Problem drug use in Scotland Contents

4Safe consumption facilities

72.In 2016 a proposal was put forward to open a safe consumption facility (SCF) in Glasgow City Centre as part of efforts to address the city’s high number of drug-related deaths and high HIV infection rate amongst people who use drugs. A SCF is a facility where people who use drugs can bring drugs to consume in a safe environment, with access to sterile equipment and medically-trained staff who are at hand to deal with complications. However, the Home Office has blocked the proposal arguing that such facilities pose ethical quandaries for medical staff and could lead to people who use drugs travelling large distances to access the facility. This has led to a protracted public debate between the UK and Scottish Governments, the NHS, third sector organisations, and the wider public. The proposal was raised by numerous witnesses and has been a key focus of our inquiry.

Harm reduction and SCFs

73.Harm reduction is a key tenet of the public health approach. Harm reduction holds that since some substance use is inevitable, the response to drug use should therefore primarily be focused on reducing the overall level of harm caused by use, rather than trying to prevent people taking drugs in the first place.196 Injecting equipment provisions are a prime example of harm reduction by reducing the risk of people who inject drugs contracting diseases or infections by sharing or reusing injecting equipment.

74.Safe consumption facilities are also a harm reduction tool which aims to; limit the acute risk of disease transmission through equipment sharing, prevent drug-related overdoses and connect people who are considered at high-risk of harm with health treatment and other related services. They also seek to reduce drug consumption in public places, thereby reducing harm to the wider community.197 Inside these facilities, medically trained staff typically provide people who inject drugs with sterile injecting equipment, supervision and education on safe injection methods, emergency care in the event of overdose, as well as referrals to appropriate social services, healthcare and drug treatment services.198 Medically-trained staff within this facility are not allowed to administer any substance on behalf of the service users. There are now around 100 safe consumption facilities in operation worldwide, including in France, Germany, Denmark, Canada and Australia.199

75.The general medical and academic consensus has been that these facilities are effective in reducing the level of harm caused by consumption of drugs. For example, the European Monitoring Centre for Drugs and Drug Addiction has shown that safe consumption facilities provide benefits such as improvements in safe, hygienic drug use, increased access to health and social services and reduced public drug use and associated nuisance.200 The Advisory Council on the Misuse of Drugs (ACMD) has also shown that they reduce high-risk injecting behaviours and overdose fatalities, based on studies of the effectiveness of facilities in Vancouver and Sydney.201 The ACMD’s report states that:

In addition to preventing overdose deaths, they can provide other benefits, such as reductions in blood-borne viruses, improved access to primary care and more intensive forms of drug treatment. No deaths from overdose have ever occurred in such facilities.202

Academic and medical evidence also suggests there is no evidence that these facilities “increase injecting, drug use or local crime rates”.203

76.We heard that SCFs reduce the sharing of injecting equipment and dangerous injecting practices, which is the biggest risk factor for blood-borne viruses such as HIV.204 Others argued that SCFs have also been proven to reduce the prevalence of drug-related litter, which has substantial health and social benefits for surrounding communities.205 Many witnesses were also clear that where these facilities have been introduced internationally, there has been “no apparent increase in crime or antisocial behaviour in the vicinity”.206 Other witnesses were clear that there is “no evidence that people prolong or progress their drug use as a result of safe consumption facilities”.207 When asked whether there is any evidence to suggest that SCFs are ineffective, have adverse impacts, or cause societal harm, Dr Priyadarshi and Elinor Dickie—expert representatives for NHS Scotland and Glasgow Alcohol and Drug Recovery Services—responded “no”.208 The Health and Social Care Committee have recently expressed their support for safe consumption facilities, and recommend that they should be piloted in areas of high need.209

