Official Report: Minutes of Evidence

The Chairperson (Ms Kimmins): I welcome Gary Maxwell, head of health development policy branch in the Department of Health; Kevin Bailey, health and social well-being improvement manager at the Public Health Agency (PHA); and Julie Haslett, social care lead for mental health in the Department of Health's community care directorate.

I apologise for the delay. I appreciate your patience. We probably have half an hour to 45 minutes max, so I ask Committee members to be mindful of the time. The session will be reported by Hansard. I invite you to make your opening remarks.

Mr Gary Maxwell (Department of Health): No problem. I can cut them short, Chair, if you want to leave more time for questions, but I will make a few quick statements.

The Chairperson (Ms Kimmins): No problem. Thank you, Gary.

Mr Maxwell: Thank you, Chair and Committee members, for inviting us. It is a good opportunity to update you on the work that we are doing on the substance use strategy, 'Making Life Better: Preventing Harm, Empowering Recovery'. I look after the strategy from a strategic policy and legislation point of view. Kevin, from the Public Health Agency, and Julie, from the Department's Strategic Planning and Performance Group (SPPG), lead on the commissioning and delivery of the strategy.

A key point that I will flag at the start is that one of the things that we noticed when we looked at the old strategy and at the new strategy was how we collectively work as a health service to address substance misuse issues, because they cut across all the tiers. I stress that we work as a team across the health service to deliver on the new strategy. The strategy goes beyond the remit of the health service and that of the Department of Health. We work closely with other Departments on issues such as homelessness and justice enforcement, and we bring the issues together. I would not want not to mention the community and voluntary sector, with which we work as real partners in this area. Its organisations are key delivery agencies for us. Importantly, we also work with those with lived and living experience of substance use and with their families. We bring that expert experience into what we do from a policy, commissioning and delivery point of view.

There are also substance use issues that go east-west and North/South. We are closely linked into developments in the UK and Ireland through the British-Irish Council (BIC) substance misuse sectoral group and the North/South alcohol policy advisory group (NSAPAG). We provided the Committee with a written briefing over the summer, as well as a more recent update on the actions that were rated as amber. Some of those actions may not be rated as amber now, but we can get into that when we get into the detail.

Substance use remains a key priority for the Department, as does working across the Executive to deliver on tackling it. Since he has been in post, the Minister has made health inequalities one of his key areas of focus. Substance use is the largest inequality in health outcomes in Northern Ireland. If you look at drug-related mortality figures, those in the most deprived communities are six times more likely to die a drug-related death. Tackling it is therefore a key focus when taking forward the work.

I will precis some of this and then come back to it. Over the past couple of years, we have focused on delivering on a number of key actions. Those are a rapid review of opioid substitution therapy in prisons; a Western Trust needs assessment review of our inpatient services; a consultation on minimum unit pricing for alcohol; a consultation on a new strategic delivery plan; work on putting robust governance structures in place across the piece; and work on developing our outcomes and indicators. The Committee recently did some work on expanding the supply of naloxone in Northern Ireland, and I thank you for your support. That was a key piece of work.

Those are headlines, but, behind them, a lot of work goes on daily to maintain the system and to try to make it better. Part of the Department's reform agenda concerns how we link up better across different domains of health while improving services within the existing pathway.

Our next big step is the launch on 26 November of our strategic plan, on which PHA and SPPG colleagues have led. Hopefully, the Committee has received a letter of invite to attend that event. The plan will set out the key bits and next steps, which focus on eight priorities: prevention and early intervention; pathways; trauma; family support; stigma; workforce development; digital innovation; and data and research. We engaged with over 150 people on the development of the plan, including those with lived and living experience. They have been deeply involved. It has taken us slightly longer than we perhaps would have wanted it to, but the process has been useful in preparing for and refining what we are going to do. Hopefully, that will be a really good piece of work and set us up well.

Yes, the plan will be for health services, and it is about delivering in line with NICE guidance on drug treatments and support services. Other agencies commission substance misuse services, however, and, instead of commissioning what, they think, should work, the plan sets out the evidence based on what we know, and, if there are gaps, rather than going off and looking at something that is not the most evidence-informed, we should instead direct people back to the commissioning plan and say, "Folks, this is where we need to fill in the gaps. These are the bits that we need to do. This is what those with lived and living experience are telling us that we need to do". That will be really important for setting us up for the future.

