COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 9 Jul 2009

Special Report No. 64 of Comptroller and Auditor General: Drug Addiction Treatment and Rehabilitation.

Mr. Gerry Kearney (Secretary General, Department of Community, Rural and Gaeltacht Affairs) called and examined.

Chairman

I draw everyone's attention to the fact that while members of the committee enjoy absolute privilege, the same privilege does not apply to witnesses appearing before the committee. The committee cannot guarantee any level of privilege to witnesses appearing before it. I remind members of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official, either by name or in such a way as to make him or her identifiable. Members are also reminded of the provisions within Standing Order No. 158, that the committee shall also refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such policies.

I welcome Mr. Gerry Kearney, Secretary General of the Department of Community, Rural and Gaeltacht Affairs. Mr. Kearney, please introduce your officials.

Mr. Gerry Kearney

The Department official accompanying me is Ms Kathleen Stack, assistant secretary in charge of the national drugs strategy.

Chairman

I also welcome Ms Gretta Crowley, HSE acting assistant national director with responsibility for primary, community and continuing care. Ms Crowley, please introduce your officials.

Ms Kathleen Crowley

I have with me, Mr. Joe Doyle, national rehabilitation co-ordinator from the Health Service Executive.

Chairman

I also welcome an official from the Department of Finance.

Mr. David Moloney

I am David Moloney from the Department of Finance.

Chairman

Mr. Buckley, please introduce Special Report No. 64 on drug addiction treatment and rehabilitation.

Mr. John Buckley

The two main objectives of the National Drugs Strategy 2001-2008 related to the treatment and rehabilitation pillars — first, to enable those dependent on drugs to avail of treatment and encourage them to do so; and second, to minimise the harm to those who continue to engage in drug taking activities that put them at risk. A new strategy for the period 2008-16 has been presented to Government and will be published in the near future.

Today's meeting focuses on the co-ordination role of the Department of Community, Rural and Gaeltacht Affairs and the services delivered directly by the HSE and the bodies that it funds to provide services in the areas of treatment and rehabilitation. A further meeting is planned to examine the role of the justice system.

This examination looked back at the progress over the strategy period and focused on three main questions: whether required treatment was being made available in a timely way; the arrangements in place for evaluating treatment effectiveness; and how well the services were co-ordinated. Before turning to the results of the examination it may be useful to give some context. Illicit drug use falls into two categories, the use of opiates such as heroin and the use of non-opiate drugs including cannabis, cocaine and ecstasy. Different addictive patterns are associated with each category which in turn impacts on the nature of the response by the health services that may be appropriate or possible.

It is estimated that 0.5% of the population aged between 15 years and 64 years use opiates such as heroin. Up to recent times its use was concentrated in the greater Dublin area, but more recently it has spread countrywide. The response to heroin addiction has been to put a needle exchange programme in place for active users in order to prevent harm and infection, to provide substitutes mainly under the methadone treatment programmes, to assist misusers who have reduced their drug dependence to an appropriate level to detoxify and to provide residential rehabilitation programmes for those abstaining from drugs.

In the case of opiate addiction, the audit found that needle exchange facilities are not provided in five of the ten HSE areas. The north east and south east areas do not or did not at the time of the audit have needle exchange facilities, in spite of evidence of a significant problem with intravenous drug use. There has been a steady increase in the provision of methadone treatment, the main substitute for heroin. By the end of 2007, just over 8,000 people were receiving treatment compared with 5,000 at the end of 2000.

In regard to the timeliness of response, we found that treatment for opiate addiction was provided to 61% of those who were assessed within the target period of one month, the period set in the strategy. We found also that services for this type of addiction are not well developed in areas such as the midlands and south, which had waiting times of more than a year for methadone treatment. The number of individuals undergoing detoxification is low compared with the numbers in treatment and represents 1.25% of those on methadone maintenance treatment. We have suggested that it would be useful to set targets for progression from methadone maintenance to detoxification and rehabilitation. The existence of these targets would provide a challenge in this area and give a focus to capacity planning.

I will deal with non-opiate drug use. The use of cannabis and cocaine among the general population is rising. In addition, polydrug addiction, that is addiction to a number of drugs, including alcohol at the same time is an emerging problem. Whereas methadone is the main response to opiate addiction, in the case of non-opiates the main helping interventions take the form of counselling, which is availed of by two thirds of clients, and cognitive behaviour therapy which is the other main intervention. On our examination of the treatment of non-opiate addiction, we found that the number of individuals treated for non-opiate addiction has not increased substantially during the life of the current strategy. In 2007, 2,000 individuals received treatment. One apparent trend is that a much lower proportion of the non-opiate drug users enter treatment in the capital than outside Dublin. It would be useful to do some research to get to the underlying cause of this. In regard to the timeliness of treatment in the non-opiate area, we found that almost all of the treatment was provided within the one-month target time set in the strategy.