77.In May 2019 we visited a safe consumption facility in Ottawa (Canada), and saw for ourselves how SCFs operate. Officials at the facility explained that the most effective safe consumption facilities are those which integrate health and addiction treatment with other relevant drug-related services, such as psychiatrists, psychologists, councillors, and welfare and housing advisors.210 Dr Angus Bancroft made the same point, highlighting that harm reduction—including safe consumption facilities—“is not an end in itself, but it is to make other things happen around it”.211 As it is often difficult to engage people who use drugs with treatment services, SCFs can act as a “gateway” to get people who use drugs to engage with housing, welfare and legal support services which can address the underlying drivers of their substance use.212 During our visit to Ottawa, we heard that approximately 85% of all clients of the safe consumption facility were referred to another service, and that there is no evidence to suggest the facility has increased or prolonged drug use.213 Members who visited Frankfurt saw a range of different approaches to SCFs, and felt the ones which offered wrap-around services, including employability training and accommodation were more effective than those which only offer a supervised space for individuals to consume drugs.214

Opposition to SCFs

78.Although the vast majority of evidence we have gathered unequivocally supports the effectiveness of SCFs, we have heard dissenting opinions. Dr McKeganey made an argument of principle against such facilities, saying that “I do not think it is the responsibility of services to facilitate drug consumption”.215 He added that SCFs establish a false choice between “just leaving them [people who use drugs] in the streets, or providing a drug consumption room”.216

79.In written evidence, Dr Ian Oliver argued that much of the evidence supporting the effectiveness of SCFs is “false”, and objected to the facilities because they “send out entirely the wrong message to people, particularly the young, that drug use is acceptable”.217 Dr Oliver contradicts a prominent study on the effectiveness of SCFs in British Columbia, and argues that official statistics show that SCFs result in an increase, not a decrease in drug-related deaths.218 However, the study Dr Oliver criticises has been through an extensive independent review process, and clearly shows that there has been a 35% reduction in fatal overdoses after a SCF was introduced in Vancouver.219 Dr Oliver also argued that the SCF in Vancouver has caused an increase in public disorder, which has turned the surrounding area into a “war zone”.220 One facility in Frankfurt, which some members of the Committee visited, did have high levels of drug use immediately outside it, which staff at that centre attributed to budget cuts which had reduced its opening hours on the day that we visited.221

80.The UK Government has also expressed opposition to SCFs. The Home Office has recognised the evidence base supporting the effectiveness of SCFs in addressing the problem of public nuisance associated with public drug use, and in reducing health risks for people who use drugs. However, they concluded that they could not support the implementation of them due to concerns over law enforcement, ethical quandaries for medical professionals and the risk that users would travel long distances to use them.222

81.The Home Office has also highlighted evidence that SCFs create a ‘honeypot effect’, whereby people who use drugs travel long distances to access the service.223 The particular example highlighted is the case of the Jutland Peninsula (between Denmark and Sweden), in which “Swedish drug users often come into Denmark to try to access harm-reduction services that perhaps don’t exist in Sweden”.224 Dr Priyadarshi argued that this is a particularly “unique situation”.225 Dr McAuley added that “there is no evidence of that happening in any equivalent services worldwide”.226 The Members of the Committee who visited Frankfurt also heard from professionals there who felt there had been some displacement of people who use drugs from Bavaria to Hessen because of the contrast between the criminal justice approach taken in Bavaria, and the public health approach taken in Hessen, including the availability of SCFs.227

82.In oral evidence to us, the Home Office minister told us that there is a “philosophical issue about […] condoning the commission of […] crimes”:

Fundamentally, those drugs are dealt illicitly and illegally, acquired illegally and consumed illegally. Paraphernalia is provided illegally. The premises would be provided illegally, unless obviously the law changes.228

83.Many witnesses took issue with the Home Office’s claim that SCFs raise “ethical quandaries for medical professionals”.229 Elinor Dickie, NHS Health Scotland, argued that “the ethical imperative to act is stronger”.230 Dr McAuley similarly told us:

I do not see what the ethical quandary would be there. They would be providing an evidence-based intervention. They would also be ethically addressing people at their point of need, reducing people’s likelihood to come to harm, so I cannot see that being a barrier.231

Dr Saket Priyadarshi—himself a practicing Associate Medical Director for the NHS—also questioned the validity of the Home Office’s argument, saying “on balance, ethically, I have not heard those concerns being raised by many [health professionals]”.232

