggled to know where to turn to help their friend or family member and that a 24/7 crisis service would be invaluable. In addition, the need for greater flexibility for individuals and families to be able to access services on a drop-in basis rather than having to try to attend appointments on time was highlighted. In particular, family members highlighted the need for the right support to be provided at the right time, particularly given the vulnerability of their loved ones. Perceived long waiting times and multiple appointments during times of crisis were highlighted as a concern. It was clear that building based services needed significant investment and that the concerns raised through engagement sessions needed to be addressed urgently.

The potential positive impact of moving from building based services to community-based services was highlighted by service users, family members and staff and the Commission also recognises that there is a key role for peer support or navigators in providing invaluable support for individuals and to help manage pressure on formal services. Some evidence of the use and development of peer support models was beginning to be emerge in Renfrewshire.

The Commission also heard evidence about access to services and support for people leaving prison. This highlighted that it was important that people had access to prescriptions for Opiate Replacement Therapy on a timely basis on returning to the community and for local relationships with prison services to remain robust. While this was not felt to be an issue locally by services, it was highlighted nationally. A number of individuals also described to Commission members how they returned to the community with nothing more than the clothes they had worn when they were incarcerated. Hospital liaison and hospital discharge were also highlighted as high-risk transitions for people, and that support needed to be better at these points.

Workforce support

The importance of giving Renfrewshire's workforce the support they need to provide effective services is recognised by the Commission. The frontline staff who engaged with the Commission told of the importance of the relationships with other services and organisations. Staff were very committed across all of the different partner organisations, and were keen to develop greater networks and to work more closely together.

Greater training on trauma informed approaches and improved signposting of local services and supports needs to be in place as a priority to support these local workers going forward. The local response to trauma informed practice and service delivery was an area in which the Commission felt that partners could be much bolder and ambitious.

Findings - Mental Health

The Commission recognises the impact that poor mental health has on individuals and it was clear from the evidence heard that accessing appropriate mental health support and services is a significant barrier to people experiencing issues with alcohol and drug use. The interconnection between mental health and addiction was discussed at almost every conversation and engagement session undertaken by the Commission and by service users, family members, GPs and frontline staff. Professional staff supporting service users and families, felt they didn't always have the right information or contacts to access support for mental health issues. There was a clear disconnect between what individuals, families and frontline staff told the Commission about access to mental health services and the information which services reported on usage, which indicated that a high percentage of local people are engaged with community mental health teams, and that a wide range of support services were felt to be currently available. Some of the barriers identified by individuals, families and frontline staff regarding mental health services included:

• not meeting the high clinical thresholds to access existing services
• lack of clear pathways
• multiple and repeat referrals from one service to another with no support from a lead professional
• lack of crisis and 24/7 support.

People using services talked about long waiting times to see specialists and often feeling that they just needed to speak to someone about anxiety, loneliness or the trauma that they had experienced and required support to deal with. On occasion individuals expressed how they were unable to cope which resulted in them self-medicating and using substances including street valium.

Families provided examples of the severe impact that they felt this was having on them and their family member(s). They shared personal experiences of crisis situations and how they feel alone and isolated and on occasion had to turn to emergency responders such as Police at these times. Police Scotland reflected this concern and highlighted a rise in officer time being spent responding to individuals in crisis.

As indicated previously, national research highlights that many people attending alcohol and drug services are thought to have a history of trauma, as well as being particularly vulnerable to experiencing further trauma. This was reflected in the discussions with frontline staff who directly attributed trauma to alcohol and drug use. Conversely, individuals described traumatic experiences, however, they didn't recognise it as trauma as they saw it as part of their normal life. This was evident throughout the Commission's engagement activity and many people cited that they used alcohol and drugs as a means of coping with, and managing, these experiences. The Commission recognises that addressing this complex and deep-rooted trauma - both by supporting those who are suffering from its effects currently and by addressing the underlying causes to protect future generations - will bring the longer term improvements needed.

The Commission heard very concerning evidence in terms of the impact of mental health on young people and their use of drugs and alcohol. This is covered within the next section of this report.

Findings - Prevention and early intervention at all stages of life

In taking forward its work, the Commission recognised that the Community Planning Partnership was keen to explore opportunities for working together more collaboratively to support greater early intervention and prevention around alcohol and drug use.