I will finish by talking about alcohol briefly. We often focus on illegal or illicit drug use and rightly so. If, however, you look at the figures, more than twice as many people died in 2022 from alcohol-specific causes, which has a much tighter definition than drug-related causes, which has a slightly broader definition. We therefore need to keep making the case that, in substance use, alcohol remains the main substance that causes harm. As members will recall, on 17 October, the Minister set out his intention at the Committee to bring forward proposals on minimum unit pricing for alcohol. He believes, on the basis of research and modelling, that minimum unit pricing has the potential to reduce alcohol-related harm and inequalities.

We hope that those proposals will be considered by the Executive in the near future, and, subsequently, the Minister is keen that we work collaboratively with the Committee to set out the policy. Some of the myths and some of the feedback that we got during the consultation tell us that people perhaps did not quite understand what the policy aims to do. It is important to determine where we should pitch it to get a balanced approach that reduces harm but does not impact more widely on society.

We are more than happy to come back to the Committee in due course on minimum unit pricing specifically, and, as we have a slightly truncated session today, we are more than happy to come back to the Committee, should issues arise today. We are keen to work collaboratively with the Committee. It presents a real opportunity for us to keep substance use high on the agenda. In particular, it presents a real opportunity for us to think about how we address the stigma that some of our service users face and get the message out that they are family members, such as brothers, sisters and daughters, and that this is not about demonising people but about supporting people who are going through something or have had traumatic experiences that impact on their substance use and about how we go forward.

I could go into more detail, but the time may be better spent on questions. I am happy to end there, if that is OK. Kevin or Julie, do you want to add anything?

Ms Julie Haslett (Department of Health): No.

Mr Kevin Bailey (Public Health Agency): No.

The Chairperson (Ms Kimmins): Gary, thank you and I appreciate your expediting your presentation. We want to delve into some of the issues through questions. I appreciate your offer to come back on any of the matters raised.

Towards the end, you made the point that these are our family members, such as our brothers and sisters. I listened to a podcast last week. I do not want to plug it or anything, but it really stuck with me. It is Caroline O'Neill at Digg Mama. Some people will know her. She does a Digg podcast, and she had a lady on who was quite glamorous and affluent. The lady came on and spoke about how she is an alcoholic. She said that she has now been sober for, I think, 10 years. What struck me about that story was how it was so hidden. Even those in her household did not realise. That can happen. It is about taking away the stigma. That is a really critical part of it. None of us can escape this, and it could happen to any of us. It is something that can happen, and everybody needs the same support.

There are two key questions that I want to ask. My first question comes on the back of last week, when we held a concurrent meeting with the Committee for Justice. I asked questions on the Department of Health's input with remand prisoners but specifically on its input where people have issues with addiction. Such issues are obviously linked to their involvement in the criminal justice system. That is a key part of the strategy. What engagement have you had across Departments? I have a particular interest in your engagement with the Department of Justice, because a huge amount of work can and should be done there. I am keen to hear a bit more about that.

Mr Maxwell: I will say something from a strategic point of view, after which Julie will talk about services. We have worked closely with the Department of Justice and all its agencies for a number of years. They are on our oversight bodies, while we are on bodies such as the organised crime task force. That is done to make sure that that link-up is there. When we look at things such as the problem-solving justice approach, substance use is really important in that. A lot of crimes are either substance use-related or substance use contributes to the crime. A lot of crimes are either facilitated by substance use or are an enabler of it.

We are therefore really keen to do work on how we intervene early in such cases and see whether there are alternatives to justice settings for people. It is about how we manage that. With the likes of a substance misuse court, where somebody has gone through the process, rather than go into prison, the person might have opportunities to get treatment-based support. There are alternatives to disposal such as enhanced combination orders. We are really keen to work with our Justice colleagues. We have worked on that agenda with them and will continue to do so.

There are some resource issues. We appreciate that, and we could probably do more, if more resources were available, but we know that those who are homeless and in the criminal justice system are caught in a cycle through our services and through the justice system. We need to look at ways to break that cycle and intervene more.

From a strategic point of view, we work very closely, and I hope that the Department of Justice would say that we work closely with it as well. There are always interface issues and bits and pieces like that, however.

Julie, I do not know whether you want to say something about treatment in particular.

Ms Haslett: Yes. We were conscious of the throughput among prisoners and the remand population. We commissioned a study of our prison population and some of the major healthcare challenges that present in prisons to do with addiction. The study was really interesting, because we are an outlier among the other nations. We have a much higher remand population, so a lot of people are going through that revolving door. The study focused on our need to do better when looking at transitions for people coming into prison in order to prevent them coming back, so it is about looking at readmissions.