84.The Home Office minister emphasised that SCFs are often seen as “a so-called silver bullet”, but that this is not the case, and that investment in treatment would instead be a more effective way to address problem drug use.233 However, most witnesses we heard from were keen to highlight that harm reduction, treatment, care and recovery are “a continuum” and that, as discussed earlier, they are a “gateway service” which is best utilised in conjunction with the provision of treatment services.234 Some witnesses also challenged the Home Office’s claim that SCFs can increase drug use in the area surrounding the facility. Elinor Dickie argued that “we see in the research that these facilities [around the world] have not contributed to any increase in the number of people who inject drugs, or in the number of drug dealers in the area”.235 Dr Priyadarshi supported this point, and added that the negative risks associated with SCFs—such as increased visibility of drug dealing—can be mitigated through appropriate coordination with the police, the local community, and service management, as well as appropriate levels of funding.236

85.Safe consumption facilities are proven to reduce the immediate health risks associated with problem drug use. These facilities do not come without their challenges. However, when effectively managed with appropriate levels of funding and cooperation from the police and other stakeholders, these risks can be mitigated. However safe consumption facilities should not be seen as a ‘silver bullet’, but as a way to get people with problem drug use to engage in other services which can address the underlying causes of their substance use.

Case for a safe consumption facility in Glasgow

86.As mentioned earlier, a safe consumption facility has been proposed for Glasgow by the Glasgow City Health and Social Care Partnership. After conducting a local needs assessment and feasibility study, the Partnership concluded that a safe consumption facility in Glasgow city centre would help address the health and social harms caused by public injecting.237 The proposal was supported by the Scottish Government, as well as groups including the Scottish Drugs Forum, National AIDS Trust, the Hepatitis C Trust, Waverley Care and Turning Point Scotland.238 The proposals have also been supported by the Scottish Parliament.239 We also heard that 79% of people using injecting equipment provision services in the centre of Glasgow said they would use the proposed safe consumption facility.240

87.Almost all of the witnesses we heard from were supportive of the proposal for a pilot facility. Dr McAuley told us that Glasgow’s case for a SCF “is arguably the most compelling case […] Europe has seen, not just the UK”.241 He added:

If you look at the most recent one that was opened in Paris, the case that that was built on was nowhere near as compelling as Glasgow, if you think about the HIV outbreak, the drug death epidemic, largest botulism outbreak Europe has ever seen. There is a whole host of reasons why Glasgow is a perfect case for the UK’s first consumption room.242

Whilst saying it would be impossible to predict exactly how many drug-related deaths a SCF would prevent, Dr Priyadarshi argued that a similar facility in Vancouver saw “a very significant reduction in the number of drug-related deaths” after its introduction.243 The Home Office minister took issue with this, and argued that “even in the best performing” safe consumption facilities, “you are looking at two to twelve” deaths being avoided.244 However, our evidence suggests that the number of lives saved could be much larger. Referring to a study on the same facility in Vancouver, Martin Powell, Transform, said “230 lives [were] saved in a 20-month period in British Columbia with a similar population to Scotland, just from their drug consumption rooms”.245

88.The UK Government also raised questions about the cost-effectiveness of SCFs. The Home Office minister highlighted that the operating cost of a SCF in Vancouver is $1.5 million, and implied that such costs—relative to drug-related health treatment and recovery—do not represent the best value for money.246 However, the estimated average lifetime cost of treating someone with HIV is £360,000 per person.247 This equates to more than £28m for the 78 new HIV cases developed amongst people who inject drugs in Glasgow for 2015/16 alone (or £500,000 per year). This suggests that a SCF in Glasgow would be a highly cost-effective measure. This was also reflected in the written evidence we have received. For example, NHS Health Scotland told us that, factoring in the savings made by reducing the transmission of blood-borne viruses such as HIV, safer drug consumption facilities are highly cost-effective and contribute to savings in health systems.248 Dr Tweed made a similar point:

We see in Canada and Australia these facilities were cost-saving, so although they require quite a substantial initial investment of money, they saved the health service money because of the averted blood-borne virus infections and overdoses. Those were quite conservative assumptions they used in looking at costs.249

The Advisory Council on the Misuse of Drugs has also made this point, highlighting that SCFs “save more money than they cost, due to the reductions in deaths and HIV infections that they produce”.250