Turning to evaluation, the State needs complete, accurate and timely information if it is to focus its treatment and rehabilitation efforts and evaluate their effectiveness. Better information on the demand for treatment and the results of that treatment could be generated by standardising the recording practices of treatment providers so as to get a better handle on the actual demand for treatment and the time people are waiting to be assessed for that treatment, and finding a way of recording treatment completion rates and outcomes by tracking the progress of individual clients and improving the information on the costs of the various treatment services.

On a more general level, it would be useful to identify the extent to which the use of illicit drugs actually develops into problem drug use. The lack of good information on the costs of treatment and the numbers treated, and the type of treatment delivered and the outcomes of that treatment, hampers any evaluation of cost effectiveness. However, it must be acknowledged that the findings of a study which followed the progress of a sample of 400 clients in treatment for opiate addiction suggests that retention rates are high, with 69% of clients still in treatment three years later and a general reduction in drug misuse being reported.

Evaluating the effectiveness of treatment in the non-opiate addiction area presents a challenge, but it may be possible to design a similar follow-up study capable of assessing the outcome of different interventions in that area. While some pilot projects on the treatment of cocaine abuse have been conducted, it would be useful to distil any lessons learned from them so that the results can be used to identify effective treatment approaches. Co-ordinating the efforts of the many agencies involved at national and local level proved to be a challenge during the life of the strategy. National structures, such as an interdepartmental group designed to provide co-ordination at a national level did not work as well as intended and this was mainly because the group did not have representation from all of the agencies involved in the delivery of the treatment and also because agencies were often not represented at the required level of seniority.

In addition, while an objective in the strategy was to establish protocols that govern interagency arrangements and thereby ensure smooth transitions for the client between the different phases of his or her treatment, in general this has not yet happened. Overall, the audit concluded, based on the best practice identified in Ireland and abroad, that in order to deliver services at the optimum level and effectively operate the continuum of care model, there would be a need to have an individual care plan for each client of the service, an identified care manager for that client in order to co-ordinate services envisaged in the care plan, and an assigned key worker in each of the agencies involved in the service delivery.

Chairman

Thank you, Mr. Buckley, would Mr. Kearney like to make his opening statement?

Mr. Gerry Kearney

I welcome the opportunity to address the committee on the drug addiction treatment and rehabilitation report by the Comptroller and Auditor General.

The nature and scale of the drug problem in Ireland has undergone significant changes in the past decade. The primary focus when the previous policy was drawn up was on the opiate problem, primarily in areas of disadvantage in Dublin. While heroin use has stabilised to an extent in Dublin, this has been offset by its wider dispersal across the country. In addition, there is now considerable concern regarding the use of cocaine, particularly combined with other illegal substances and-or prescribed substances as well as alcohol.

The report of the Comptroller and Auditor General focuses on the delivery of treatment for both opiate and non-opiate drug users, as well as issues around access and effectiveness. Clearly the evaluation of treatment effectiveness is complex and this is acknowledged in the report, while it also points to research work undertaken through studies done by the national advisory committee on drugs. Co-ordinating structures and oversight arrangement for the national drugs strategy as raised in the report are matters that fall within the remit of my Department and in this context, particular issues raised by the Comptroller and Auditor General in his report concern improving co-ordination mechanisms, strengthening performance indicators and the governance of local projects. The local and regional drugs task forces and the national advisory committee on drugs which undertake key drug related research also come within the ambit of my Department.

I will briefly outline how the co-ordination arrangements have worked and the measurements that are currently in the pipeline arising from the new drugs strategy, as approved by Government

The drugs strategy which covered the period 2001 to 2008 was delivered through five pillars, namely, supply reduction, prevention, treatment, rehabilitation and research. A wide range of statutory, community and voluntary sector organisations were and are involved in its delivery at national, regional and local levels. This constitutes a complex cross-cutting area of public service policy and service delivery and is therefore a significant challenge. The principal co-ordination structures for the delivery of the National Drugs Strategy 2001-2008 have until recently comprised the national drugs strategy unit in the Department, which works to co-ordinate the inputs of various Departments and agencies delivering the strategy, and to manage the development policy. The second is the national drugs strategy team which oversaw the operation of the local and regional drugs task forces. Relevant Departments and agencies, as well as representatives of the community and voluntary sector were represented on the team on a half-time basis. The work of the team concluded at the end of April. The third structure for delivery of the national drugs strategy is the interdepartmental group on drugs chaired by the Minister of State at the Department of Community, Rural and Gaeltacht Affairs. A significant role of the group has been to resolve emerging operational difficulties in implementing the strategy and monitoring the progress of mainline services. These structures are in addition to the local and regional drugs task forces through which a range of community-based services is delivered.