How do we do that? We need to upskill our workforce by taking a multidisciplinary approach, including social work, so that staff have a holistic, whole-system point of view. A prisoner is not just a person who is in prison but a person who has a family, has a support network and needs housing, so it is about how we link up better. We also need to look at the pathways through which the Department, prisons and probation colleagues can link up better and get people treatment much more quickly.

A lot of recommendations have come from that study that we are proactively looking at now with our colleagues involved in healthcare in prison, with the Probation Board for Northern Ireland (PBNI) and with our colleagues on community addiction teams in the health and social care trusts. Another important element is linking with our housing colleagues, because we all know that people cannot go into recovery if they are lying in a doorway, are sofa-surfing or are in temporary accommodation or a hostel. That part of the jigsaw is really difficult, so it is important for us to work with them all.

The Chairperson (Ms Kimmins): That is good to hear, Julie. From my experience, my frustration with the process is that, when people are on remand, where they can be for months, as you know, a lot of them may never meet the threshold for being in prison, where they would get support. I always think that that is a missed opportunity, because, while they are on remand, a lot of them have not been drinking or taking drugs or whatever their addiction is, which normally stems from a mental health issue.

Ms Haslett: Or from trauma.

The Chairperson (Ms Kimmins): Or from trauma. They are then released, perhaps with nowhere to go and no support, as you said. They are back to square one, and, in a couple of weeks or months, they are back in prison. For me, it is a cost worth paying: you invest to save, and you then give people a real opportunity to achieve a better outcome. That work is good, and I would like to keep track of it, because it is key. That was the main issue on which I wanted to ask a question.

Ms Flynn: It is lovely to see you all again.

Gary, it is important that we get the detail of the launch of the strategic plan, as it will set out the direction of travel for commissioning and for services. It is important to bear in mind the point that you made that the strategic plan has been designed mainly in conjunction with people with lived experience, because, at different times, different issues will come up for discussion and be debated. In all of that, my decisions will always be determined by the families with whom I work, the people who have lost loved ones and the people who are battling addiction.

I have a couple of questions. Gary, you mentioned the work on health inequalities that the Minister is doing. Do any elements of that work specifically relate to addictions? You said that people in the most deprived areas are six times more likely to die a drug-related death.

That is the largest health inequality in the North. Is there any specific work on health inequalities?

Your work with other Departments is crucial. We know that the majority of people who end up on the streets and have nowhere to go are battling addiction. We have a meeting in two weeks with the People's Kitchen and the Department for Communities to discuss concerns that the out-of-hours service will be pulled. The Housing Executive might have to cut back its out-of-hours emergency service, and organisations like the People's Kitchen, which deals with people who are homeless and are battling other complex issues, have said that cutting or losing that service will have a massive impact. We will speak directly with the Department for Communities on that, but I am trying to get a wee sense of your work with the Department for Communities. You are dealing with people from a health perspective, so are you alerted to issues like that as and when they arise?

Finally, on the dual diagnosis work, we met a health worker from ward 15 a couple of months ago. The issue of dual diagnosis comes up time and time again. Has there been any progress on that? We have spoken to the trusts on that, and it seems to be about getting a mind shift and changing the culture in two Departments that work separately on mental health and addiction. Do you have an update on that work?

You sent me a written update on how we can fit addictions into the work of multidisciplinary teams (MDTs), but will you give the Committee an update on that? The hope is that we will have the MDTs expanded across all areas. Is there a way to filter dealing with addictions into the roles of the primary care multidisciplinary teams? That would catch a lot of people during the small window in which they are looking for help?

Mr Maxwell: I will start with the inequalities piece. The whole strategy focuses primarily on inequalities, because we realise that that is where there is such a big gap, although we have lost sight of the need to take a universal approach to prevent people from moving into those categories. Live Better is the Minister's pilot initiative to address health inequalities. That is engaging with communities and looking at the GP registers to identify the issues in those areas. The issues have not been picked yet because the process is still being worked through. That will be led by the community and by need as well as by what, we think, we need to do.

In one of the areas, prescription drug use was one of the issues that came up, so there may be something that we can specifically look at to address that. Alcohol may come up in one of the other areas as a key inequality. Whatever happens in those areas to address inequalities will be helpful to address substance misuse, because that is often used as a crutch or mechanism to self-medicate for other issues, such as pain or depression. Even if it is not specifically focused on substance use, it will have a positive impact.

