Official Report: Minutes of Evidence

Public Accounts Committee, meeting on Thursday, 21 October 2021

Members present for all or part of the proceedings:

Mr William Humphrey (Chairperson)
Mr Roy Beggs (Deputy Chairperson)
Mr Cathal Boylan
Miss Órlaithí Flynn
Ms Cara Hunter
Mr William Irwin
Mr Maolíosa McHugh
Mr Andrew Muir


Mr Stuart Stevenson, Department of Finance
Mr Gary Maxwell, Department of Health
Professor Sir Michael McBride, Department of Health
Mr Richard Pengelly, Department of Health
Mr Brendan Whittle, Health and Social Care Board

Inquiry into Addiction Services in Northern Ireland: Department of Health; Health and Social Care Board

The Chairperson (Mr Humphrey): I welcome Richard Pengelly, the accounting officer and permanent secretary at the Department of Health; Professor Sir Michael McBride, the Chief Medical Officer (CMO); Mr Brendan Whittle, the director of social care and children at the Health and Social Care Board (HSCB); and Mr Gary Maxwell, the head of health policy branch at the Department of Health. Gentlemen, good afternoon. I also ask that Mr Stuart Stevenson, Treasury Officer of Accounts (TOA), be brought into the meeting.

Sir Michael, I have not seen you since you received your knighthood in the recent honours list, so I take the opportunity to congratulate you; it is very well deserved, and I hope that you are long spared to enjoy it.

I ask members who are joining us remotely to mute their devices because there is quite a bit of feedback from papers rustling and whatever that is interfering with the recording. Mr Pengelly, I invite you and your colleagues to make an opening statement, and, at the conclusion of your opening remarks, I will open the meeting for members to ask questions.

Mr Richard Pengelly (Department of Health): Thanks very much, Chair. You have already introduced the team. Before I get into my opening remarks, I say a sincere thanks to you, Chair, and members. The session was originally scheduled for November 2020. At the time, we were grateful for the Committee's recognition of the wider pressures that my departmental colleagues and I were facing. It was incredibly helpful of the Committee to agree to defer the hearing. I emphasise that that in no way dilutes the importance of the issue. In our eyes, owing to other circumstances at the time, we may not have been able to do justice to this hugely important topic. I want to record our thanks for that.

The Northern Ireland Audit Office (NIAO) report highlights key issues and challenges that have developed in respect of substance use over the past years, including, in particular, the growing use of polydrugs; the misuse of prescription-only medicines; the increasing complexity of cases; the demand on substance misuse services; and the need for us to get better at capturing data and outcomes from treatment services. The report also highlights the effectiveness of harm reduction services such as needle exchange and the take-home naloxone programme and the work that has been put in to address waiting lists for key services, including, in particular, the substitute prescribing programme in Belfast.

The report rightly puts the spotlight on the harm caused by substance use. Alcohol-related harm alone is estimated to cost Northern Ireland up to £900 million per annum. Adding in the costs that relate to drug misuse brings that to well over £1 billion per annum. While those figures are important and clearly deprive other important public services of funding, the real issue is that they do not fully reflect the full cost of that harm to families, individuals and communities across Northern Ireland. That is why, for us, reducing the harm caused by substance use is a key priority. Those who suffer harm from substance use are already a marginalised and vulnerable group. That is likely only to be exacerbated by the current challenging environment and the impact of the pandemic. As a Department, we very much welcome the publication of the report and the range of issues and recommendations in it.

At the stage when colleagues in the Audit Office began work on the report, the Department was well advanced in updating its substance use strategy. A formal review of that previous strategy, the 'New Strategic Direction for Alcohol and Drugs Phase 2', was published in January 2019. That was followed by a preconsultation exercise and then, in 2020, a formal public consultation on a new strategy. After revision following the outcome of the public consultation, the new substance use strategy, Preventing Harm, Empowering Recovery, was launched by the Health Minister on 7 September 2021. It is important to highlight the fact that, while it is a departmental strategy that the Minister launched in September, prior to its launch, it was agreed by the Executive. That is an important point that we will return to in the context of the cross-sectoral work that is needed.

The new strategy is underscored by five population-level outcomes, but, importantly, its vision is that:

"People in Northern Ireland are supported in the prevention and reduction of harm and stigma related to the use of alcohol and other drugs, have access to high quality treatment and support services, and will be empowered to maintain recovery."

That co-produced strategy took full account of the review of our previous strategy, and, importantly, the timing of the Audit Office work allowed the recommendations that flowed from it to be factored in. It also folded in the consultation responses and direct input from service users and stakeholders from within and without government and from colleagues across the wider health and social care sector and criminal justice sector. Again, I emphasise that many of the actions in the new strategy can be directly related to the work of the Audit Office and the recommendations that flowed from it.

The key issue in the Audit Office report was the resources that were available. Therefore, as part of the strategy development phase, the investment required to deliver the new strategy has been a sharp consideration for us. Our initial projections are that we will need in excess of £6 million per annum from 2022-23 onwards in order to progress all the actions and fully achieve the outcomes in the strategy. At the risk of repetition, Chair, I emphasise that the strategy is there, with the vision, the outcome and the actions. As yet, we do not have the funding to ensure that we can deliver all the actions. That is an issue for us in the Budget process. The additional funding, if secured, will help to address the recommendations in the Audit Office report and, indeed, offset the wider costs of alcohol and drug use to Northern Ireland.

Those funding requirements were highlighted to the Executive when the strategy was submitted for approval over the summer. We have begun the process of engagement as part of the Budget process. We need to recognise that ongoing work on the pandemic and, in particular, the recovery may impact on some of the actions proposed. Without the pandemic, we would, of course, be further on in the process of implementation. As the situation eases and we move forward, services continue to return to a more normal footing. Staff have been able to take on board key learning from the pandemic. The changing operational landscape has highlighted the need to build and improve capacity in services and actively to consider adopting new ways of working.

Finally, Chair, I highlight the fact that, while the report, which, as I said, we found incredibly helpful, focuses on addiction treatment services, the new strategy is much broader than that. It recognises the need to prevent substance use-related harm and to intervene at an early stage to stop issues progressing to the stage at which individuals need treatment. It recognises that treatment is not the end of someone's recovery journey and that we need to ensure that support is in place to help people in the longer term.

Importantly, the strategy recognises that, while this is a Health-led issue, it cannot be solved by the health sector alone. Substance use and related harm are interlinked with wider health and social care outcomes, including, in particular, health inequalities and, more widely, the economic, social and environmental circumstances in which people are born, grow, live, work and age. There are overlaps and interactions between substance use and many other issues, including, to name but a few, poverty; deprivation and homelessness; mental health well-being; community relations, community safety and justice; employment; economic development; trauma; and the impact of our past. To truly address the issue, we need to work collectively to tackle those wider determinants. The strategy seeks to do that and to add value to the initiatives that are already in place.

That is all that I wanted to say by way of introduction. I hope that it is helpful. We are happy to move into questions.

The Chairperson (Mr Humphrey): Before I open the meeting to questions, do any of your colleagues wish to add to anything that has been said? No. OK.

Mr Pengelly, I welcome your remarks towards the end of your contribution, when you said that the new strategy will focus on early intervention and prevention. Prevention and early intervention are obviously more cost-effective and more effective in dealing with the problem that we face, which will have been exacerbated by COVID-19 and all that has flowed from it.

Are you sufficiently content that government is joined up across regional government at Stormont, local government and the bodies within your Department, such as the Public Health Agency (PHA) and so on? Are you content that that "joined-up-ness" is there? In the past — I am not being critical of anyone — clearly, it has not.

Mr Pengelly: I am absolutely content that there is a level of connectivity in both the health and social care sector and the wider public sector and society. I am equally certain that we are not yet as good at that as we could be. I am optimistic that we are getting better at it, and key points can be drawn out from the new strategy to emphasise that. It is of huge importance that the strategy was taken to and agreed by the Executive as a whole. It is hugely important that the strategy contains the vision and the five outcomes that focus on issues from prevention through to ongoing support and empowerment. Under each outcome, there is an action plan. If you look at the action plan, you will see that the action owners are not in any way limited to colleagues in Health and Social Care (HSC). They include the PSNI, the justice community and colleagues in local government, as you articulated. My clear point is that we are on a journey across the totality of public-sector services when it comes to connectivity, breaking down silos and working together. We are conscious of the need to improve. We are improving, but there is a way to go, and we will keep a sharp focus on that.