Proposals for a new national drugs strategy to cover the period up to 2016 were approved by the Government last month. The new strategy will continue to focus on tackling the drugs problem based on the five pillars to which I referred. In developing its proposals for the new strategy, the steering group, which comprised representatives of public bodies, the community and voluntary sector and other players, examined the progress and impact of the existing strategy. It also reviewed the operational effectiveness of the structures underpinning it, including co-ordination mechanisms.

Several issues emerged as particularly significant arising from the steering group's extensive consultation. The first of these is the nature and scale of the current drug problem. Another is the problematic use of alcohol, both as a stand-alone public health issue and in association with illicit drug use. This issue was repeatedly raised during the consultation process. Another issue discussed was the importance of bringing together Departments, agencies and the community and voluntary sectors to develop a collective response to the drugs problem. The value of this partnership approach is recognised and will continue to underpin the implementation of the new strategy.

The Government has given approval for the development of a combined national substance misuse strategy to cover both alcohol and drugs, which is expected to be developed by 2010. A further recommendation from the new strategy is that a dedicated office of the Minister for drugs be established to support and drive the implementation. This follows from concerns regarding previous co-ordination arrangements across the national drugs strategy team, the task forces, the Department and the interdepartmental group. It is intended that the office will be established shortly. It will provide a more cohesive and integrated framework which promotes closer co-operation and accountability between the different Departments and agencies involved in delivering the actions set out in the strategy. It will also aim to provide greater transparency for expenditure across agencies.

I hope the brief overview I have given of the structures and issues relating to the national drugs strategy will be of assistance to the committee in considering the Comptroller and Auditor General's report. Clearly, public bodies such as the Health Service Executive, the Garda Síochána and education organisations are major players in the delivery of the strategy. However, it is important also to acknowledge the key role of the community in the fight against drugs, at both local and national level.

Chairman

May we publish Mr. Kearney's statement?

Mr. Gerry Kearney

Certainly.

Chairman

I invite Ms Crowley to make her opening statement.

Ms Gretta Crowley

As the public body primarily responsible for the provision of treatment and rehabilitation services, the Health Service Executive welcomes the report of the Comptroller and Auditor General on drug addiction treatment and rehabilitation. The key issues identified in the report which are of relevance for the executive are those relating to the setting of targets for waiting times for methadone treatment, the expansion of needle exchange services, and the upgrading of the current national drug treatment reporting system to provide improved information in regard to non-opiate treatment.

The Health Service Executive fulfils its responsibility in regard to the provision of treatment and rehabilitation services through a combination of direct provision by executive staff, significant funding of voluntary agencies to provide services on its behalf, and a broad range of partnerships with community-based groups and agencies. Individuals presenting for treatment for opiate-related issues are provided with a full and comprehensive assessment in terms of both their medical and psycho-social needs. The range of interventions includes assessment, stabilisation, harm reduction measures, care planning, methadone maintenance, counselling, and detoxification within specialist clinics, residential settings and community settings. It should be noted that due to the complexity of this client group, people will enter and re-enter services and may need interventions on more than one occasion. This necessitates focused engagement and flexibility.

The approach adopted by the Health Service Executive has enabled us to exceed the national drugs strategy target of 6,500 places for the provision of methadone treatment, with a 73.3% increase from the 5,032 patients in treatment as at 31 December 2000 to 8,718 as at 31 December 2008. It has also allowed us to develop innovative responses to facilitate the roll-out of needle exchange services throughout the State. We have developed appropriate responses to emerging needs within existing resources. The executive has also commenced the roll-out of the rehabilitation strategy.

As referenced in the Comptroller and Auditor General's report, the funding committed to addiction services has increased year-on-year over the lifetime of the national drugs strategy from 2001 to 2008. In 2008, €101.87 million was spent by the Health Service Executive on specific addiction services provided either directly by the executive or by community and voluntary addiction services funded by it. This represents an increase of more €45.9 million from 2001 levels of funding. In addition, it should be noted that mainstream health services such as accident and emergency, acute hospitals and mental health services address the treatment needs of alcohol and other substance misusers who avail of them. Those services are not included in the figure of €101.87 million.

Notwithstanding current pressures on Health Service Executive finances, the numbers receiving treatment continue to rise and addiction services continue to develop. Provision was made for 3,686 additional methadone treatment places from 2001 to 2008. Needle exchange services have been established in 13 local drug task force areas and five regional drug task force areas, covering the areas most affected by opiate misuse. The establishment of the national addiction training programme, in partnership with Waterford Institute of Technology and the community and voluntary sectors, resulted in the upskilling of 1,645 front-line staff, utilising 17 evidence-based treatment modules. This training has enabled the Health Service Executive addiction service to respond to the changing trends in prevalence, such as polydrug use involving cocaine, alcohol and so on, as well as keeping a focus on opiate abuse.