In regard to specific groups, there is the Complex Lives work, which reaches out to homeless and at-risk individuals and injecting drug users in Belfast. There is also the Belfast Inclusion Health Service and the work around that. Kevin, do you want to say something about those groups? They are focused on cliff-edge inequalities in specific groups.

Mr Bailey: On policy and strategy, one of the things to highlight, Órlaithí, is the infrastructure that involves each of the agencies, including DFC, the Housing Executive, the health trusts and, particularly, the PSNI. There are operational outworkings of that. Complex Lives is one such example, where a multidisciplinary group of professionals comes together across the community, voluntary and statutory sectors to identify and target those who are most in need — the most vulnerable in our community — and wrap support around them. That is working well. A big issue continues to be access to long-term housing, not just temporary accommodation.

We see people coming through with co-occurring issues, be they mental health and addiction issues or physical health issues. Sometimes we forget about physical health because we see the two big elements, but physical complications are another issue, particularly for those who inject drugs on an ongoing basis. Wrapping support around those people, from an infrastructure perspective, is crucial for us. Complex Lives is one vehicle through which we will do that. In the plan, we also have an opportunity to roll that out outside Belfast, as and when the funds become available to do so.

Ultimately, it is about meeting the person's needs and wrapping the support around them. Talk to anyone who is addicted to a substance: no one wakes up in the morning saying that they want to be addicted. They find themselves in that situation for various reasons. Having that person-centred and compassionate approach is key. Those services and the individuals who deliver them do that daily and meet those needs. They are also developing, within that cohort, a peer element, whereby people who have come through the process and are a bit more stable can engage through services, such as the needle exchange programme, that we also provide across the region.

Mr Maxwell: We are represented on the interdepartmental homelessness group that the DFC leads, and it is represented on our group, so there are those connections at the strategic level. I presented recently to some of that group. There are some challenges with that, and it is great to look at those issues. There is a strategic connection, so, without going into huge detail, when issues arise — I am thinking about recent issues that arose — there are conversations between the PHA, the Housing Executive and the Departments on how we should look at them, what the impacts and spillovers will be and how we can best mitigate some of the harms that may be caused.

Mr Bailey: You will be aware of the Welcome Organisation and the challenges there. That has caused a big issue with providing the right services at the right time for people experiencing homelessness. It is also connected to the Belfast Inclusion Health Service, so trying to find a home for those two services is a high priority for a range of agencies that are coming together in the city centre. They are really being supported by the council, which is taking a lead role in trying to find the right premises for those services. That also connects to Justice and, as you mentioned, the link with the multi-agency support hub (MASH) process for triaging those who find themselves in a vulnerable position. That process is led by the PSNI and provides a core link to other services. People are being captured at multiple interfaces, and, wherever that interface is, we are trying to provide the right service for them.

Mr Maxwell: Órlaithí, do you want to come back on that before I move on to dual diagnosis?

Ms Flynn: No, go ahead.

Mr Maxwell: I will ask Julie to come in on dual diagnosis in a second. Of the people who use our substance use services, 85% or 90% have mental health issues. Sometimes, people think that that is a complete barrier. There are interface issues — there is no doubt about that — but, if we did not deal with people who had a dual diagnosis, there would be a lot more space in our services, because they are a major cohort. As we have seen substance use change in Northern Ireland, the intensity of support that is required has really changed. You do not see massive changes in the levels of young people drinking or using drugs — they are relatively stable and may actually be falling — but the harm that people are coming to is up because of polysubstance use and co-occurring mental health issues.

Julie, do you want to say a wee bit about what we are doing?

Ms Haslett: Yes. Órlaithí, your point about the culture was well made. What we will have to turn around is a cultural leviathan. When we see a scarcity of resources, people often retreat to their silos, and that is a difficulty that we see daily. In putting the plan together, we had an extensive cross-agency and cross-specialism group to look at some of the challenges. We have put that together and set up a task and finish group, which will meet on Monday. Kevin is the co-chair of that group, which will look at some of the challenges, such as how we move people out of their silos and how we look at the workforce and make sure that people feel confident on both sides and are well trained. Also, every contact counts. We talk about that, and it is easy to say, but it is hard to do. Our vision for the cultural piece is for it to be everybody's business. That is the way that we want to tackle it.