89.However, the Home Office has rejected an application for a full statutory exemption for the reasons outlined in the previous section—namely, law enforcement concerns, ethical quandaries for medical professionals and the risk that users would travel long distances to use the facility.251 The Home Office said “there is no legal framework for the provision of drug consumption rooms in the UK, and we have no plans to introduce them”.252 The Government also reiterated that the Home Office has “no plans” to devolve responsibility for the control of drugs to the Scottish Parliament.253

90.The Scottish Government minister, Joe Fitzpatrick MSP, argued that if the UK Government does not want to grant a legal exemption for the facility, then the relevant drug laws should be devolved to the Scottish Parliament. He told us that there has been “absolutely” no attempt from the Home Office to continue discussions to find a mutually beneficial outcome in relation to SCFs, and that the Government has refused to engage with the Scottish Government on this issue for some considerable time.254

91.In oral evidence to us, the Home Office minister put less emphasis on his opposition to SCFs being based on his department’s previously made arguments around “ethical quandaries” or moral arguments. Instead, he said he has an “open mind” about potential solutions to problem drug use, and that he would be happy to have discussions about these.255 The minister’s principal concern appeared to be based, firstly, on the legal difficulties of practically implementing SCFs. Referencing the Lord Advocate’s evidence, the minister explained that under current legislation there are “some significant legal hurdles”, including civil liability issues.256 We address this later in this chapter.

92.The minister’s other primary reason for opposing SCFs, is that there are “lots of things that can be done immediately” and that we should not be fixated or distracted by one solution.257 He pointed to investment in heroin-assisted treatment, naloxone and methadone as examples of treatment services which are more “efficient and effective”, and result in better outcomes for people who use drugs.258 He added that financial resources are finite, and that funding a SCF may not be the best use of the Scottish Government’s resources.259

93.We believe there is a strong evidence base for a safe consumption facility in Glasgow, which would be a practical step to reducing the number of drug-related deaths in Scotland. Health is a devolved matter, and it is therefore deeply regrettable that the UK Government has chosen to block the proposed facility. We are not convinced by the UK Government’s argument that it will not give permission for such facilities because it believes that there are more cost-effective health care interventions. Under the devolution settlement, spending on health delivery is a matter for the Scottish Government. We recommend that the UK Government supports the proposed pilot safe consumption facility in Glasgow.

In the following section we will explore in more detail how the proposed facility could be lawfully implemented.

Legal options for Glasgow SCF

94.Under the Misuse of Drugs Act 1971, the proposed safe consumption facility in Glasgow would be illegal, and some form of special legal dispensation from the Act is therefore required for the facility to be lawful.260 The proposal would also result in a number of common law offences and issues of civil liability, which would need to be addressed. The Home Office has said “there is no legal framework for the provision of drug consumption rooms in the UK, and we have no plans to introduce them”.261 However throughout our inquiry it was suggested that, despite the Home Office’s rejection, it may be possible to open a facility under the existing legal framework. We explore these options in the following sections.

Letter of comfort

95.The first proposal was for the Lord Advocate—Scotland’s chief public prosecutor—to issue a ‘letter of comfort’. This document would contain a guarantee that the facility’s operation would not be legally challenged or the subject of prosecution, despite the technically illegal activity that would be conducted inside. Glasgow City Health and Social Care Partnership wrote to the Lord Advocate seeking such a letter. In November 2017 the Lord Advocate declined to offer the requested guarantee on the basis that “while the Lord Advocate can make decisions as to whether or not a criminal offence will be prosecuted, he cannot alter the basic quality of the activity as criminal in law”.262 In other words, the Lord Advocate argued that the legal guarantee sought by the Partnership was beyond the scope of the dispensation he was able to offer.