The Health Service Executive as the lead agency has commenced the implementation of the report of the working group on drugs rehabilitation by establishing the national drugs rehabilitation implementation committee and employing a national senior rehabilitation co-ordinator. This committee is developing a rehabilitation framework for all addiction services, as recommended in the report. The Health Service Executive welcomes recognition in the report of co-ordination arrangements already in place in several areas.

We acknowledge the challenges that exist in regard to waiting times for treatment in certain parts of the State where drug usage has increased significantly in recent years. While there are approximately 600 clients on waiting lists, more than 10,000 clients received methadone treatment in 2008. Furthermore, 454 patients successfully completed treatment and ceased their methadone maintenance programme in 2007, a figure that has been increasing year-on-year since the commencement of the strategy. The fact that clients have commenced and remained on a methadone programme is of immense significance in stabilising the quality of their family life, workplace involvement and social interaction. This is particularly relevant as approximately 35% of patients received methadone services from a local general practitioner.

To address the issue of waiting times, the Health Service Executive, with the assistance of minor capital grants from the Department of Community, Rural and Gaeltacht Affairs, is developing additional methadone clinics in Limerick city, Cork city, the south east, the midlands and the north east this year. The recruitment of additional level one and two GPs and pharmacies to participate in the methadone programme is essential to reducing waiting times for treatment. The Health Service Executive is actively pursuing this through our GP and pharmacy liaison officers. In 2008, 274 GPs and 496 pharmacies participated in the methadone maintenance scheme. An on-line level one GP training module is available through the Irish College of General Practitioners to assist with the recruitment and retention of GPs at community level. This will facilitate the transfer of clients from Health Service Executive clinics to community-based provision. The executive intends to recruit an additional liaison pharmacist to support pharmacies outside the greater Dublin area to participate effectively in the protocol.

While methadone maintenance is the main form of treatment, the Health Service Executive, in collaboration with the Department of Health and Children, is currently undertaking a suboxone feasibility study. We expect to have 80 clients in treatment in both clinic and community-based settings by year end.

The HSE's collaboration with the Irish Pharmacy Union, pharmacy providers and the Elton John AIDS Foundation will see access to harm reduction or needle exchange services available countrywide by year end. It is hoped that this significant public health measure subsequently will have a positive impact on both health and social gain for heroin users and the community at large.

Finally, in regard to updating the national drug treatment reporting system, the HSE acknowledges that it now is time to develop an Internet-based system that will collect data on client access to all addiction services, including counselling, support services and methadone, as well as to client treatment progression; and on service costs aligned to treatment provision. The HSE has commenced this process with the support of the Health Research Board and plans to develop an Internet-based system for the entire country building on local systems that already have been established as pilots. This system will be made possible with the introduction of a unique identifier for clients accessing addiction services.

Chairman

May the committee publish Ms Crowley's statement?

Ms Gretta Crowley

Yes, it may.

Deputy Róisín Shortall

I welcome the witnesses and thank them for their presentations. I will start with Mr. Kearney and the role of the Department in respect of the National Drugs Strategy 2001-2008, part of which was considered by the Comptroller and Auditor General in his report on treatment and rehabilitation. A mid-term review of that eight-year strategy was carried out in 2005 that provided a highly detailed progress report on its various objectives. Why was an end-of-term review not carried out? The progress report was a comprehensive and helpful document. Why was something similar not produced at the end of the eight-year strategy?

Mr. Gerry Kearney

The process of the end-of-strategy review comprised the work undertaken by the steering group in the development of the new strategy. It looked at what had been achieved, consulted community groups and developed a number of papers for deliberation. It might be helpful were I to ask my colleague Ms Kathleen Stack to say a little more on that point.

Ms Kathleen Stack

As the Deputy will see when the new strategy is published, a substantial block of work in the new strategy looks at the impact and is a continuation of the mid-term review in that it goes through each of the pillars and assesses how the actions have progressed. It is a similar exercise to what was done in the context of the mid-term review and will form part of the new strategy.

Deputy Róisín Shortall

Is that available to members for examination?

Ms Kathleen Stack

It is being printed at present. It was approved by the Government in the middle of June, is being printed and will be published.

Deputy Róisín Shortall

It is a review of the previous strategy.

Ms Kathleen Stack

Yes.

Deputy Róisín Shortall

It will form part of the new strategy.

Ms Kathleen Stack

Yes.

Deputy Róisín Shortall

Very well. Halfway through 2009, why has the new strategy not appeared? The previous strategy ended at the end of 2008. What is the reason for the delay in producing a new strategy?