As well as the ongoing task and finish group, which starts on Monday, we will also have a worker employed in SPPG to look specifically at quality improvement and how we get our services to be more interlinked. Interestingly, we have just launched a needs assessment in the Western Trust to look at the needs of the population on substance use. We have found that there is a plethora of services but they are not always well linked. Our task is to look at the services that we have, break down the barriers and get the culture that we need. This is for everybody: we need to have a collective vision and then work on how we start to do that on a daily basis in the operating procedures and all of that.

Mr Maxwell: The other opportunity for us is the setting up of the single mental health service and the collaborative board and how we cut the co-occurring issues across all the networks? There cannot be a stand-alone solution. The issue touches on all those pieces, so there is work for us to do to advocate for that and make it happen, but, also, that worker could do some of the linking work across all the groups, so there is an opportunity for us there.

Ms Flynn: I had that point written down, Gary. I will finish with this. The regional mental health crisis service is where you will get plenty of dual diagnosis and plenty of people who are battling mental health problems and addiction. Since the Minister has been in post, he has, to be fair, given a lot of time, as you have, to those with lived experience and to families who have been bereaved. Next Friday, the Minister will visit the People's Kitchen with me and come face to face and speak with people who are at the worst point in their lives and are battling addiction and homelessness. Fair play to the Minister, because all that is part of breaking down the stigma around how we treat people with those issues.

Mr Maxwell: To answer your question about MDTs, we are having conversations on how we can best link with their work. When we approached them, our approach was welcomed and they were really keen to think about how GPs and MDTs can help us across the piece from prevention through to recovery and where the space is for them to do that. Those conversations are in their early days. Some areas are probably slightly ahead because of work that they have done with GP federations etc, but, as that rolls out, there is a real opportunity to think about how we mainstream some of that work before people get to the point where they need addiction services and how we manage people in the community and stop them getting to those crisis points. There is a real opportunity there, but the conversations are in their early days.

Ms Flynn: Brilliant. Thank you so much.

Mr Donnelly: Quite a few of my questions were answered in the responses to Órlaithí. There are so many questions because it is such a serious issue; it is huge. There are higher levels of trauma in Northern Ireland than in the rest of the UK. I think that the levels of anxiety and depression in children are 25% higher in Northern Ireland than they are in the rest of the UK, which is absolutely shocking. We also have higher levels of prescription medication use than anywhere else in the UK. We have an established high-prescription culture. What are the reasons for that, and what are you doing to address it?

Mr Maxwell: That is a really interesting issue, and, over time, Northern Ireland has possibly been a slight outlier in prescription drug misuse. Ten years ago, it was probably the main issue that we faced, and benzodiazepines were probably the most common substances recorded on any death certificate. You can certainly see higher rates of prescribing in certain areas. When you look at the evidence, you will see that prescribing rates closely match deprivation rates and map closely with areas where there is leftover trauma from the Troubles or where peace infrastructure still exists. The closer you get to a peace wall, the more likely you are to have a prescription. That is the long and short of it. There is research that absolutely demonstrates that.

That has created two things. One is that, for a time, prescription drug misuse was an acceptable form of substance use in Northern Ireland when the likes of heroin or whatever were perhaps not seen as acceptable in our communities. There were lots of reasons for that. It might have been harder to get a supply of those substances, and so, over time, taking a pill or a tablet became normalised. There is definitely a legacy of that. Look at the situation in England and Scotland, particularly in Scotland. The benzodiazepine issue is alive and well in Scotland, and there is a clear market for synthetic benzodiazepines and pregabalin, which I should have mentioned because it is another key drug.

There are different aspects of what we are doing about it, and one is that colleagues in SPPG, not us, are looking at what prescribing rates are like in GP practices and whether they are within the norm for the level of need.

That is really complicated work, because it is hard to say who does and who does not need a prescription. There is work to look at that and think about how we manage the prescription bits. Then there is the work on the supply of illicit medicines, be they counterfeit, diverted or whatever. Specific work in the plan will look at prescription drug misuse and how we address that. We are already well in that space, because our services have seen it for so long that they are used to doing that.

The real challenge on the horizon is the introduction of synthetic benzodiazepines. They pose a real risk, particularly in polydrug misuse. They can be a lot stronger; their effect is different; and they might not present in an overdose situation in the way in which they did, so people may think that the user has had an opioid overdose. We are conscious of that. We are very much looking at and trying to learn from the work that Scotland is doing, because it is such an issue there.

Kevin or Julie, I do not know whether you want to add to that.