Whilst the Community Planning Partnership was keen to explore opportunities in terms of children and young people it also heard in its evidence of the impact that alcohol and drugs can have at all stages in a person's life. For example, in response to traumatic events such as a bereavement, relationship breakdown or health issues. The Commission reflected that it is equally important to consider opportunities for early intervention or prevention at all stages of life.

Impact of alcohol and drug use within the family

The Commission recognises that alcohol and drugs within the family environment, can have a significant impact on children and young people. The evidence heard during the programme of engagement as well as from frontline staff, highlighted that the seeds of later alcohol or drug use are often sown in childhood in the form of trauma, abuse and neglect.

Parental drug use is one of the reasons behind many children being accommodated by the local authority in foster care or placed with extended family members in kinship care. The issue of parental drug use is a factor in almost half of the situations where children are accommodated locally. The impact of alcohol on children can also begin even before a baby is born. Foetal Alcohol Spectrum Disorders (FASD) results from alcohol exposure in the womb and is preventable yet is the most common neuro-developmental condition in Scotland.

Research undertaken by Glasgow Royal Infirmary found that in one-in-seven of all babies born there were at high risk of FASD, which suggests a much higher prevalence than previously thought. FASD affects neurodevelopment, attainment, physical and mental health and without adequate support, it reduces life expectancy to around 34 years of age.

Whilst the Commission did not review local data on FASD, it was agreed that services in Renfrewshire should consider what is done currently to highlight the "No Alcohol, No Risk" message to potential parents and to identify and support those who are affected by FASD. Commission members felt that it was vital that all women are supported not to drink during pregnancy and consideration must be given as to how best to do this.

Given the important link between early childhood experiences and positive life outcomes, the Commission would like to highlight the importance of children, young people and families having access to the right support at the right time. The Commission welcomes the findings of the Independent Care Review and endorses the findings of the national group on holistic family support and The Independent Care Review's Intensive Family Support Principles:

• Community Based
• Responsive and Timely
• Work with Family Assets
• Empowerment and Agency
• Flexible
• Holistic and Relational
• Therapeutic
• Non-Stigmatising
• Patient and Persistent
• Underpinned by Children's Rights.

Through its programme of engagement, the Commission saw examples of services which strongly reflected these principles - most notably, Renfrewshire Council's Home Link Service where there was a positive, rights-based approach to supporting families and young people to maintain their education. It was clear that the Home Link team is highly valued and trusted by young people, families and communities. The team has very low staff turnover and workers have built up trust and are well established in schools and in the community.

The importance of consistency, long-term relationships, persistency and assertive outreach undertaken by the team was highlighted.

The Commission believes that the principles of this service should be considered as a blueprint for others across Renfrewshire in terms of providing person-centred support. 

Children and Young People

A key focus of the Commission's early work in this area was also around children and young people and views on alcohol and drugs. This was important to the Commission in being able to determine what could be done differently to reduce levels of harm in the future from alcohol and drugs. 

"It's all around you, all the time."

Unknown contributor

The Commission considered the impact on children of alcohol consumption both in the home and in the wider community. This included work by the Scottish Children's Parliament which had conducted an investigation into an alcohol free childhood, and what this means in Scotland. The findings from the report 'It's all around you, all the time' which was published in September 2019, were presented to the Commission.

The children who participated in this national investigation spoke about how visible and available alcohol is and the negative impact that this has on their lives. They described encountering alcohol when they open the fridge in the morning to get their breakfast, in adverts on their way to school and on sale in shops when they go to get snacks, as well seeing adults drinking at home and in public spaces. They spoke of feeling 'unsafe' and 'ignored' when people around them are
drinking.

Through input from Alcohol Focus and the Director of Public Health at NHS GGC, the Commission considered some changes that partners could make to alter the culture and the acceptability of alcohol consumption in Renfrewshire. It was agreed that community planning partners could provide leadership in terms of restricting alcohol advertising, ensuring that school fetes and fayres never involve alcohol tombolas or raffles, and also consider the provision of alcohol on premises and during events. This linked to wider discussions about the important role of licensing boards at a local level to implement relevant legislation to improve public health. 