Mr. Gerry Kearney

One reason was that in the course of consultations, massive concern was expressed at community level, and this will come as no surprise to the Deputy, that we no longer should deal with the drugs issue on its own. Alcohol was becoming much more influential and had a bigger place in respect of the issue of the drugs strategy. This meant that part of the process before the finalisation of the strategy entailed travelling to the Government and securing cross-departmental agreement to develop a joint strategy on alcohol as a drug and drugs. That was part of the delay.

Deputy Róisín Shortall

Concern about alcohol abuse is not a recent phenomenon and has been coming through to the Department from local drugs task forces for many years. It is not really an excuse for delay in producing a new strategy, is it?

Ms Kathleen Stack

The Government has now decided there will be a substance misuse strategy that will cover both drugs and alcohol. Consequently, the drugs strategy element will form part of a wider substance misuse strategy that will be published next year. The drugs elements had to be done first and that took some time to work itself through. However, it has now been approved by the Government.

Deputy Róisín Shortall

Okay, but that still does not explain the reason for the delay.

As for treatment and rehabilitation, what would Mr. Kearney consider to be the main lessons learned from the first strategy?

Mr. Gerry Kearney

I will address this question at a more general level, as the Accounting Officer of the Department, rather than as a specialist. The main thing, which was brought out by the Comptroller and Auditor General's report, must concern the quality of the indicators that are put in place at the time of the development of the strategy. The second thing learned must be the highly volatile nature of the clientele with which we are dealing. The third lesson we have learned is that the central mechanisms in place, both to manage treatment and rehabilitation and in general, have not been sufficiently effective to secure coherence across the €270 million that was spent directly last year in drug interventions generally.

Deputy Róisín Shortall

Mr. Kearney referred to a figure of €270 million last year. I thought the figure for treatment was €140 million.

Mr. Gerry Kearney

Yes, it was. I was simply talking about expenditure across Departments generally.

Deputy Róisín Shortall

Very well. However, €140 million per year constitutes a highly substantial level of expenditure. What has the Department learned from that? What will be different in the new strategy in respect of the Department's approach to treatment and rehabilitation?

Mr. Gerry Kearney

The first thing that will be different will relate to the quality of the data that must be collected, which must be much more centred on the individual. Second, the approach to treatment must be based around a full continuum of care for the individual. From where I am standing, the third point concerns the alignment of the projects at local level and the services provided by the public bodies, which must be improved.

Deputy Róisín Shortall

There is an obvious lack of target-setting in respect of the objective of treatment. Does Mr. Kearney accept this is the case? At the outset of the strategy, the drugs problem was new to many people and to various State agencies. There is a certain element of people finding their feet and learning how to deal with this relatively new phenomenon. The thrust of the approach and the policy regarding treatment appeared to have been to get opiate users into treatment without thinking about what such treatment would entail or its duration, cost or objective. Does Mr. Kearney accept this was a problem and that the focus was to contain the problem at community level in particular communities with a particular focus on reducing crime?

Mr. Gerry Kearney

I am unsure whether I would fully accept that. To return to the Deputy's original question, at the time when it was done a particular priority was to improve radically the availability of methadone for treatment and to improve the availability of needle exchanges and other things. However, the strategy developed and was subject to a mid-term review. As for the specifics regarding the development of the indicators, I would be more comfortable were the HSE also to comment in this regard. However, the point made by the Comptroller and Auditor General, with which I would agree, was there were specific indicators and targets set out in the national drugs strategy that were revisited in the mid-term review but that these were not as strong on the qualitative aspects of a client, rather than on particular volume targets being met. Were the HSE's representatives also to comment on this point from the perspective of their direct experience, I would be more comfortable.

Deputy Róisín Shortall

While I may go on to that in a few moments, I am keen to pursue this a little from a policy perspective. There was a definite political imperative to deal with the associated crime related to the issue of drugs, which was a legitimate objective. As someone who has a couple of drugs task forces and methadone clinics in my constituency and like other public representatives, I was happy to sell the idea of treatment centres from that point of view and there was a definite correlation between the provision of treatment and a reduction in crime. That is perfectly valid. However, is it not the case that this was the extent of the policy in this regard and that adequate consideration was not given to what the objective of the treatment plan might have been from the user's perspective? From the ROSIE review, the figure for people still in treatment at the three-year follow-up is 69%. Is this a good or bad figure?

Ms Kathleen Stack

I would view it a different way. It is positive that 69% of people are still in treatment. As the Deputy knows from her experience with the task forces, heroin use is a chronic relapsing condition. While we all aspire to setting targets, trying to set them for people who may relapse 15 or 20 times, depending on their motivations, can be a problematic business. Much of it comes down to motivation. It is important to say that we have made progress under the current strategy in terms of getting people into treatment. It is time to reflect on where the treatment has brought us and to plan ahead. The new strategy will try to promote people out of treatment and into detoxification, rehabilitation or whatever. What we have done to date has reflected the problem that we have been trying to address.