Mr Bailey: This is connected not necessarily to prescription drugs but to the other element, which is over-the-counter medication. Ongoing work around that includes a programme that is jointly led by the PHA and the SPPG to target community pharmacies, the development of a patient information leaflet and a training package for pharmacies. There is also an animation — I think that that is what we are calling it — that can be shown in pharmacies, most of which have flat-screen TVs or billboards on which that can be shown. It is about raising awareness. It is about that idea of psycho-education and getting people to stop and ask, "Do I actually need this pill? Will this pain or other thing that I am feeling be resolved by using a pill?". That apples whether it is an over-the-counter pill or one obtained through a prescription. It is about getting people to stop and think about that and wrapping around the support of the community pharmacist.

Mr Donnelly: That leads me on to my second question, which is about the accessibility of drugs. I noticed that, I think, outcome A relates to reducing the supply and accessibility of drugs. That is a huge challenge. I know that there has been an increase in drug supply in my constituency and, from what I hear, across Northern Ireland. I do not see it reducing. I appreciate the efforts of the police, but I do not see it being reduced. There is such a market that we will always have to deal with the issue. I see that one of the actions is to work with the UK Government to ensure that the Misuse of Drugs Act 1971 works as intended in Northern Ireland. Will you tell me a bit about how that works?

Mr Maxwell: The Advisory Council on the Misuse of Drugs was set up under the Misuse of Drugs Act to advise all UK Ministers, whoever they happen to be. In different Governments, different Ministers will be responsible for drugs: for example, in England, responsibility sits with the Home Office. We are now standing members of the advisory council, so we can seek advice from it and feed in our information on the Northern Ireland situation. For example, its recent report on cocaine provided a really useful opportunity for us to feed in the fact that we have seen an increase in the numbers injecting cocaine in Belfast, which they are not necessarily seeing in bits of England, although they are now starting to see that in Scotland. The advisory council was therefore able to take account of that.

There is a general point there about working collectively across all Governments, including North and South, and joining up on enforcement issues. You are right: reducing the supply of drugs will be a real challenge. Part of that is about reducing supply, and part of it is about reducing demand among the population — reducing the number of people seeking those substances. That will continue.

From our point of view, certainly, we will continue to feed into the Advisory Council on the Misuse of Drugs or our four-nation groups via the British-Irish Council etc, to say, "These are specific Northern Irish needs, and they need to be taken account of as part of the process". We will see how the new Government in England take that forward and how they position themselves on drugs issues. We will continue to watch those developments. Certainly, I sense that there is a greater willingness across the piece to reach out to all the devolved Administrations in order to take account of their needs and try to feed their evidence into the system.

Mr Donnelly: I have one last question. Given the number of deaths from injectable overdoses, which are, for the most part, preventable — I know that the naloxone distribution system has been expanded, which is fantastic; the more we get that out on the streets, the better and the more lives we will save — has any thought been given to progressing an overdose prevention centre here, probably in Belfast? Has that been progressed at all?

Mr Maxwell: The strategy does not contain a specific action about an overdose prevention centre. The UK Misuse of Drugs Act does not currently allow for that, and the position was the same when the strategy was being developed. Interestingly, the Advocate General for Scotland has allowed dispensation for a pilot in a specific area in Scotland. That is in the process of being set up. We had anticipated that it would be up and running by now, but there are always issues with getting those things in place. At the same time, our colleagues in the Republic of Ireland are piloting a system. Two differing approaches are being taken: one is much more clinically led, and the other is led much more by the community and voluntary sector. We will look at those two pilots to see what the outcomes are. Those are real UK and Ireland examples of how effective that will be in our cultural circumstances. We are different culturally from America, Switzerland and Australia, so we will look at the evidence really closely and, on that basis, make a case for needing or not needing something similar in Northern Ireland.

One of the other challenges is that budgets are incredibly tight. Against the commissioning plan of any service, we have to ask, "If we get additional money, where is that best spent?". It may well be that evidence from Scotland and Ireland will show that an overdose prevention centre is where that is best spent. Alternatively, do we invest more in prevention services or in our treatment and support services? There are conversations to be had about cost. There are huge differences in the price of the models, so it depends on which one you choose. Is it affordable, and, if it is, where would it sit? The first piece is about seeing evidence of local examples of delivery.

The other thing is that we are in a different place stigma-wise from Scotland and Ireland. We need to build that into the consideration of where we would put a centre, if we were to put one in place. I am thinking of the example of the Welcome Organisation. We would need to think about putting it somewhere where everybody could be safe. That would be a key consideration. There are, perhaps, more nuances in our culture than Scotland or Ireland has to deal with.