Professor Sir Michael McBride (Department of Health): I echo Richard's comments, Chair. One of the feedback points from the review of the last strategy, which was published in January, related to the recognition by stakeholders that the collaboration and joined-up working that was achieved through the last strategy and the profile that had been afforded as a consequence of that across government. Some of the consultation responses pointed to the very issue that you flag, which is the need for better integration of strategic and operational matters. We have covered that through our approach to the new strategy.

I absolutely agree with your wider point. We have close cooperation at a UK level through the alcohol and drug subgroup of the British-Irish Council (BIC) and with our colleagues in the Republic of Ireland through the North/South alcohol policy advisory group. Certainly, I work closely with the UK Chief Medical Officers on all matters related to alcohol and drugs, and we share learning across the jurisdictions to ensure that we take that coordinated and joined-up approach. You can see that manifest in the growing UK approach to issues such as the minimum unit pricing of alcohol, for instance, and the work that we have been doing on that with colleagues in the Republic of Ireland.

The Chairperson (Mr Humphrey): Thank you for those answers. Mr Pengelly, you said that we are getting better at joined-up working, but we are not as good as we could be. What are the barriers? As a Committee, we have looked at and discussed that with former heads of the Civil Service and with permanent secretaries from other Departments. What are the barriers that lead to the potential silo approach that impede or have impeded that joined-up approach and that, if removed, would allow a more efficient and effective strategy that deals with the issue? I am proud to represent this city, but all we have to do is walk around Belfast on a Saturday morning to see so many people who are negatively affected by addiction. It is absolutely tragic. It is clearly endemic in our society. What are and have been the barriers, and what specifically can we, as politicians and members of the Committee, do to help?

Mr Pengelly: I suspect that there is maybe a day's worth of debate in the answer to that, Chair. I will compress my answer as best as I can. When we talk about "cross-departmental" and "cross-silo" working, we need to be absolutely clear on differentiating between people issues and system issues. In my experience, the issues are not people-based. As I journey through the health and social care sector, I try to speak to colleagues on the ground as often as I can. For example, when I speak to social workers, they say that they would never think twice about lifting a phone to a teacher or a colleague in the probation service or youth justice system. They do not see organisational barriers; they see clients and service users whom they are trying to help. That is true of operational colleagues across all public services. They see the issue in front of them.

When we come to a system level, the truth is that, sometimes, the problems are caused by people in my position. We fixate on an accountability structure that says that I am accountable for what the Department does and the amount of money that we get in the Department. We need to think at an Executive and governmental level about an accountability environment in which a bit more prominence is given to the contribution that we make to wider societal problems and, in particular, the cross-cutting outcomes enshrined in the Programme for Government, rather than to a set of narrow performance indicators. We need to be prepared, sometimes, to take the trade-off where departmental or sectoral performance can dip. I am comfortable about coming to you and the Committee to account for that. The dip is in the context of us, in the offset or trade-off, making a bigger contribution to a higher-level and more strategic cross-cutting objective. That is the direction of travel that, I sense, the Executive are on with the cross-cutting Programme for Government. It is incumbent on me and my colleagues, as accounting officers, to follow that lead and put in place the clear signal to colleagues at all levels in our system that that is our direction of travel and that it is in society's better interests to get there as quickly as we can.

The Chairperson (Mr Humphrey): We would all echo your last point. I like the vision and the focus of the new strategy on early intervention and prevention. What is your response to the critics who say that the fact that the strategy has taken five years to update since 2016 suggests that tackling substance abuse has not been a priority for the Department?

Mr Pengelly: First, I put it on record that it is a priority for the Department. I do not say it as an alibi or any form of excuse, Chair, but we wrestle with a lot of things that are hugely important and are significant priorities. I do not want that to come across as an alibi. From my perspective, it was of huge importance that the new strategy contained a couple of clear foundations, the first of which was a substantive and meaningful review of the previous strategy. There was real, meaningful and inclusive stakeholder engagement and then a mature period of co-production with all the players. Those are essential building blocks to get us to what, I believe, is a powerful strategy. Those things necessarily took time. It is not unreasonable, Chair, for you to say that maybe we could have done them a bit more quickly; with the benefit of hindsight, maybe we could have. I would not die in a ditch defending that, but, for me, it was important to get it right. Michael was part of it.

Professor Sir Michael McBride: Very much so. I was intermittently involved in the oversight of the implementation of the strategy. It was a deliberate policy decision by the then Health Minister to make the time frame for the strategy five years — it was originally four years, but that was not long enough — to realise the progress that we wished to see. We then extended that, as the Chair knows.

We had a significant number of preconsultation events, with the attendance of over 250 people. We had 78 formal responses. I was present at a number of the preconsultation events. As Richard said, the review involved service users, affected families and the bereaved in communities, and it looked at all the evidence that was accumulating on alcohol and drugs across the UK and internationally.

I reassure the Chair and the Committee that we were not not doing things in the meantime. The implementation and roll-out and the achievement of objectives of the previous strategy continued. If we look at the review published in January, we see that two of the objectives — 1% — were not achieved, and we had set those aside as being no longer relevant. Some 98 — 70% — of them were on track for implementation, and 24 — 17% — had been fully achieved. We have made significant progress on the implementation of the recommendations in New Strategic Direction for Alcohol and Drugs Phase 2. I am confident that, through the process that Richard has outlined, we have secured cross-government buy-in, outside government buy-in, academic buy-in and, most importantly, as the Chair mentioned, buy-in from communities, service users and those directly affected.

We face many challenges. As the Audit Office report rightly points out, the complexity and challenges have become greater. We need to recognise that and not be complacent. The new strategy puts us in a good place from which to go forward.

The Chairperson (Mr Humphrey): This is my final question for the moment before I bring other members in. I do not disagree with your final assertion that the challenges are greater, and I think that we all accept that that is clearly the case. Richard talked about all the players. I am pleased that there was such a large response from people being consulted on the new strategy and about their input to that strategy. I will be devil's advocate for the moment, however. My constituency is hugely affected by a lot of these issues. Everyone's constituency is, but North Belfast and the greater Shankill area are particularly negatively affected by all this. At events that I have been at and from the work that I have pursued on the issue over the last number of years, I have heard the argument that there are too many players, particularly at community level. I am not saying that that is my view; I am simply playing devil's advocate. What is your response to that?

Mr Pengelly: I understand the frustration of some individuals thinking that. At times, we are in a co-production environment, particularly in the space that we are currently in and the wider range of services that we provide. Aside from the simple fact that there are service providers in the room, it draws in relevant staff, service users and the families of service users. At times, that can crowd out the core elements of the conversation, which are about how we identify and give effect to the necessary changes. With too many budget holders in the room, the conversation sometimes becomes more of a turf war about budgets than a laser light focusing on the needs of service users and on how we deploy the totality of the budget. I think that Brendan and Gary in particular have been a part of those lower-level conversations. Gary?

Mr Gary Maxwell (Department of Health): That is a fair point. Given the diversity of the determinants of substance use, there are a lot of players in the field. It overlaps with homelessness, mental health, community safety and criminal justice. One of the criticisms could be that, because that is such a messy playing field, it can be hard to focus and be specific. A key thing that we ask with the new strategy is that the board and the PHA work with key stakeholders across those groups to develop a new strategic outcomes plan for substance use services. That should not just be for Health and Social Care services; it should look at what we provide through community planning and through the PSNI and other providers, pulling that together to look at delivering one connected commissioning plan. That could be through education and information from the Education Authority (EA) and the education sector, right through to inpatient beds where people can go for treatment for a specific time. That is not easy. It will be difficult to do that, but having that one seamless vision should help to provide focus and reduce some of the messiness that can exist when there are lots of players and overlapping issues. Hopefully, that will be key in pulling that together and having one focus.