Deputy Róisín Shortall

While it is better that 69% of people are still in methadone maintenance after three years instead of injecting heroin and being chaotic on the streets, should the objective not be to facilitate them in reaching a drug-free lifestyle?

Ms Kathleen Stack

If it is possible, but the individual, his or her motivation and risk factors, such as the family or home environment, must be reflected. An individual care plan is necessary for the 69%. A generic target that could work for everyone would be difficult to reach. It comes down to motivation. For some, being on methadone for three years is progress. It depends on how progress is defined. The National Treatment Agency in the UK regards it as someone being on methadone for 12 weeks.

Deputy Róisín Shortall

The problem for the committee is the difficulty in measuring whether we are getting value for money from the substantial public moneys being spent on drug treatment. Individual care plans constituted the main point in the Comptroller and Auditor General's report. Measuring value for money is difficult, as we have not been provided with, for example, European standards. How do our guests measure their performance?

Ms Kathleen Stack

Perhaps this is an opportune time for the HSE to comment, as it has more direct responsibility in that regard.

Deputy Róisín Shortall

The HSE is responsible for the provision of services, but the Department of Community, Rural and Gaeltacht Affairs is responsible for this substantial spend and for setting the policy. How does it measure its performance?

Ms Kathleen Stack

It is positive that the numbers in methadone treatment continue to increase on a monthly basis. We should not lose sight of this.

Deputy Róisín Shortall

That is only one aspect of the numbers entering treatment. While that is good, what is occurring to them when they are in treatment and how long do they spend there?

Ms Kathleen Stack

The new strategy must address this issue. We must track individuals through the process more, but this reverts to the question of being able to identify them via, as mentioned by Ms Crowley, a unique identifier.

Deputy Róisín Shortall

Being unable to make that measurement has been a failure in the previous strategy.

Ms Kathleen Stack

That people in treatment cannot be tracked through unique identifiers is a matter of data protection and does not necessarily have anything to do with the strategy.

Deputy Róisín Shortall

Is that really the case? There may be issues of data protection, but they have not stopped the Department from measuring its performance.

Ms Kathleen Stack

In terms of treatment specifically, it is an issue.

Deputy Róisín Shortall

Would it be fair to state that we have not been ambitious enough in terms of providing the kind of treatment and rehabilitation that drug users need to live lives free of drugs?

Ms Kathleen Stack

It is an ongoing process. In recent years, the focus has been on getting opiate users into treatment. This has been a positive step, but we are at a point where we need to reflect where the users go from there.

Deputy Róisín Shortall

Before moving on to the HSE in terms of the nuts and bolts of the treatment, what is the Department's co-ordination role? The establishment of a new office of the Minister for drugs has been discussed, but a Minister of State has had specific responsibility in this regard for many years. Why has co-ordination been so weak in this area? As a long-time member of the Ballymun drugs task force and a past member of the Finglas drugs task force, the weak links were statutory agencies at local level. Community groups and local drugs task forces tried to plug the gaps left by the statutory agencies, principally the HSE but also the Department of Education and Science. What will be different in the new strategy that will ensure that those statutory agencies will play a full part at local level through the drugs task forces, that sufficiently senior decision makers will be present and that the agencies will start co-operating instead of just filling a chair at a table?

Mr. Gerry Kearney

The Deputy speaks with a great deal of experience on the ground. A number of problems were inherent, the first being that the previous arrangement had diffused responsibilities. Successive Ministers of State would have complained about material from various sources arriving on their desks that they were to rubber stamp. We had a national drugs strategy team, an interdepartmental group, a drugs section within the Department and a Cabinet sub-committee. There was not a strong, single locus of responsibility for executive decision making.

The second problem was the lack of a strong space within the structures for clear ministerial decision making and policy initiatives. What will be different in this context is that the establishment of the office of the Minister of State must seriously examine other models, such as the establishment of the Office of the Minister for Children, which pulls in functions from the HSE and the Department of Education and Science in an executive way and brings direct ministerial control or, at least, input into the setting of their budgets, their activities and their accountabilities for what they are doing.

Deputy Róisín Shortall

There have been developments in that regard, but there have also been major problems. This matter must be driven politically, but that energy has not been applied in recent years.

I will ask the witnesses from the HSE specific questions on the provision of methadone treatment. How many people are on waiting lists for methadone treatment?

Ms Gretta Crowley

Some 545.

Deputy Róisín Shortall

Where are they located predominantly?