96.The Scottish Drugs Forum was critical of the Lord Advocate’s decision, and argued that the proposed guarantee would be within the scope of the Lord Advocate’s powers, noting that a similar exemption from prosecution has previously been granted for similar harm reduction measures—notably, injecting equipment provision services—and that it is therefore possible to do the same for safe consumption facilities.263 Dave Liddell, CEO, Scottish Drugs Forum, told us that:

Our view—and obviously that was the view of Glasgow as well when it put it forward—was that the Lord Advocate could issue a letter of comfort, as he has done in other related areas like naloxone, for example.264

However, the Lord Advocate told us that a SCF requires a legal solution which provides “an appropriate system for licensing and oversight, addresses the scope of exemptions from the criminal law, and deals with issues of civil liability”.265 He explained that a legal solution of that complexity is beyond “what it is appropriate for me to do as the person charged with the enforcement of the criminal law”, and that “I simply cannot create that kind of regime through a letter of comfort”.266

Police agreement

97.Instead of formal dispensation from the Lord Advocate, some witnesses argued that an agreement between the facility and local police not to pursue drug-related offences within the facility might be sufficient. During our visit to a SCF in Ottawa, we heard that a working agreement with local law enforcement is crucial to the effective operation of the facility.267 Professor Alex Stevens explained such an arrangement is also used for a comparable facility in Copenhagen:

The drug consumption room in Vesterbro in Copenhagen has a police-declared non-enforcement zone for possession offences around it. Within that zone, people who use drugs will know that they are not going to be arrested and punished for possession of substances.268

Elinor Dickie, NHS Health Scotland, suggested a similar agreement might be an avenue worth exploring in Glasgow.269 Detective Chief Inspector Kew, Thames Valley Police, also expressed support for this approach, and questioned whether the ‘public interest’ test would be met for taking legal action against the proposed SCF in Glasgow. DCI Kew argued that “if there is no public interest to meet that threshold for a prosecution, the positioning of the legislation standpoint is undermined by that health emergency”.270 This view was also supported by Assistant Chief Constable Johnson, Police Scotland, who argued that “given our [police forces’] duty around preservation of life, I do not think it would be in the broader public interest”.271 ACC Johnson added that if the proposed facility was “legitimate”, Police Scotland would work with the NHS and other stakeholders to support it.272

98.However, we heard concerns that any solution short of a full legal exemption—including the proposed agreement between local law enforcement and the facility—could place staff who work in the facility in legal jeopardy. This was the view of Professor Stevens, who argued that the absence of a full legal exemption puts police services and individual officers “in invidious positions”.273 This concern was shared by police force representatives. Assistant Chief Constable Steve Johnson, Police Scotland, explained the difficult position legal ambiguity presents for on-duty police officers:

From an officer perspective, if you are an officer and you are walking the streets of Glasgow where that facility is and you stop someone who is on their way [there] in possession of those drugs, there is a hefty dose of the “woulda, coulda, shoulda” squad. If the person does not then go to the safe facility […] but takes themselves down by the side of the Clyde and injects and falls in the river and dies, the “woulda, coulda, shoulda” would be “what are the police doing? You had a power; you did not exercise it”. That person should have been in a custody facility, put in front of the sheriff, from the sheriff to the court […] That is a harsh reality faced.274

The Lord Advocate did not comment at length on the legality of an agreement between a facility and police authorities, but stated that “in my view that would not be an appropriate approach”.275

Exemption from the Misuse of Drugs Act

99.Given the problems with both approaches, we returned to the question of what legal changes would be needed to allow a SCF to be opened in Glasgow. Our evidence suggests that the implementation of a legal framework would not require a substantial or lengthy legal change,276 and could be implemented using existing powers under section 22 of the Misuse of Drugs Act 1971. This was the preferred position of NHS Health Scotland, who have recommended that the UK Government make the necessary changes to reserved legislation to allow a facility to open or, failing that, to “devolve the powers in this area”.277 Waverley Care similarly advocated for the removal of legislative barriers, or the devolution of drugs laws to the Scottish Parliament. The Lord Advocate argued that, if it is decided that the proposal should go ahead, it is “absolutely” the responsibility of Westminster to legislate, rather than it being up to him to create a legal work-around. He added that, since SCFs are a controversial solution, legislation is the most appropriate way to “resolve the policy issues in a democratically accountable way”.278

100.The Home Office minister argued that “it would take some time to sort out the legislation” necessary, and that “there are other things that could be done much more quickly”.279 However, the necessary legislative changes could be made with simple and expedient regulations under existing powers in the Misuse of Drugs Act.280 The minister also argued that even if the criminal aspects of SCFs could be dealt with through legislation, there is still the risk of civil liability which, he argued, cannot be dealt with by legislation.281 However, our legal advice (see footnote) suggests that civil liability issues could be dealt with through primary legislation.282 It was also not clear whether the civil liability risks the minister identified were any different to those associated with any other lawful medical intervention.