Anyone operating premises or organising events that include the sale or supply of alcohol must have a licence. Renfrewshire Licensing Board considers liquor licence applications for the Renfrewshire area. The board has a quasi-judicial status, which is distinct from the main governance arrangements for Renfrewshire Council. The main piece of legislation that controls the sale of alcohol is the Licencing (Scotland) Act 2005 which underpins the licencing regime in Scotland, based on five licensing objectives:

• preventing crime and disorder
• securing public safety
• preventing public nuisance
• protecting and improving public health
• protecting children and young persons from harm.

With the support of Public Health professionals, there is potential to strengthen national licensing policy, as well as to provide greater information to members of the Licensing Board to better inform decision making. This particularly relates to Public Health information which the board may not presently have access to. It is recognised that licensing boards are required to operate within the parameters of existing legislation and that lobbying of Scottish Government is required to strengthen legislation even further.

Local engagement with young people aged between 12 and 17 years illustrated the significant impact that alcohol and drugs have on them and their peers. Alcohol and drugs were both felt to be readily available, and it was suggested that social media was making access to drugs much easier. Although many of the young people we spoke to in S3 and above, didn't use cannabis, they did feel its use was normalised among their peer group.

Some older young people (16+) reported that their parents allowed or helped them to access alcohol. The Commission considered that advice should be made available to parents on the risks of providing alcohol to their children and how to manage this. Young people also spoke about requesting adults to purchase alcohol on their behalf (this is known as a 'jump in' or a proxy purchase). The nature of 'jump ins' varied and while some young people approached strangers to purchase alcohol for them, others knew people that would be waiting in close proximity to a local shop and would buy alcohol for them for a charge. On some occasions young people reported having their money or alcohol stolen.

The Commission considered that the Police and Council, could strengthen joint work with local retailers and communities to tackle proxy purchase. The Commission also recognises that while young people themselves did not identify proxy purchase as a risk, it is a criminal offence and also a child protection issue and should be highlighted as such. Third sector workers echoed concerns about the availability of drugs and alcohol, suggesting they had become normalised and speaking of a 'vicious cycle' of use by parents and young people in some cases.

Despite some of these very significant concerns, local data from surveys of local children demonstrates that progress has however been made in the last ten years in terms of initiation of alcohol and drugs amongst young people in Renfrewshire.

The ChildrenCount wellbeing survey undertaken by Dartington Service Design Lab on behalf of Renfrewshire Council, Children's Services found that between 2011 and 2017, early initiation of substance use amongst Renfrewshire secondary pupils decreased by nearly half. This is positive and the results of the next survey will be of great interest in terms of tracking the scale of these issues in Renfrewshire.

Whilst alcohol use seemed to be lower amongst children and young people than in the past, the Commission expressed serious concern that 53 children under the age of 18 had required emergency treatment for alcohol intoxication in 2018-19.

Support to make the right choices

The Commission recognises the importance of prevention and early intervention in supporting young people to make positive choices around alcohol and drugs. Commission members highlighted the need for positive role models and messaging around the issues young people face. Young people and staff working in schools told us that the inputs received during Personal And Social Education (PSE) on alcohol and drugs needed to improve, particularly in S3 and above. Young people told us that they would like to hear from people with lived experience and would also like to learn about how to keep themselves and their friends safe and well. Staff working with young people in schools recognised that more specialist support to meet the ever-changing needs of young people would be beneficial. It is recognised from research that preventative approaches that focus on supporting children and young people to develop the self-confidence and skills to make positive choices and to keep themselves safe have a greater impact than those which try to scare young people. The Commission heard about the local work that was being led by young people to develop support and educational materials and looks forward to seeing this launched across learning establishments in Renfrewshire.

In addition, some young people, family members and staff indicated that the presence of community-based police officers in schools (dedicated campus cops) was a missed opportunity to engage and build relationships. Whilst these are not currently funded and provided in Renfrewshire, partners should make a clear commitment to multi-agency partnership working, explore examples of good practice in neighbouring local authorities and give consideration as to whether campus cops could be put into place in Renfrewshire.