In the strategy, we have also been clear about things that do not work in some areas. Some places have rolled out things that are not particularly evidence-based. The key thing with the PHA and the board leading that work but not owning it is that they can bring that evidence base to community planning, local players and stakeholders to show them that the evidence shows what elements will make most difference. It is also about getting feedback from communities about what works well for them and what works in those areas. That will hopefully build on things like community planning, which brings in those community voices. I do not know whether you want to add anything to that, Brendan.

Mr Brendan Whittle (Health and Social Care Board): Thank you, Gary. The only thing that I would add to what you said is that the aim of the work that we will take forward on behalf of the board and the PHA is that the strategic plan will create the care pathway across all providers so that there is a smoother journey for service users.

The aim is to align our commissioning and procurement across HSC and more widely. Their better alignment will make for a smoother place and make it less bumpy for people to navigate.

The Chairperson (Mr Humphrey): OK. Thank you very much.

Ms Hunter: Good afternoon, everyone, and thank you very much for your important briefing. I

[Inaudible owing to poor sound quality]

on the cross-sectoral work that is needed on addiction. I agree that a joined-up approach is necessary to help with the aspects of recovery that you touched on from housing to mental health and more. You touched on the level of engagement ahead of the strategy — the number of consultations and working with service users — and that is most welcome.

The review of addiction services in 2013 stated clearly that a regional approach to rehabilitation was necessary. Eight years later, two trusts do not have proper access to rehabilitation beds. Why have those issues not been addressed, and what is being done to address them? As a representative of quite a rural community, I know that there is also a fierce regional imbalance when it comes to accessing those facilities. Any clarity on that would be most welcome.

Mr Pengelly: That question is about the commissioning of the services. Will you answer that, Brendan?

Mr Whittle: Yes. Thank you.

Professor Sir Michael McBride: I will start, Brendan. Thank you for your question, Cara. You are right that a review in 2013 looked specifically at inpatient services. I think that the recommendation in the Northern Ireland Audit Office report deals with tier 4a services.

There are now 33 beds across the system, and all trusts have access to those beds. That was previously not the case, and I think that that is what you may have been referring to. They are now provided in the South Eastern, Western and Northern Trust areas, but all trusts have access to those beds as part of the four tiers of service.

A huge amount of work has been done to ensure that all of those inpatient services operate to the standards and best practice in the National Institute for Health and Care Excellence (NICE) guidelines and the Orange Book etc. What we do not have is effective integration with residential addiction services. That work has been committed to in the new strategy and will be taken forward by board colleagues.

As you will know, we provide residential addiction services in Northlands in Derry/Londonderry and Carlisle House. However, the report rightly highlighted that residential services were not agreed and there is a need for a seamless integration between the residential and inpatient services and right the way through from low-threshold services to tier 2, 3 and 4 services. There should be no bumpiness in that, which goes back to the point that Gary and Brendan made. Those care pathways need to be absolutely clear, and service users, families and communities need to know what we are referring to when we talk about those services.

Part of the work that will be undertaken in the new mental health strategy and in the action plan that will fall out of that will be that regional structures will oversee mental health services, not to remove the responsibility from trusts but to ensure that there is consistency in approach and to address some of the issues of access and the transfer of individuals between facilities. Those pathways need work, and there is a commitment in the strategy that that work will be taken forward.

Brendan, I do not know whether you want to come in.

Mr Whittle: Thank you, Michael. Apologies for the slight delay in coming in.

As Michael said, the Audit Office report pointed out that the tier 4a services, the statutory services that provide initial detox and stabilisation, were reviewed in 2013. Those three sites, which are managed by the three trusts, are now provided on a regional basis, so any citizen across Northern Ireland who needs to access one of them can do so. The three operate as a network. Likewise, the services at tier 4b, which relate more to rehabilitation than to the detoxification and stabilisation arrangements, were not part of the review. Those will need to be looked at as we go forward in the plan that was referred to in the last question.

I acknowledge that all substance use services in tier 4a and tier 4b should be available on a regional basis, where possible. That will be an essential part of the work that we bring forward to develop a strategic plan for those services. We will seek funds to further support and reinforce those services and to improve the coordination of and accessibility to them.

Ms Hunter: That is lovely. Thank you.

I have one more question, and it touches on the delivery of the new strategy. I know that there has been a lot of discussion about dual diagnosis, and that featured in the strategy. I am mindful that Órlaithí also has a keen interest in that. I am curious to know how services will adapt to the needs of those with co-existing mental health and addiction issues.

Mr Pengelly: At a high level, the programme board, which Sir Michael will chair, for his sins, will work on the delivery. That will be taken forward very much in parallel with the delivery of the mental health strategy. Forgive me for making the bleating point about the budget, but the mental health strategy requires in the order of £1·2 billion to be delivered over the next 10 years. That is a big challenge for us and, indeed, the Executive. The action holders will look at the specifics of that. Michael, do you want to say something on that?

Professor Sir Michael McBride: Yes, and I will bring Gary in on this as well. One of the issues that were fed back to us during the preconsultation events and raised repeatedly at the time of the implementation of the previous strategy was dual diagnosis. As you know, alcohol and drug addiction often go hand in hand with mental health problems. Sometimes, people use drugs and alcohol to self-medicate in order to deal with underlying mental health problems. We also know that the use of drugs and alcohol often exacerbates underlying mental health problems. The antecedents and origins of that lie in adverse childhood experiences and all of the environmental, cultural, family and community problems that Richard referred to in his opening comments.

During the preconsultation work, there was a lot of discussion about having a separate dual diagnosis service. We looked at all the evidence and consulted widely, and we came to the view that that would create additional barriers to access when what we need is to ensure that those working in mental health services and addiction services have the skills and expertise to address individuals' needs, irrespective of where they present. There should be no closed doors and no passing around of individuals from pillar to post and from one service to another.

The commitment in the strategy is to establish and manage a clinical network, particularly for those with dual diagnosis. The board is committed, in the short term, to doing a review of services available for those with dual diagnosis. The strategy gives a commitment to raise experience and awareness and to build expertise into the managed network. What we absolutely need to see — this goes back to the Chair's comments at the outset — is joined-up working between the oversight and implementation of the new mental health strategy and the oversight and implementation of the new substance use strategy, because those issues are cross-cutting. Similarly, they have strong links with Protect Life 2 and all our work on suicide prevention. Unfortunately, many of the origins of those problems lie in our troubled past, the high levels of deprivation and socio-economic issues. Those are the fundamental, cross-government issues that Richard referred to, which we can address only if we work at that strategic level through the Programme for Government.

Mr Maxwell: Michael has covered that really well and very succinctly. I will just add that the other developments are around the one mental health system. We are working closely together to ensure that addiction services or substance abuse services are linked into that as appropriate. It might be that, in due course, when implementation structures are more up and running, we fold some of this together more closely to create less structure. We are not quite there at this point, but it is important to make sure that addiction services are strongly referenced in that one mental health service, particularly in the crisis review service work. It is important that people in crisis do not get turned away because they turn up when intoxicated with alcohol or other drugs. It is vital that we make sure that it is linked in. As Richard said, it is not a personnel issue in those services when dealing with co-occurring issues. It can sometimes be a system issue, but we are trying to solve that by bringing the two systems much closer on a regional basis. Hopefully, that will pay dividends in due course. However, because the demand is high and the cases complex, it will take time to work through.

Mr Whittle: Reference to the regional mental health service will directly benefit patients by removing variation in services. Everyone, wherever they live across Northern Ireland, will have access to similar services when they need them. It will also help us in improving the movement of patients across trust boundaries so that there is no falling off when a patient moves from one area to another. That single mental health service, overlaid on the addiction service, is an optimistic picture of how we can coordinate the services better for our citizens across Northern Ireland.

Ms Hunter: That is positive. Thank you very much.

Ms Flynn: Thanks very much to the panel for appearing before the Committee to talk about an extremely important report.

Five years ago, you were working on the new strategic direction for drugs and alcohol. Gary, I think that it is about five years since I first met you to talk about this. It is brilliant to see how much progress has been made. I commend all of you for the work that you have put into this. Obviously, the Minister has prioritised this as well, given that the strategy has got to this stage, been consulted on and is now published, despite all the pressures around COVID.