101.We do not believe that it would be acceptable to try to open a safe consumption facility in Glasgow under the current legal framework. Doing so would risk putting clients, NHS staff, and governance bodies in legal jeopardy. We recommend that the UK Government brings forward the legislation necessary to allow for the lawful establishment of a pilot safe consumption facility in Scotland. If the UK Government is unwilling to do so, it must instead devolve competence for drugs legislation to the Scottish Parliament, so that it can implement the health approach it deems to be in Scotland’s best interest.

196 Harm Reduction International. 2016. What is harm reduction?

197 Scottish Parliament Information Centre, Drug Misuse, March 2017

201 Advisory Council on the Misuse of Drugs, Reducing Opioid- Related Deaths in the UK, December 2016; Transform (UMD0043)

202 Advisory Council on the Misuse of Drugs, Reducing Opioid- Related Deaths in the UK, December 2016

203 Potier, C. et al. 2014. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend. 1(145). Pg. 48–68; European Monitoring Centre for Drugs and Drug Addiction. 2018. Perspectives on Drugs—Drug consumption rooms: an overview of provision; Advisory Council on the Misuse of Drugs, Reducing Opioid- Related Deaths in the UK, December 2016

209 Health and Social Care Committee, Drugs Policy: First Report of Session 2019–20, HC 143

213 Public Health Ottawa, Report to Ottawa Board of Health: Harm Reduction and overdose prevention - Follow-up report, February 2018

217 Ian Oliver (UMD0047)

218 Ian Oliver (UMD0047)

220 Ian Oliver (UMD0047)

222 Letter from the Home Office to Glasgow City Council, obtained by Committee team

223 Home Office, Drugs: International Comparators, October 2014

229 Letter from the Home Office to Glasgow City Council, obtained by Committee team

237 Tweed, E. Rodgers, M. 2015. “Taking away the chaos” The health needs of people who inject drugs in public places in Glasgow city centre. Glasgow. NHS Greater Glasgow and Clyde

238 Scottish Government, Letters publicly provided under the Freedom of Information (Scotland) Act 2002; Q33

239 Scottish Government, Letters publicly provided under the Freedom of Information (Scotland) Act 2002

247 NHS Health Scotland/NHS National Services Scotland (UMD0021)

248 NHS Health Scotland/NHS National Services Scotland (UMD0021)

250 Advisory Council on the Misuse of Drugs, Reducing Opioid- Related Deaths in the UK, December 2016

251 Letter from the Home Office to Glasgow City Council, obtained by Committee team

252 Scottish Government, Letters publicly provided under the Freedom of Information (Scotland) Act 2002

253 Scottish Government, Letters publicly provided under the Freedom of Information (Scotland) Act 2002

261 Scottish Government, Letters publicly provided under the Freedom of Information (Scotland) Act 2002

262 Lord Advocate (UMD0049)

263 Scottish Drugs Forum (UMD0024)

276 Qq315–316; see footnote 283

277 NHS Health Scotland/NHS National Services Scotland (UMD0021)

280 See footnote 281

282 The criminal consequences of operating a SCF, under the Misuse of Drugs Act 1971, could be avoided by simple, expedient regulations made by the Secretary of State under section 22 of that Act. These would be made by statutory instrument and subject to Parliamentary scrutiny under the negative resolution procedure, whereby either House of Parliament could cancel (annul) the regulations: see section 31 of the Act. The offence of being the occupier or manager of premises and knowingly allowing the supply of a controlled drug, contrary to section 8, could be avoided, as could offences of, for example, supplying syringes contrary to section 9A. The possibility would remain, though, of those operating SCFs being sued (e.g. for damages) in civil proceedings by, for example, anyone injured as a result of things done in the SCF. If operators could not insure against the risk of civil liability, primary legislation might be needed.

Published: 4 November 2019prob