Preventing higher levels of need

Renfrewshire Adolescent Drug and Alcohol Resource (RADAR) works with young people age 12-20 whose alcohol and/or drug use is having an impact on their wellbeing. RADAR is an outreach service which works flexibly to ensure that young people get the support they need when they most need it. The service works with young people and their families to make positive changes to their lives and to reduce the harm that they experience from their drug or alcohol use.

Young people involved with RADAR highlighted the positive impact of the service on reducing their alcohol and/or drug use and on their wellbeing more generally. It was clear that young people and staff had excellent relationships and trusted each other, which seemed to be genuinely valued by the young people we spoke to. The team at RADAR had a "stickiness" to the young people and were there to help them with all aspects of their life in a truly person-centred way.

The Commission was saddened to hear the fatalistic views of some young people about their past alcohol and drug use. It was clear from some of the conversations with young people, that they felt their life was always meant to turn out this way due to the impact of alcohol and drugs on their own family life.

"My life would never have been any different, this is the way it was always going to be."

Renfrewshire teenager accessing RADAR service

Concerns were raised by young people and staff about the transition to adult services as they were worried that they wouldn't receive the same holistic and individually tailored support. Young people were also concerned about the stigma associated with accessing Renfrewshire Drugs Service and that they didn't want to need to use a drug or alcohol service at all.

In a number of different sessions including one at the RADAR service, young people told us that S2 was often a key turning point in terms of their alcohol and drug use, with this being the point that they felt that it had begun to negatively impact on their lives or become a more serious issue.

Although stated previously, it is important to emphasise that young people also identified mental health service provision as a priority and although school counselling and Child and Adolescent Mental Health Services are available, they felt that there still remained a gap in terms of low to moderate tiered support. This was also reflected during the engagement sessions with frontline staff.

The young people also spoke to Commission members about their ambitions and aspirations. They recognised that they faced a number of challenges, but their aspirations were the same as those that would be expected of any young person, and included:

• a stable life
• a house
• a stable relationship
• a job
• wanting to be good parents to their children.

The Commission heard some examples at an individual level, where young people were being supported to access innovative training and employment opportunities.

How do we know who needs help and when?

The Commission recognises that a significant number of people affected by alcohol and/or drugs will not be in contact with public services which makes early intervention and prevention challenging. Members discussed the research undertaken by the organisation We are With You in in other local authority areas, which had highlighted that significant numbers of people were using drugs and alcohol on a very regular basis but had never been in contact with an alcohol or drugs services. It also found that often people were trying hard to maintain jobs and relationships against the backdrop of this heavy drug or alcohol use.

Commission members representing support organisations, also talked about some of the evidence that was available about the changing nature of alcohol and drug use that they were seeing from contacts to their organisations, including an increase in the use of drugs like cocaine. There is limited local data on these issues, and the Commission felt that it would be beneficial to undertake further work to gain a clearer picture in terms of trends in Renfrewshire.

The potential of the third sector to offer lower level community support which is accessible to all who require it, was highlighted to the Commission on several occasions. At present, very few groups/organisations in Renfrewshire are directly commissioned to provide support of this kind. Lessons from other parts of Scotland are that the third sector and mutual aid groups can provide significant support to people on their recovery journey, however, those in public services need to be aware of and to have confidence in these options in order to actively promote them to those in recovery.

"It was really encouraging when the Commission made the effort to meet with frontline staff and young people. Marginalised young people are not used to being listened to, and it was great to see how happy they were to share their views on services and also identify what could be better. Engagement events are not always easy to run, but I felt that the Commission members and the young people worked really hard to make it a meaningful process. We look forward to the outcome of the work and will continue to look for opportunities for young people to remain involved in the shaping of services that they receive."

Senior Social Worker, RADAR

The Commission also heard how the issue of stigma can act as a significant barrier to people accessing the help they need and sustaining their recovery. It is important that services work collaboratively with individuals and families with lived experience - as well as with frontline workers - to reduce stigma and to ensure that people feel able to access the support they need when they need it. Action is required to increase understanding of, and support for, recovery in Renfrewshire.

The Commission heard about the work of the Sunshine Recovery Cafe in Renfrewshire and the development of the new Recovery Hub, as well as the role of the Scottish Recovery Consortium in supporting and connecting such communities across Scotland. The Commission proposes that a "Year of Connection" is co-produced with those in recovery, to engage people across recovery. Renfrewshire in developing a culture of Criminal justice services The Commission identified the importance of diverting people from the justice system wherever possible. Criminal and community justice services in Renfrewshire remain under significant pressure given factors such as the presumption against sentences of 12 months or less, and there are opportunities to support the awareness and development of community alternatives to custody.