I can see that, since the Audit Office report was completed and published, the Department has put a lot of work into the issue. Richard, you mentioned that the elephant in the room — the problem over the next couple of years in progressing the report — will definitely be funding, and that is one of my concerns. How, if we do not have the funds, can we realistically tackle addiction issues?

You will be aware of the health inequalities in the North. Michael, at nearly all the briefing sessions that you and the Minister have with the Health Committee, I raise that issue with you. Drug and alcohol deaths remain the starkest health inequalities in the North. In the most deprived communities, people are three or four times more likely to die from drugs and alcohol than those in the most affluent communities. That is about more than an Audit Office report and a strategy; lives are being lost, and that trend is not changing. In fact, we know that it is getting worse: the number of drug deaths has trebled over the past 10 years. It is about how that link between health inequalities and addiction links to the report and the substance abuse strategy. Is there anything that the Department can do proactively to work alongside the Minister to tackle the issue from a health inequalities perspective?

Mr Pengelly: Thank you for your acknowledgement of the work that has gone into this. A lot of work has gone into it, and, as you said, Gary has made a huge contribution in particular. The other three of us in the room certainly tip our hats to Gary for the role that he has played.

The first point is one that my Minister constantly makes: health inequalities cannot be viewed as a health issue. Health issues are the outworking and the impact of health inequalities at a societal level. The way in which we fundamentally address health inequalities is to come at them from a wider societal perspective and by going back to the cross-cutting Programme for Government. We talk about some of the issues here being a multiple of four between the least deprived and the most deprived areas, and that is recognised. Successfully targeting that, for example, is not just about closing that gap, in the sense that "all it does" is help the most deprived elements of society. This helps all of society. Any society needs to be measured by how it looks after those who are most disadvantaged, and, if we do that effectively, there are benefits at a societal level for everyone.

The Executive have certainly set their stall out to tackle inequalities wherever they occur at a societal level. That will be at the heart of the Programme for Government. That, in itself, gives me some comfort that the budgetary debate is not all doom and gloom. We need a lot of money to address this. We talk about the £6 million, for example, that we need to deliver the actions in the strategy. There is money at play, and we are spending money. Some of that £6 million, we think, may come from recalibrating how we spend our existing money. There are economies of scale and opportunities for synergy from working effectively with budget holders in other sectors. If they have £100 and we have £100, we can get £300 of value from spending that more cohesively and coherently together.

Your core point about inequalities is an essential issue for us. This is not something that would be nice to do if we had the money. We will fight tooth and nail to get the money to take this forward because we are absolutely seized of the importance of it. Michael is passionate about it.

Professor Sir Michael McBride: If I may digress for a moment, I grew up in the part of North Belfast that the Chair was talking about, so I am acutely aware of the health and education inequalities and their impacts, and those have got more difficult as the years have passed. The one thing that I would say is that the strategy fits into the broader context not only of the Programme for Government but of 'Making Life Better', our wider public health framework, which has been adopted and approved by the Executive. It represents joined-up working across government to improve the health and well-being of the entire population.

I do not get much of an opportunity to talk about money; I leave that to the gentlemen on my left. The Audit Office report makes the point that, back in 2008, we estimated the cost of alcohol and drug use across Northern Ireland. However, when it was updated in 2014, the cost of alcohol misuse was somewhere in the region of £900 million. If we add in the cost of drugs, pro rata, from Dame Carol Black's report, that takes it up to somewhere in the region of £1·5 billion. That is a considerable cost. As Richard said at the outset, let us be aware that that is a cost on people — on families and communities — but £250 million of that is a cost to the health service, the criminal justice and courts system, policing and across society. Through the vehicle of the Programme for Government, it should be possible for all of the permanent secretaries, with their chequebooks, to get around the table and agree and recognise what difference the individual contribution from Departments will make, as the Chair indicated, in a particular space.

We have good local examples of that. At a local level, in Belfast, for instance, Belfast City Council comes together with the Public Health Agency and the Health and Social Care Board to take a whole-system approach to dealing with the issue, adopting a model that has been successful in Doncaster. It can be done. It is being done at a local level. The challenge for us with the budgetary pressures is to ensure that we elevate that to the strategic level, as Richard suggested.

As you pointed out, Órlaithí, the figures are stark. Alcohol and drug inequalities are starker than any others. People in deprived areas are five times more likely to die from a drug overdose and four times more likely to die from alcohol. The strategy recognises that. It has taken a universal approach at an entire population level and a targeted approach in terms of those who are most at risk, including those living in deprivation, as Gary said, the homeless and injecting drug users. There is a commitment to develop an intensive outreach programme that board and PHA colleagues will commission to ensure that we reach those at greatest risk from alcohol and drug use. It will not be easy — far from it. We face into a difficult time. Look at, as was referred to, the increase in harms related to alcohol. There are positive indicators at a population level, but the harms associated with drugs and alcohol in terms of deaths and hospital admissions are going the wrong way across every part of the United Kingdom, perhaps with the exception of Wales, which is in a slightly more stable position at this point.

Mr Maxwell: One of the key drivers of the inequalities here is stigma. That came out strongly in our preconsultation work on the report. When the Minister launched the strategy, he met some service users and listened to their stories. They came for treatment later than they should have because they felt the stigma of their substance use with their family and those around them. Harm reduction focuses on those most at risk through needle exchange and naloxone programmes. That is really good at helping to reduce inequalities, but, in the longer term, if we can reduce the stigma of people seeking help, we will be able to get those people into services earlier and provide them with support, which means that the inequalities will reduce. There will always be an inequality — deprivation will always drive some difficulties in this — but we can do better by tackling stigma as well as by having some of the strong harm-reduction approaches that Michael touched on.

Professor Sir Michael McBride: That was one of the strong things that we heard from the West Belfast Community Drugs Panel report: that stigma affects not just the individuals but their families and relatives. Unfortunately, you see in a community the stigmatisation of individuals and their families, which creates a vicious cycle of almost trans-generational problems with alcohol and drugs.

Ms Flynn: Thank you very much. You have all made really important contributions. Richard, I take your point: the issue of health inequalities cuts across every Department, so it is important for all Departments collectively to prioritise the issues and try to change some of those stats for the better.

Michael, I am glad that you mentioned the West Belfast Community Drugs Panel report. I made a note about that when Gary was talking about stigma. We know that that stigma exists, but I take something positive from the fact that we have got to where we are with the strategy. Also, the 10-year mental health strategy suggests that the conversation around mental health and, more broadly, addiction is starting to change and that what you do in your work and what we all do collectively will help to reduce that stigma a bit. The bigger problem for you, as a Department, and for us, as a society — you referenced it, Michael — is that the culture and complexity of drug-taking are changing. You all mentioned that drug-taking behaviours are changing and becoming more complex, so it is about trying to get our systems to adjust to that, which will be a massive task. Hopefully, the strategy and the recommendations in the Audit Office report will help with that.

I want to come back to the cost and the figures that were quoted: around £1 billion a year. Alcohol-related costs to the health service amount to £900 million. The Department has included in the strategy the need to undertake research so that we have evidence to provide the best policy development. Are we doing any research locally to identify how much money comes from our budget to tackle drug use? We spend £900 million on alcohol-related issues, but are we doing any work to identify the cost of harms caused by drug use?

My final question is on the issue that Cara raised: dual diagnosis. Cara has worked on this, and she chairs the all-party group on addiction and dual diagnosis. I have spoken with officials, and I take the point that a separate service might create additional —

The Chairperson (Mr Humphrey): May I push you for a question, please?

Ms Flynn: For me, the problem with a dual diagnosis service and with trying to create a more managed network with the services that we have at the minute is the definition. When we talk about changes in the complexity and nature of drug-taking —

The Chairperson (Mr Humphrey): Ms Flynn, will you ask a question, if you do not mind?

Ms Flynn: I am just getting to it, thank you, Chair.