Ms Gretta Crowley

They are spread throughout the country. In the Cork area, 106 are on the waiting list. In a number of areas, there are no waiting lists. The HSE operates 69 clinics, 43 of which have no waiting lists and 15 of which have waiting lists comprising fewer than ten people. The waiting times in 11 clinics are significant, but we are addressing these. Before the end of the year, we will open two additional clinics in Cork, which will reduce waiting times significantly. A clinic will open in Limerick, the south east and the midlands.

Deputy Róisín Shortall

What is the reason for the delay in meeting demand?

Ms Gretta Crowley

Given the current situation, there is an issue of resources. We must also be careful at community level because the introduction of a methadone clinic can sometimes cause communities concern. GPs must be trained and skilled resources must be put in place. A number of factors will have an impact on the waiting list. We take this very seriously. Our target is that next year all clinics will respond within a one month timeframe.

Deputy Róisín Shortall

Is the figure of 500 awaiting methadone treatment accurate? There is an indication in the report of the Comptroller and Auditor General that some degree of the waiting list was hidden.

Ms Gretta Crowley

There are issues in terms of standardisation and having complete understanding of what it means to wait for methadone. The agreement with the Health Research Board is that people are put on waiting lists once they have completed the assessment and methadone maintenance is indicated as appropriate to their need at that point. People move through a continuum of care. At one point, depending on clinical judgments and assessments, one may determine that methadone maintenance is suitable. In some areas we have issues with our reporting structure. There may be a tendency to put people on a waiting list when they telephone a clinic saying they are on heroin and would like to get on a methadone programme. People think it is good to put them on a waiting list and work through the assessment process. We are addressing the matter of standardising the approach and having confidence in the numbers.

Deputy Róisín Shortall

Does the figure of 500 refer to people who have been assessed?

Ms Gretta Crowley

If everyone reports it as that, then it is. Our understanding is that the figure may be lower because people who have not yet been assessed may be on the list.

Deputy Róisín Shortall

Is there a further cohort of people who have not been assessed yet?

Ms Gretta Crowley

No, they are all included in those figures.

Deputy Róisín Shortall

Has everyone who presents for treatment been assessed?

Ms Gretta Crowley

Yes, there may be a waiting time for an assessment but these are not very long. Other elements, such as counselling or other interventions, may start in that time. If someone has not received methadone, it does not mean that no service is being delivered. One takes a holistic approach, working on all aspects of someone's life.

Chairman

What does Ms Crowley mean by not waiting too long?

Ms Gretta Crowley

It varies across the country. It depends on the point in time when our waiting lists are done.

Chairman

Some are waiting up to six months.

Ms Gretta Crowley

Yes, that is outside the average but it is one of the areas we are targeting.

Chairman

We are not going to shoot the messenger but surely someone who presents for treatment and who needs attention needs it today. These are addicts. Telling addicts that they must wait six months does nothing for them. They may change their minds tomorrow. That approach is useless.

Ms Gretta Crowley

We work with them to get them to participate. They must be willing to do it. People who telephone and say they are on heroin and want to get off may not be in a place where they are capable of working with the programme and the councillors. We do much work with people to bring them to a place where they can be successfully maintained on methadone.

Chairman

The document refers to a figure of 106 for Cork. Last Monday Dr. Declan O'Brien said there were 150. What is the difference?

Ms Gretta Crowley

I cannot answer for Dr. Declan O'Brien. These are our figures and on our current list there are 106 people. We have had that confirmed.

Deputy Róisín Shortall

What is the longest waiting time?

Ms Gretta Crowley

In the south east the average waiting time is listed as two years, which is unacceptable. That is one of the areas we have targeted. One of the issues we are dealing with is the increase in supply and numbers outside of the greater Dublin area. The focus and funding was directed to the Dublin areas, which are continuing to use that funding. Outside that area, we see a shifting pattern. The south east is an area targeted for increase. The numbers may be low.

Deputy Róisín Shortall

Can Ms Crowley give an indication of the numbers that might be waiting two years for treatment?

Ms Gretta Crowley

In Waterford, 40 people are waiting for treatment.

Deputy Róisín Shortall

Is this for up to two years?

Ms Gretta Crowley

Yes. That does not mean they are not getting other services. In the Waterford area we were relying on level 1 GPs travelling from Dublin and accessing those to provide a service. We have targeted training additional GPs through our liaison officer in that area. That caused some of the difficulties. They had to travel from Dublin to provide the clinic. That was a causal factor in many of these issues. We have a targeted programme for getting level 1 and level 2 GPs trained. Our liaison officer is working with the GPs in the area to encourage them to participate in the scheme. A working group has been established.

Deputy Róisín Shortall

Is there a treatment centre there?

Ms Gretta Crowley

Yes.

Deputy Róisín Shortall

When will that be in place?