The importance of the close link between addiction, criminal justice and mental health services was also recognised, with potential to further strengthen partnership working.

The Commission heard evidence that the focus nationally is on reducing custodial sentences and the use of remand for those who do not present a risk of serious harm. This involves providing interventions at as low a level as possible - such as diversion which can provide a short term focus on the issues which impact on offending. Additional funding has been provided to local justice services in 2020 to extend diversionary services and implement structured deferred sentences and bail supervision. Progressing these services during a pandemic - where the primary focus remains on existing face to face provision for those who present the highest risk - is recognised as challenging.

The role of wider community justice partners including addiction and mental health services is therefore key where the issues impact on an individual's behaviour. As reflected in the Lankelly Chase report, criminal justice has become a safety net for those suffering severe and multiple disadvantage where other services have not met needs. Sheriffs know that individuals subject to court orders will receive a statutory service, and thus be compelled to engage with services (with sanctions available for non-engagement).

Sadly, sanctions are often a short sentence which disrupts the lives of individuals and their families, and does not address the needs of vulnerable individuals. It is essential that analysis of need is undertaken for those involved with justice services and that co-ordinated services and pathways are established through the Community Justice Partnership, within Community Planning Arrangements. This would then allow consultation with Sheriffs and the Crown Office and Procurator Fiscal Service as to greater focus on earlier intervention within Renfrewshire. The role of the CORRA Just Recovery post could also assist in taking this forward.

Findings - Recovery

According to the national strategy 'Rights, Respect and Recovery' recovery is a journey for people away from the harm and the problems which they experience, towards a healthier and more fulfilling life. 

Recovery means different things to different people, and the Commission recognises that recovery is unique to every individual and that people have the right to health and life, they are respected and achieve their recovery.

In order to achieve this, a person-centred approach is required which respects that people's recovery must be focused on their aspirations. This reflects what some individuals, families and frontline staff told the Commission during the various engagement events held locally.

It was felt this approach to recovery could be improved upon in Renfrewshire and that for some this had not been the case for them, with people reporting that they had been told that they would be on medically assisted treatment 'for life'. Staff supporting individuals however viewed this at times differently in terms of being there for as long as people need them.

There was a plea for better access to psychosocial interventions which would help people reconnect into society and that these should be accessible throughout the recovery journey. Evidence provided to the Commission from frontline staff, highlighted that staff in the alcohol and drugs services provide these interventions, but that due to the size of caseloads and the number of service users overall, it can make this approach difficult to deliver intensively. Staff and service capacity issues are also highlighted in the Hard Edges Scotland study, with time/capacity constraints often making it difficult for frontline workers across the country to take a strengths-based approach to providing support rather than just responding when individuals are in crisis.

The capacity and willingness is there

The Commission recognises that the recovery community has much to offer in Renfrewshire, including the opportunity to harness the capabilities and capacity of local people who wish to support recovery communities and the importance of valuing lived experience as part of this approach. A key message highlighted to the Commission during the engagement sessions was the importance of peer support.

This came across strongly in each and every session involving individuals and family members with lived experience. The impact of support from others who have had similar experiences cannot be underestimated. The reciprocal nature of this was also highlighted with individuals and families welcoming the support received while also welcoming the opportunity to provide support to others who need it.

"I am grateful for the family support group because it's where I go to let off steam, have a good cry or share my progress with people who have 'lived experience' of trying to cope with a son or daughter or other close relative with addiction issues. We can empathise with each other and learn from each other's experiences. We can also lean on each other, know that we're not being judged and we can feel 'normal' for a while. It's a safe space which gives us a little bit of healing... even if only for a short time."

Family Member

Feedback from the Commission's engagement activity and other evidence heard highlighted that local services could better recognise the strength of the recovery community in Renfrewshire and its impact on individuals. It is clear that services and supports such as the Sunshine Recovery Café are highly valued by individuals who used them and their family members who wanted to see this type of supported extended and expanded across Renfrewshire.