The problem is that dual diagnosis means that we are talking about mental illness and addictions; we are not talking about mental health problems. That needs to be factored into the work of the Department, because that is where we miss people, and we miss the opportunity to help people presenting in crisis in emergency departments. They are not getting the help that they need. Can that definition be considered by the Department? Will that be part of the work with the managed care network? Can we look at that so that people are not being turned away when they go to an ED? They may not have schizophrenia or bipolar disorder, but they might be in a genuine mental health crisis while battling addictions. We have not yet dealt with that problem.

Mr Pengelly: Thanks. Gary, will you take that second point?

Mr Maxwell: In the new strategy, we have tried to move away from the term "dual diagnosis" and towards "co-occurring mental health and substance use issues". It occurs in a spectrum, ranging from issues that will not really impact on mental health right up to a diagnosed illness. That is one of the reasons why we think that a managed care network across co-occurring would be superior to a specialised unit. A specialised unit will focus specifically on those with the most need, those who have a dedicated diagnosis and an addiction issue. It will get all the hardest cases referred to it, and there will be another barrier to entry: do you meet the threshold to go into this service? We hope that the managed care network will be more of a co-occurring care network. It might be called "dual diagnosis" at the moment, but the intention is to build capacity in all areas involved in treatment services in the statutory and community and voluntary sectors or elsewhere to recognise the interrelation between the two issues. Some of that might be just about providing little additional supports to people who have depression and substance use issues or anxiety and substance use issues, as opposed to somebody who has a personality disorder, which needs a completely different level of intervention and service requirement.

The intention is for that network to build capacity, experience and expertise and bring together the workers from the two sections. The skills overlap an awful lot. The skill sets are similar. It is more about feeling confident in addressing the issues and making sure that you feel that you have the ability to deal with them, pass them on and escalate as appropriate.

I hope that that reassures you that we are looking at this more broadly. It is more complicated without a diagnosis. With a diagnosed mental health issue, you can say that there is a diagnosis. When you come down to it, it is more difficult without a diagnosis. However, that is certainly our intention.

Professor Sir Michael McBride: I am conscious of time. I reassure you that we have a research subgroup in the existing strategy and that there is an equivalent to that in the new strategy. We have commissioned local research as well as using international research.

For instance, back in 2015, I think it was, we commissioned the University of Sheffield to do some research on minimum unit pricing of alcohol and its impact. We commissioned research from the Institute of Public Health in Ireland to do North/South work on, for instance, alcohol density in terms of off-sales and the impact that has on alcohol-related harm and its consequences. We have commissioned a range of research on other issues, and we will continue to do that through the R&D office of the Public Health Agency.

Mr Pengelly: Briefly, and this is the performance management freak in me coming out, your question was about the overall cost of drug misuse. I will be honest: I do not lie awake at night wanting to get a precise figure for it because I know it is a problem and I know that taking forward the strategy will improve lives and society. If you try to chase down a number like that to find the overall impact of drug misuse, on any given day of the week, your calculation will probably come up with a slightly different number.

The Audit Office report made valid points about deficiencies in our data collection. The interesting thing is that, in the strategy, we have set out some metrics for the five outcome areas that will be indicators for how we do against those outcomes. They are real, tangible numbers that we can measure with certainty, and that is where we can start to move the dial on the matter. We might want to explore the overall societal impact. I want to really sharpen our focus on the indicators in order to get them moving in the right direction so that we can start to improve lives.

Finally, you talked about the problems evolving in the changing landscape. I will highlight that this is a 10-year strategy with a five-year review point, because, as sure as night follows day, five years in, the landscape will have shifted again, and we need to be ready to recalibrate our action plan to take account of that.

Ms Flynn: Thanks very much.

The Chairperson (Mr Humphrey): Mr McHugh, can you hear me?

Mr McHugh: Hello, Chair. Tá fáilte romhaibh uilig anseo an tráthnóna seo. You are all welcome this afternoon. It is nice meeting you, agus gabhaim buíochas libh as bhur ráiteas. Thank you for your statement, even though it gives me some cause for concern.

Many of the points have been covered. There is one point that I want to make. Although you mentioned the strategy that has now been developed, yet and all, the funding is not in place to deliver it. How much will that impinge on the ability to meet the objectives in the strategy, especially when there is a need to build the capacity that we talk about? How will we address many of the drug and alcohol abuse issues that, at the outset, are impacted by a lack of funding?

Mr Pengelly: Where the funding landscape is concerned, the Audit Office report said that £16 million has been spent in that space. Some of the work we have done on the strategy and on the development of the new strategy goes to my previous point about this being an evolving landscape. If you look at it, you will see that the numbers move. We reckon that the more accurate figure will be £21 million. We say that we need another £6 million per annum to fully deliver the strategy, but that is in the context of something in the order of £21 million being spent in that space. I say that to give you a sense of proportionality.

Without that £6 million per annum, we will not be able to do everything in the strategy. The money is there at the moment for us to certainly make a good start on it and to progress it. To be fair to the Executive, the strategy was signed off only in early September 2021. Since it was signed off, there has not been a Budget process. I do not want to inadvertently suggest that there has been a decision not to fund the strategy. There just has not, as yet, been an opportunity to seek funding for it. We are doing that now as part of the Budget process. The comments that have been made today on a cross-party basis will certainly be replicated at the Executive, bearing in mind that the Executive have signed off the strategy.

I think we are pushing at an open door in seeking to ensure that there is funding for the strategy. That said, the Executive are under intense financial pressure. Even if we are not completely successful in getting that £6 million per annum ask, we have enough funding to make good progress in taking forward the actions in the strategy.

Mr McHugh: That is good to hear. I listened to your responses to previous questions. Do you accept that there is a disparity in regional provision? I talk from the perspective of West Tyrone, the area that I represent, which is rural in many respects. There is the feeling that, once again, much of the funding is geared towards the greater number of people and specifically to those in city areas like Belfast and Derry.

Mr Pengelly: There is an issue that we need to be clear about: in my mind, there is a difference between the debate about where services are provided and the debate about who has access to services. We need to be absolutely certain, with no hesitation or caveats, that every individual across Northern Ireland has equitable access to services where needed. However, that does not mean that we provide every service in every location. Were we to do so, we would destabilise services. We would drive their cost up at a time when there is not the money to do that. Those individual services would not be resilient, because they would be small services that would be fragmented across the region. The logical conclusion of what I say is that we have centres scattered across Northern Ireland that provide services on a regional basis. We need to look carefully at how we structure and locate those services, and we need to marry up services across a range of areas so that we get proper geographical coverage. We cannot expect the rural community, for example, to always have to travel to big urban areas to access services.

Sorry, that was a long preamble. Brendan, I think, will talk about the commissioning model and where the services are. I am just introducing the difference between access to services and where the services are located.

Mr McHugh: Just before Brendan comes in, I will say that I am not talking specifically about the location of a unit but about access to the correct services from the very outset.

[Inaudible owing to poor sound quality.]

Mr Pengelly: Certainly.

Mr Whittle: Certainly, with regard to how funding is currently spent across HSC trusts, there is a range of funding across each trust that reflects the service model in each trust. By way of example, in the year 2019-2020, the Belfast Trust area had expenditure of £2·1 million; the Southern Trust had £1·3 million; the South Eastern Trust had £2·7 million; the Western Trust had £3·6 million, and the Northern Trust had £2·8 million. You will see from those figures that there is a variation, and that reflects the location of the units. In that, I am minded to think that the operation of the units as a managed network, certainly in tier 4, is helpful with regard to access to services for people who need them. As we develop the future planning arrangements for addiction services, we need to be mindful of the resources that we have available and how they would be best deployed to meet the strategy's objectives.

Mr McHugh: Finally, I want to ask you something more specific. There is particular concern about the drug pregabalin. The North of Ireland has a high prescription rate for that drug despite warnings to GPs to be vigilant when prescribing it. That drug is a major factor in the rise of drug deaths. Is that your opinion? What exactly can be done about that? Pregabalin is, essentially, a drug that is used to treat epilepsy and the likes, yet and all it seems to be giving rise to

[Inaudible owing to poor sound quality]

in terms of addiction and to people suffering serious consequences as a result of that.

Mr Pengelly: I will make a couple of comments on that, but Michael, as our medic, will be more informed.