Mr Donnelly: The worldwide evidence for those centres is huge. The number of lives that they save is phenomenal. Overdoses are preventable when they are medically managed. It is a good idea.

Mr Bailey: For context, I will add that those other countries have a high population of injecting drug users. Our population of injecting drug users in Northern Ireland is relatively small. Our population has a bigger cohort of users who will use poly-substitutes, which are pills and powders, such as cocaine and other benzodiazepines. We would need to consider how we cater for the right cohort of people. Is it more than an overdose prevention centre? Is it a safer injecting site, for example, or is it something different? The international evidence base is slightly different, depending on which service you look at.

The Chairperson (Ms Kimmins): I remind members that it is almost 4.30 pm, and we have another briefing.

Mr McGrath: Thank you for the presentation. I will be quick.

I have two points. First, we can see that the final stage of tier 4 is about the importance of retaining inpatient services. I can see ward 15 when I look out of my living room window, and I know how important it is to our community. There have been changes in staffing, and there are pressures on the staffing in order to maintain the service. As part of what you do, will you review how services are staffed, so that we do not leave ourselves in a situation in which one member of staff exits and a whole service is in danger? Is there a way of fixing that?

My other point is about dual diagnosis. One of the more traumatic cases that I am dealing with involves a young person who is in a vicious circle of experiencing mental health issues; getting them sorted out; receiving their benefits twice a week, a big amount that goes straight to them; going straight out and using that money to buy drugs; and ending up in a bad way. It seems as though they go round in circles. The case that I have been helping with has been going on for years. The family are at their wits' end as they try to provide support. Is there a way in which we can finally crack that? Is there a service that we could direct people to in extreme cases? I share the family's concerns: they are just waiting for bad news coming through at some stage, and that is not what they want to face.

Mr Maxwell: I will pass to Julie to talk about tier 4 in a second. We recognise its importance in the system.

You touched on a wider point that is really important, which is workforce across all of the tiers. It is really important that we are connected into the mental health workforce review, because this is a specialism within mental health services and addiction psychiatrists are a specialism within psychiatry. We need to increase the number of both. We will not increase addiction psychiatry on its own. We need to increase the number of psychiatry roles and then addiction psychiatry roles within that. I reassure you that we are linked into those conversations on workforce and mental health, which is really helpful.

Julie, do you want to say anything on tier 4?

Ms Haslett: On your point, you will be pleased to know that we have kept ward 15 open, but there are real workforce constraints with that.

One of the things that the tier 4 review has looked at is the MDT approach in each of the wards and not being wholly reliant on the consultant-led role. The tier 4 review, when it comes out for public consultation on 26 November or thereabouts, will be really helpful in looking at that. As Gary has highlighted, that is a real issue in psychiatry. In addictions, three psychiatrists recently handed in their notice and have left the service. For such a relatively small service, that has a huge impact. We are struggling to recruit, so, as Gary said, that will be looked at in its wider sense.

The tier 4 review, if members want to know a bit more about it, is, essentially, looking at inpatient detox and our residential rehab services. That has been a very in-depth piece of work, looking at our current system, what works elsewhere and our demand from the population. Again, that will report on 26 November with recommendations. From that, we envisage a recovery network that looks at community detox through to the other end: how someone, once they have gone through treatment, is supported in a very assertive way post recovery, with the understanding that addiction is a condition where people can relapse and that the recovery line is always wavy and never a straight path. How do those people get supported all along the way?

That leads on to your next point. That assertive outreach part seems to be the way forward. People will falter. It is about how we as a system pick those people up again and remind them that there is hope. We are clear in our vision that we need enough services to keep that hope alive for individuals so that the family do not get to the point of ultimate despair and thinking that it will never change. There is always hope that it will change, but we need our services to be assertive enough to help with that.

Mr Maxwell: The other point, as Órlaithí mentioned, is that we need to make sure that the regional crisis service is responsive to those who "appear intoxicated". I put it as widely as that because it might not be a substance-use issue as part of the crisis but, often, the crisis will involve substance use. It is important that those people are not ruled out and are followed up in whatever way is needed. We will continue to work with our colleagues to make sure that that is the case. We recognise that those individual circumstances are always really challenging and difficult. As Julie said, the nature of this is that it can be a relapsing issue, and we acknowledge that, in the past, we have not done enough on the recovery bit. If we are going to sustain change for individuals and really give them hope, that recovery piece is really essential going forward.