Individuals, families and frontline staff welcomed the proposed development of the new Recovery Hub which will provide recovery opportunities and a full programme of activities, support and events. It is clear that there is motivation and enthusiasm to make this work, however services require to work collaboratively with the recovery community and those with lived experience in all aspects of the design, delivery and ongoing development of the Recovery Hub.

Given that the initial development of the hub is well underway and staff recruitment and selection has been undertaken, the Commission would like to see the continued and full involvement of the recovery community and people with lived experience in this journey. The Commission welcomed the recent involvement of members of the Sunshine Recovery Café in the Recovery Hub steering group and during the recruitment process of key posts within local alcohol and drug services. The recovery hub was felt to be a great opportunity for stronger collaboration, by all of the groups the Commission spoke to.

"The Sunshine Recovery Café is once a week from 12.30pm to 3.30pm on Wednesdays. It's like a phone charger - when I go out, I feel powerful but by Sunday I don't, I feel drained."

Participant at the Recovery Conversation Event in January 2020

Relationships and Social Connections

Research indicates that Portugal has demonstrated a significant reduction in problem alcohol and drug us as a result of programs that are specifically designed to re-create connections between an individual and their community. The Commission recognises that some people use alcohol and/or drugs due to a lack of relationships and social connections that add value to their lives. The same can be said for those who struggle in their recovery journey. This results in individuals feeling abandoned, hopeless, that no one cares, that they can't connect with anyone emotionally and they fear that things and feelings won't change. The Commission was saddened by the loneliness and isolation expressed by some of the people we spoke to but also very much heartened by the hopes for the future that people had. 

In partnership with the Sunshine Recovery Café and Scottish Recovery Consortium, the Commission undertook a relatively large-scale engagement event to hear feedback from people in recovery. Those who participated told the Commission that they were struggling to find things to do which would allow them to meet with other people, or to undertake purposeful activities which would make them feel valued and support their ongoing recovery.

The Commission also heard how individuals and families benefited from local groups and how the number of groups had slowly grown over time. Many of these groups were organised and managed by the third and community sectors and provide peer to peer and/or family support. However, it was highlighted that many of these groups and organisations were self-funded and regularly faced issues of sustainability.

The Commission heard consistently from individuals, families and frontline staff that support for recovery could be strengthened within communities if:

• people had better information on who to turn to in different situations and what services/supports/activities are available
• more support was available at a community-based level, it would help people to access support closer to home and not just in Paisley
• something be done to tackle the barriers associated with the cost of transport which could hinder people from accessing .support.

"Lived experience can act as a bridge between services."

Jardine Simpson, Chief Executive Officer, Scottish Recovery Consortium

Family members shared their fears, stresses and anxieties when trying to support a loved one in recovery or who is unable to stop using alcohol and/or drugs. The role that they play is vital but can be very difficult as they sometimes feel like they are alone and trying to be doctor, psychiatrist and police officer all at once. Building on the GIRFEC approach already embedded within children's services in Renfrewshire, a whole systems approach should be taken when supporting individuals and families who use alcohol or drugs - with prevention and early intervention being key.

Stigma

According to the World Health Organisation, stigma is a major cause of discrimination and exclusion and it contributes to the abuse of human rights. Individuals, families and frontline staff shared their experiences of stigma in Renfrewshire, including within the community setting, accessing building based services and within the workforce.

The Commission recognises that individuals with lived experience have the expertise, empathy and connections that make them experts in how best to tackle stigma and that they should be involved in the design, development and delivery of services and support.

The Commission welcomed the recommendation by Dundee Drugs Commission on the use of the 'Language Matters' resource developed by the Network of Alcohol and other Drug Agencies in Australia. The Commission recognises the importance of using language which is non-stigmatising, person-centred and focuses on the individual - not their substance use. The purpose of the resource is to provide guidelines on how to use language to empower individuals and reinforce a person-centred approach. Renfrewshire Alcohol and Drugs Commission endorses the approach set out in the resource (see appendix D) and would welcome its use across the HSCP.

Since the Commission was established, a stigma strategy has been published by the Scottish Drug Deaths Taskforce. The Commission welcomes the publication of this strategy and recognises that it should be used to inform local approaches to eradicating stigma.