We need to tread carefully. A problem with prescription drugs does not automatically equate to a problem with the way in which those drugs are prescribed. People can access prescription drugs through underhand measures, for example. Any analysis of prescribing patterns in Northern Ireland compared with those in other places needs to recognise the different health needs of the population of Northern Ireland. There are some stark disparities. That is the main point that I want to make on that comparison.

Professor Sir Michael McBride: Yes. Thank you for the question, and you are absolutely right to flag pregabalin and other gabapentinoids. The Northern Ireland Audit Office report rightly flags the growing problem we have had with the misuse of prescription drugs.

Since 2015, we have had a significant change in culture and in the availability of drugs in Northern Ireland. It is fair to say that, prior to that, class A drugs such as heroin were not as accessible in Northern Ireland as they were in other parts of the UK. One can speculate on the reasons for that; indeed, there has been discussion about the role of the paramilitaries in perhaps controlling the drug market and the impact that that had on the availability of class A drugs. We have been working closely with the Department of Justice and the PSNI on that. Unfortunately, we have now seen the increased availability of class A drugs with the emergence of criminal gangs and international gangs.

Prior to that and because of that lack of availability, in Northern Ireland, we undoubtedly developed a significant problem with prescription drug misuse. As Richard said, many of the deaths associated with drugs — there were 191 deaths in 2019-2020 — are associated with polydrug use, including counterfeit drugs and prescription-only medicines. Those drugs, again, are found predominantly, sadly, in young men. Other drugs such as the benzodiazepines and gabapentinoids are more generally prescribed in older individuals.

We did a lot of work in Northern Ireland on flagging the issue with gabapentin and pregabalin. We identified it as a problem back in, I think, 2011 and 2012. We saw the increase in deaths associated with those drugs in 2013, and, indeed, we flagged it to the Home Office through the Advisory Council on the Misuse of Drugs (ACMD). I think that we played a significant part in changing the drugs' classification in order to ensure that they were less available. We have done quite a piece of work on the Northern Ireland Formulary, where pregabalin was previously recommended as a treatment for neuropathic pain as well as epilepsy, as you rightly pointed out. That is no longer the case. It has been relegated to a second-line drug when drugs such as amitriptyline are not effective in that respect.

If we look at the pattern of prescribing over the last number of years, we see that there is certainly room for improvement. There is no doubt about that. The combined use of pregabalin and gabapentin in Northern Ireland is less than that in Wales — that is not to say that that is a good thing — and we are on a par with Scotland. Yes, there is much more to be done, and we work closely with the organised crime task force (OCTF), which has a subgroup on alcohol and drugs, and with the Department of Justice and PSNI colleagues. Unfortunately, however, we see opioid-type drugs, benzodiazepines and other prescription drugs featuring increasingly prominently on death certificates. As I say, there is a specific action on attacking those issues in the strategy and a commitment from the Health and Social Care Board to update the prescription medicines action plan so that we can further drive down inappropriate prescribing.

Again, I make the point that, unfortunately, those drugs are available on the internet. If we take benzodiazepines as an example, we know that even reducing their prescription, as has been successfully done in Scotland, does not necessarily reduce their misuse or the deaths associated with them, because, unfortunately, they are available on the street, which means that there is diversion from legitimate sources. Gary, I do not know whether you want to come in on that.

The Chairperson (Mr Humphrey): Sorry, I have other members waiting to ask questions. We cannot have three or four people answering questions, with all due respect. If there is something to add that is absolutely relevant and particularly important and salient to the answer, that is OK, but I cannot have three or four people answering questions. Frankly, I do not have the time for that; I have members here who have other commitments. I do not mean to be prescriptive, and I do not want to guillotine the meeting, but I have to keep it on time. If the other contributor has something to say that will add to the answer, and I am not suggesting they do not, that is fine. I simply ask you to be brief and succinct in answering the questions, because, if three or four people answer, it is difficult to manage the meeting.

Mr McHugh: I want to point out one piece of information. The North of Ireland has the highest per capita prescription of pregabalin in the UK.

Once again, go raibh míle maith agaibh, and thank you ever so much for your answers.

The Chairperson (Mr Humphrey): That is not what the Chief Medical Officer said when he talked about Wales.

Mr Muir: Apologies for my lateness.

In considering the inquiry, it is important to understand that there are other policy and legislative interventions that could and should have been made by the Assembly over the past number of years on, for example, gambling addiction and alcohol pricing. It is important to bear that in mind.

My question is more of a practical one about Belfast city centre, which is an example of where we need a better policy response from government on addiction services. People have seen over the last number of years how things have developed in Belfast city centre and the impact that that has had, most importantly, on the individuals concerned and on the traders and the general environs there. People will be aware of the general issues in Belfast city centre and of the sad number of deaths that have occurred there, particularly during the pandemic. The response to addiction needs to be a joined-up one from different statutory bodies, including the police, Health and Social Care and different organisations. Why has that situation been allowed to develop? What more could be done to address it? Addressing the situation will be one of the practical outworkings of the inquiry and its findings.

Mr Pengelly: On why the situation has been allowed to develop, I would not want to suggest, and I do not think that it is the point you are making, that we have sat back idly and watched it develop. It is a societal issue, and society, behaviours and access to illegal drugs are changing. If you track the position in Northern Ireland going back a number of years, you will see that there used to be low levels of illegal drugs as distinct from prescription drugs. That has changed.

Going back to one of our early discussion points, fundamentally, we need a cross-sectoral and cross-departmental approach. If you drive through Belfast city centre you will see problems, but they are not necessarily health problems, although their outworkings land very much at our door. I hope that this is a sufficient answer.

The work set out in the strategy with the vision and outcomes is very much about driving forward a collaborative effort to bear down on the problems. We have not been as good at that in the past, and, Michael, you might be able to say something about that. There has not been a stand-off between sectors about who should address the problem, but there was a sense that one sector or another needed to grip it. We are now coming together to jointly grip the problems and try to take them forward.

Professor Sir Michael McBride: I am conscious of the Chair's comments, so I will keep mine succinct.

I referred to the Doncaster model and the work being taken forward by Belfast City Council, the PHA and the board on that. I have attended a number of those multi-agency meetings involving PSNI liaison officers, those on the streets, the street injectors support service (SISS), local government officers and those who work closely with community and voluntary sector organisations. I reassure you that that work is ongoing and continues. It has been in place for some time. The issues are in the access and availability of drugs, and the report has pointed out some issues around the age profile of users, because they are developing other health problems etc. Despite the improvements we see at a population level, we see significant changes in the harms that come from risk-taking behaviour. That is manifested in the number of deaths and hospitalisations from polydrug use. As Richard said, the complexity has become much greater because of a variety of factors, but I reassure you that that commitment and joined-up working is already under way and is happening as we speak.

Mr Muir: Thank you. I promised the Chair I would ask a succinct question, so that is me done.

The Chairperson (Mr Humphrey): Very good. You are so disciplined. Mr Boylan is next.

Mr Boylan: Thank you Chair. Next time, I might sit at home on Zoom to get in quicker for a question.

I thank the witnesses for their presentation. Richard, I will take it as sold when you say that the additional £6 million will be got to help to deliver the strategy. You may want to comment on that.

I have three key points. The first is on people who need help to be directed to the right service. The report clearly says that there is lack of awareness of tier 2 services in some respects. How do you intend to ensure proper referral in the future to those lower-threshold services?

Mr Pengelly: I would love to be certain that we will get the £6 million. The nature of Budget settlements tends to mean that there is an overarching Budget settlement in response to an ask that comprises many component parts. This will be a key component of our ask in the Budget process. Budget settlements tend not to allocate money to every component, and the reality is that it is unlikely that any Department will get everything it asks for. There will be a decision for the Executive on prioritising the allocation, and, ultimately, there will be a decision for the Health Minister about how he chooses to prioritise his resources when he sees the Budget settlement. It is difficult to pre-empt that. All I can say is that I know that there is a strong measure of support at the Executive for the strategy. I know my Minister is committed to trying to do this, but, equally, there is a huge range of pressures on his desk at the moment, and it is not for me to pre-empt that.