Ms Haslett: I will just add that we are also focusing on substance misuse liaison nursing. We have talked with families about how painful it is when people come into ED, go back out and then come in again after they have overdosed. How do we get those people supported at the right time in the right place? We are working with South Eastern Trust colleagues to scope our current provision, looking at all of the data that we have and looking at models of best practice for what that looks like in our ED services to try to break some of the cycle that we have talked about.

Mr Bailey: It not just the individual experiencing this; the family are. One of the things that we are looking at and that we will commission imminently is part of our adult Step 2 service, which has wrap-around support for families. Families can be part of that support as a treatment partner for the individual, or they can get support in their own right, because, even after the person goes through the service and into recovery, the family are left with some of the things that have happened during that traumatic process and might need their own support.

Certainly, we can link in afterwards with localised support.

Miss McAllister: I will ask a quick question. Addiction is a societal problem, and many issues, such as poverty and poor mental health, which has been explored today, lead people to addiction. I sit on the Policing Board, and one element of our committee meeting this morning was drug seizures and what the police are doing to tackle drugs. We are seeing a lot of drugs being taken off the streets, but the problem is constant. It will always be a battle, and it is not just a policing issue, so it should not be just a policing fight. Addiction often results in criminality for people, but it is not their fault. I know that the police are trying different things to manage it differently, but what is the Department doing to work with the police and the Department for Communities to put pressure on to ensure that there is a Health approach to tackling poverty and the use of drugs? I am not talking about changing the law but about helping people and not turning them into criminals. Will you talk about your work with the police and the Department for Communities?

Mr Maxwell: We work really closely with police colleagues, primarily through the organised crime task force, which is our linking point for that. There is a lot of joint activity, and a lot of joint messaging goes out from us collectively. With the task force, we recognise that we will not seize our way out of the problem, but seizure can be part of the solution in that it can remove particularly dangerous drugs from the street, and it sometimes allows us to understand what substances are circulating in Northern Ireland and to put out harm reduction messages. We link up with a lot of police activity: if they are undertaking activity, we try to align with that. For those offences, we are keen to see what alternatives there are and to link in through things such as the substance misuse court that I mentioned earlier and different disposal options. We know that, if your crime is primarily about substance misuse, prison might not be the best place for you to deal with the issue or the trauma in the longer term. It is about linking those people back into our services.
We link well with the Department for Communities on the anti-poverty strategy. The Venn diagram of the overlap between poor health outcomes and poverty is almost a complete circle. There are almost no gaps: where you have poverty, you will have poorer health outcomes and health inequalities. Not just on substance use but across the piece, we are reaching out to our colleagues who are developing the new anti-poverty strategy to determine how that can be supportive of our wider health work, particularly focusing on inequalities and how we might target some of that more on those who need help most, where the biggest inequalities are. We know that health inequalities drive poverty, because we are talking about people who cannot engage in the workforce or take opportunities, so there is a vicious cycle. Healthy life expectancy for men in the most deprived communities is something like 58. That is, clearly, working age. It is about folks who cannot work because they are unhealthy. Not working is bad for their health — good health is good for your work — and it is also bad for our economy in Northern Ireland. There are lots of connections in working closely together across the piece.

We have really good working relationships with the PSNI in particular. We are really well linked in. We get intelligence reports that inform our harm reduction outputs. We have systems for testing substances of particular concern. We are well connected. We can always do more, and we will always try to do more and to build those connections, but obviously on some things such as disposal options, although we can make our case, the decisions are made elsewhere and in line with court guidance.

Mr Bailey: That space also includes Forensic Science Northern Ireland. Its information is key because we use it for our drug and alcohol monitoring and information system — DAMIS — alerts to our community, voluntary and statutory organisations with harm reduction information, advice and guidance so that they know what is happening in communities. A practical example of how the police and Health work together operationally is the operation and collection of remove all prescription and illegal drugs (RAPID) bins. As members may be aware, RAPID bins are found across communities, largely in community organisations or shopping centres — your Tesco and Asda and things like that — where people can dispose of any type of medication or drug. Using RAPID bins, the police and our commissioned Connections service work together to take those drugs out of the community. That is another practical example that does not often hit the headlines but happens across the Province daily.

The Chairperson (Ms Kimmins): Thank you all. That was very helpful, and other things will probably come out of it as we go along. The framework is next week, on 26 November, is it not?

Mr Maxwell: On 26 November, yes.

The Chairperson (Ms Kimmins): I am sure that Committee members will attend that. I appreciate your time.