Mr Maxwell: I have two quick points on tier 2 services, again taking on board the Chair's comments. There is a piece of work about making contacts count in primary care and making primary care colleagues more aware of all the services out there. I feel sorry for them, because there is a plethora of services, so it is about attempting to make that easier for them and to do brief interventions with people in front of them.

The second point is that we have asked the PHA in particular to update its Drugs and Alcohol NI website, which has a directory of all the services available in Northern Ireland. One of the challenges with a directory of services is that people do not know they need the service until they are in crisis, and, when they are in crisis, they do not particularly want to go to a website to find that source of information and support. It is also about making sure that our colleagues in EDs or other key community groups or others are aware of this work. We are happy to work with anybody, including elected members, to encourage awareness of the services that we have. One in particular that I want to point out is our family support services. Those are underutilised, so we are really keen to push them out there. They are available to any family member, whether their loved one is in treatment or not.

Mr Boylan: Thank you. My other point is on data quality and completeness. Why has it taken so long to address those issues?

Mr Pengelly: Part of the issue has been the multitude of players in this all working to the same standard. Ultimately, if we want to use the data, it has to reach a certain qualitative threshold to be accepted as a national statistic. We are a long way from that. There is a multitude of players, so it is a fair comment, which we accept without reservation, that colleagues in the Audit Office have made. Outcome E in the new strategy is very much focused on governance, implementation and research and on trying to address that, just to get that quantitative information to underpin this.

Mr Boylan: I appreciate that. I asked that in the context of developing a new strategy. If you do not have that data, it is difficult. I appreciate some of the earlier answers about cross-departmental working with other sectors. The context of the question is that you have developed a new strategy under the pretext of data quality not being there. That is my key question.

Mr Pengelly: That is a fair point. I just wanted to make the point that the data, where those qualitative issues lie at the moment is, in many cases, with organisations at tier 1 and tier 2 level, which are outside our direct control, so it is difficult. We can be prescriptive with our organisations, which tend to work on standard platforms, and we can issue standards, but, when you are working with the community and voluntary sectors in particular and other partners, it is more difficult to be prescriptive. It is about having a dialogue and trying continually to nudge things forward. The comments about the data quality issues are fair ones; it is a subject on which we will focus.

Mr Boylan: I appreciate that. Thank you for your answers and for your presentation. I know that other members want to get in.

The Chairperson (Mr Humphrey): Mr Boylan, let me reassure you that, whether you are here in person or joining us virtually, you are called when you signal. It will not make any difference whether you are here or not. There is no partiality. It is simply about when people are called.

Mr Beggs: I welcome the new strategy document, 'Preventing Harm, Empowering Recovery'. The challenge, of course, will be in delivering on it. Are you certain that there will be the necessary cross-departmental support for that? When I read the Audit Office report, I was a bit surprised that the biggest cost is not to the health service but to the Justice Department. Are you confident of being able to implement improvements?

Mr Pengelly: I am confident, but, facing forward as we do, I do not think that any of us can be certain. Again, I emphasise that our Minister, in finalising the strategy, took it to the Executive, so it has Executive support. As part of the governance arrangements under which we are taking this forward, there will be a programme board that Michael will chair. We also intend to establish a cross-departmental ministerial group. Ministers have indicated that they stand behind this and support it. We absolutely expect the officials on the programme board that Michael will chair to come to it with that in mind. We will work together, and there will be an opportunity for Ministers to have oversight of the governance arrangements for that.

I do not doubt for one second that everybody will come to this in the spirit of collaboration, seeking to work together. Just as I have never failed to put down the marker about the intense financial pressure that we face, my colleagues in the justice sector would, similarly, never miss an opportunity to identify the issues and pressures that they face. Michael's point is that we are absolutely in spend-to-save territory here. Every pound that we spend on the proper and effective implementation of the strategy will be reaped four-, five- or sixfold down the line in future savings and interventions in the justice and health and social care sectors.

Mr Beggs: The Audit Office report also indicates that the majority of drugs-related deaths involve prescription drugs. Is there any assessment of how many of those drugs come via the National Health Service and how many from the black market?

Professor Sir Michael McBride: That is difficult to determine on the basis of an autopsy and toxicology report. We know that some of them are. Some of the benzodiazepines cited in deaths are not prescribed in Northern Ireland. They are a mixture of novel psychoactive substances and ones that are prescribed elsewhere. It is difficult to get an absolute breakdown on that, given how it is reported, but we know that some of those deaths will have been caused by prescribed drugs because they will have been prescribed for certain treatments or for pain relief. There is a range of substances also taken as part of a polydrug misuse in which there is risk-taking behaviour. Therefore it is difficult to get an exact breakdown of which are prescribed and which illicitly purchased.

Mr Pengelly: This does not answer your question, but, in May 2021, Operation Pangea was a cross-sectoral exercise to look at the illegal importation of prescription drugs. Over one week, some 94,000 tablets or doses destined for Northern Ireland were recovered from the mail. That is a significant marker.

Professor Sir Michael McBride: Yes. One hundred thousand pounds' worth of drugs on the black market, including pregabalin, diazepam and the benzodiazepines that Gary referred to that are appearing on death certificates. A significant illicit and counterfeit market contributes to that as well.

Mr Beggs: Would you accept that the high prescribing levels in Northern Ireland tend to normalise some of those drugs, and people think they are familiar and safe? There is also a risk of some people acquiring them to misuse them. For instance, there are three and a half times as many prescriptions for diazepam per capita in Northern Ireland than in England. Is that a fair comment: that there is a risk of normalising the drugs and a higher risk of misuse?

Professor Sir Michael McBride: There is a valid point in your comment. There is no doubt that prescription drugs are misused because some regard them as safer to use, but no drug that is not prescribed for you is safe to use. There is no doubt that the use of benzodiazepines — diazepam being one of those — is higher than in other parts of the UK. However, it has fallen, as it has in other parts of the UK. That is down in no small part to the efforts of the Health and Social Care Board in monitoring returns to prescribers of drugs.

We need to put it in the wider context. We have 25% greater mental health needs in Northern Ireland compared with other parts of the UK. We have some of the highest levels of socio-economic deprivation. Research by universities here demonstrated that your proximity to a peace wall directly correlated to the rates of prescribing for anxiolytics such as benzodiazepine and antidepressants. We are dealing with the legacy of a community that is coming out of conflict; indeed, we still live in communities where we see some of the impacts of that conflict.

As Richard said, we should not necessarily see equivalence between prescribing levels and inferring that somehow or other prescribing is inappropriate. What we absolutely need to do is reduce levels of prescription drugs without any shadow of a doubt. That involves providing alternatives as well in terms of some of the pressures that we have in mental health services. That involves alternatives to prescription drugs, such as cognitive behavioural therapy, counselling etc, which are equally important and can be as effective as prescription drugs.

Mr Beggs: On who specifically is doing the prescribing, the Audit Office report states:

"Under the shared care model the expectation is that GPs should be responsible for 'a significant part' of providing care and prescriptions for stabilised service users."

However, the accompanying graph shows a huge variation from 3% to 30% of prescriptions being led by primary care. Why is there such variation? Who is doing the prescribing? Is it locums in A&E giving a prescription and then it just being maintained? Who is doing the prescribing, and why is the model not being followed?

Professor Sir Michael McBride: Maybe we are conflating two things. I think that what you are referring to, if I understand the question, is in relation to shared care in terms of substitute prescribing. I think that that is the diagram and reference that you are referring to in the report; please correct me if I am wrong. What that demonstrates is an absolute commitment to ensuring that there is a more uniform approach to shared care and substitute prescribing across Northern Ireland. We know that we have had pressures in substitute prescribing services over the last number of years, and the Audit Office report correctly pointed to those pressures.

We also have to say that shared care is not appropriate in all cases. There are complex and complicated cases, such as substitute prescribing in pregnancy. There are also those who have been discharged from the criminal justice system, for instance, who are particularly at risk at those transition points. It is appropriate that those individuals' prescribing and management care needs continue to be met in community addiction services. The one —

Mr Beggs: I fully accept that, but my question was why there is such a variation between 3% and 30% being prescribed in primary care only. That was my question.

Professor Sir Michael McBride: Yes, I know. Apologies.

You referred to, I think, 30% in the Northern Trust. We also need to bear it in mind that there is a difference in the complexity of drug misuse and some of the factors that we see. Indeed, one of the members referred to the particular problems in Belfast. We have some chaotic drug misuse in the greater Belfast area that is compounded by other problems, and some individuals are less suitable for a shared care model.

As you say, it is 30% in the Northern Trust and 14% in Belfast. Work was undertaken just before the pandemic to increase the number of GPs involved in shared care, because that helps to drive up the knowledge, experience and expertise that Gary referred to. We had a project called Project Echo that provided telehealth or telemedicine support to those GPs. That had to be put on hold during the pandemic or, at least, the worst of it, but that work is now under way again.

As you rightly said, there is a commitment to increase the percentage of GPs involved in shared care, but it is not compulsory. There is no doubt that many GPs have concerns about it; indeed, there is the issue of providing the experience and the confidence to GPs to participate in the shared care model.

Mr Beggs: If it is thought to be the right model to follow, why is it as low as 3% in the Southern Trust area?

Professor Sir Michael McBride: I cannot answer that question. I do not know the details of why it is so low in the Southern Trust.

Mr Beggs: OK. I want to move on to the issue of hospital bed days. Between 2014 and 2018, I guess that there was about a 35% increase in hospital bed days in Northern Ireland. Over the same period, there was a 25% reduction in England and a 9% reduction in Wales. What are they doing differently? Hospital bed days are expensive and are not necessarily the best approach for patients. What are they doing that we are not? Have we learned anything?

Mr Pengelly: Part of the issue with any comparison between Northern Ireland and England, Wales or other places is that we were at different points of the journey with the problems that we were encountering. In 2015, illegal drug availability and use in Northern Ireland was much lower than it is now. Part of the issue with that comparison is that, in the here and now, we face a slightly different problem from colleagues in England and Wales. That is not to say that there are not still lessons that we can learn, and part of the strategy is about looking at experience, innovation and new developments in other places. However, we are not always comparing like with like in comparing ourselves with other jurisdictions.

Mr Beggs: OK. I have another question for Dr McBride. You referred to alternatives to prescribing, and I fully support that idea. How has social prescribing been developing? Sometimes, it is of much greater or long-term benefit to patients than simply giving them tranquilisers. It was launched a few years ago, and it is an important alternative to prescribing medicines.

Professor Sir Michael McBride: Yes. Roy, I know that you did not mean that GPs are simply reaching for their prescription pads. However, to reassure you, no GP simply reaches for the prescription pad when it comes to prescribing diazepam. If we look at the Northern Ireland Formulary, we see 77% compliance with the formulary in relation to some of the central nervous system (CNS) active drugs. The formulary covers only 80%. We know that there is good compliance with the Northern Ireland Formulary in the prescription of those drugs.

You are absolutely correct: there has been an expansion and there needs to be further expansion of social prescribing, whether that is individuals being involved in other activities that could improve their mental health and well-being; connecting with other people in their communities; experiencing the benefits of physical activity; or having cognitive behavioural therapy to deal with some of the precipitators and triggers that resulted in their alcohol or drug addiction. We have made good progress, but I do not think that we have made as much progress as we would wish. There is certainly much more to be done in that space.

Mr Beggs: My final point relates to the importance of links to the community and voluntary sector that can fill a gap in the statutory sector. There have been significant projects in the past. The Hope Centre in Ballymena, which was jointly funded by Health and Justice and perhaps some other cocktails, provided a vital service that was greatly appreciated by the community. Sadly, because of the end of cross-departmental funding, it was closed, and the expertise and the team were dispersed. How will such community and voluntary sector activity be built up again?

Mr Pengelly: That is a real challenge across all sectors. I suspect that, over the last half dozen or so years, it has been a huge frustration to the community and voluntary sector that, when central government is under financial pressure, there is often the tendency for the scrutiny of funding to the voluntary and community sector to be one of the early moves. In my experience, generally, each pound that you give to the voluntary and community sector levers in well in excess of a pound in value when it comes to the other issues that colleagues from those sectors bring to the table.

We have put that collaborative approach at the heart of the strategy. We wanted to refresh and renew it and work on it. It will have to be done in the context of pressurised budgets, but you make a strong point. Sometimes, the best services at local level are those that have a strong local dimension through colleagues in the third sector. We need to redouble our efforts in relation to how we work and engage with those colleagues on a mature basis and how we lever out some funding for them, because, in my experience, strong value is added by propositions from colleagues in that sector.

Mr Irwin: Thank you for your presentation. I will be brief.

I am not an expert on this, but, for me, the concerning thing is that the level of harm caused by substance misuse is high. The bigger concern is that it is still rising. It is evident to me that, in the past, any strategy that we had has not worked. Are you confident that the new strategy will make a difference?

Mr Pengelly: The short answer is yes. I have no doubt that the strategy will make a difference. We can sharpen your question and ask this: am I confident that the strategy will turn the tide and start reducing the numbers? I do not think that society will allow us to be in that position. The numbers have increased over the years. It would be a matter of conjecture what the numbers would be had we not been working on the strategy. As Michael said, the review of our previous strategy showed that 80-odd per cent of actions in it were either delivered or on track for delivery.

I am confident that we have made a significant contribution towards improving that space. We are all aware — Committee members may be more aware than I, owing to the work they do at community level — of the societal challenges. The pandemic will make the landscape all the more difficult and challenging in the months and years ahead. Yes, it will make a difference, but I think that we are in the territory of reducing rather than reversing the trend in the short term.

Professor Sir McBride: That is a fair comment. We look at what happens in other parts of these islands with significant concern. For example, the situation in Scotland and some parts of England has strong links to socio-economic deprivation. None of us wants to get into that situation.

As Richard said, we made significant progress on the actions in the last strategy. I am confident of the same commitment, particularly because of the excellent working relationships that we have with the community and voluntary sector, which are key partners in that silo. They have shared responsibility for co-production and collaboration and are equal partners. I also point to the strong user voice that we have at every level in the strategy. We had that in the last strategy, and we have a strong user voice in this strategy. That voice keeps it real and keeps us focused on the things that are important. Going back to your question, that gives us feedback about the things that work and the things in the system that are, frankly, not working and need to change.

The Chairperson (Mr Humphrey): Thank you very much. All the members who indicated have asked questions. Thank you for coming to the Committee today.

Mr Pengelly, you made a point about the pandemic's negative societal effect not just on our nation's health but on mental health. The societal challenges are and will be immense. Perhaps it will be only in the ensuing years that we will see that challenge. I agree with the points about costs and the opportunity cost of not having early intervention or a strategy to deal proactively with the challenges. Having said that, I welcome the buy-in from the Executive. However, as the old saying goes, "Talk is cheap; it takes money to buy whiskey". If we do not have the extra £6 million per annum, what will happen to the strategy?

Mr Pengelly: The reality is that the strategy will probably remain partially implemented. However, it is important to say that it will be partially implemented. There are elements of the strategy that we absolutely will take forward without any additional funding. It will reuse the money that we already have. It is not all or nothing. We will end up with a partial implementation.

The Chairperson (Mr Humphrey): Holistically, if you do not have the £6 million, it will be much more problematic for the strategy to meet the challenges in society.

Mr Pengelly: Yes. Equally, however, I suspect that we could be talking about another issue on another day that will be every bit as emotive and have the same financial challenges. It is about trade-offs.

The Chairperson (Mr Humphrey): I understand.

At the outset, you mentioned the Committee's request to you to attend in November 2020. We decided that the Committee should act responsibly, given the challenges that you and Dr McBride, as he was then, faced. We appreciate the work that has been done since then. It is tragic that so many people have lost their lives. However, without the roll-out of the vaccination programme, no doubt, we would be looking at much more challenging figures. I thank you, the permanent secretary, and Sir Michael, the Chief Medical Officer, for the leadership that you have given. We have faced unprecedented challenges in the most difficult of times, and we continue to face those challenges. The only way to eradicate the challenges is if we all work together and people act responsibly.

I listened carefully to the presentations and the answers, and I hope that the strategy is funded and implemented in full to improve the lives of our people and our society. Thank you for your time this afternoon.

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