Ms Gretta Crowley

A new clinic will start before the end of the year.

Deputy Róisín Shortall

It is hard to understand how the list could have grown so long with no action by the HSE. It has not put in place a service to meet the demand.

Ms Gretta Crowley

We have been trying to source and train GPs. The protocol is quite strict so one must have a certain level of training to open a clinic. Certain clinicians must be available. We fully realise that it is unacceptable. We are confident that our waiting times will be reduced to three months for that area.

Deputy Róisín Shortall

In the case of Waterford the problem was not funding but the availability of GPs. Does the HSE have a premises? What is the difficulty with GPs?

Ms Gretta Crowley

I cannot speak for individual GPs but the option to get training for level 1 or level 2 is a choice GPs make. We cannot insist someone does the training and takes on methadone patients. We must work with them in partnership mode. We work with shared care to encourage GPs because many GPs have concerns that if they take them on they will not have the support services to deal with other aspects of care that someone on heroin needs.

Deputy Róisín Shortall

What is the annual cost of having someone on methadone maintenance?

Ms Gretta Crowley

I do not have that figure to hand but I can supply it. I am not in a position to give it now.

Chairman

Can Ms Crowley provide the figure before the end of the meeting?

Deputy Róisín Shortall

Does Ms Crowley have a global figure? Some 10,000 were in methadone maintenance last year. Is there a global figure for the cost of that?

Mr. Joe Doyle

We do not separate the cost for methadone from the overall addiction services, which cater for all types of addiction. Funding is broken down so that we have a figure of the ingredient cost of methadone. We could come up with a rough calculation.

Deputy Róisín Shortall

How does Mr. Doyle know if the HSE is getting value for money if it does not know the cost for methadone maintenance?

Mr. Joe Doyle

Comparing 2000 to 2008, we know there is a 75% increase in numbers attending methadone maintenance. We received 50% more in our budget.

Deputy Róisín Shortall

That does not answer my question. I am keen to know how much it costs to maintain someone on methadone. What is the annual cost? I am interested in hearing whether there are cost savings to be made by having someone attending a GP rather than a treatment centre.

Ms Gretta Crowley

The total costs for GPs amounted to €5.3 million.

Deputy Róisín Shortall

Can we have the cost per person?

Ms Gretta Crowley

I apologise.

Deputy Róisín Shortall

That is our focus in terms of how much this programme is costing. They key is that there is not just methadone but support services such as counselling and rehabilitation to facilitate people to move through treatment and, it is hoped, to a drug-free lifestyle.

In recent years the focus has gone off rehabilitation. The initial plan was to have methadone maintenance, a high level of counselling and rehabilitation to get somebody to move through as quickly as possible. However, that has gone and we are at a point where people have been on methadone maintenance but they do not seem to be going anywhere.

Ms Gretta Crowley

Our figures on detox and getting people off treatment indicate that this year, between residential and community-based detoxification schemes, 539 people completed their treatment and came off methadone maintenance.

Deputy Róisín Shortall

That is 539 out of a cohort of 10,000.

Ms Gretta Crowley

Yes.

Deputy Róisín Shortall

How does that performance compare internationally?

Ms Gretta Crowley

We are not performing too badly by international scales. My understanding is that many of those in the remaining cohort are on a reducing dose of methadone. They may start off at a higher level and their clinicians take decisions to reduce their dose to get them stabilised. Approximately 35% of the cohort receive it from GPs. They live in their communities and they may have jobs and be attending counselling or addressing other issues and they are very stable. I consider that to be very successful. I accept the point that there is an ideal——

Deputy Róisín Shortall

Does Ms Crowley have figures on that?

Ms Gretta Crowley

Of those on the low dosage?

Deputy Róisín Shortall

On the average length of time that people stay on methadone.

Ms Gretta Crowley

We could ask them individually. One of the benefits of having a unique patient identifier would be to allow us to track that and establish how many are on a particular dose and how many are on a lower dose.

Deputy Róisín Shortall

But Ms Crowley does not have that information.

Ms Gretta Crowley

No, it is not easily extracted from the information that we have at present because of data protection issues and client confidentiality. If we had a unique patient identifier it would be possible to do so in a more comprehensive way.

Deputy Róisín Shortall

Both speakers mentioned the problem of data protection. What is happening on that front? Has that issue been dealt with?

Ms Kathleen Stack

I understand the Department of Health and Children is drafting a health information Bill and that proposes to try to address the issue. I am not sure where it is at but the issue of the unique identifier is being addressed in that context.

Deputy Róisín Shortall

How much of the overall treatment and rehabilitation budget is spent on counselling and rehabilitation?

Ms Gretta Crowley

I ask the Deputy to give me a minute to go through the figures to extrapolate that information.

Chairman

In his opening address Mr. Kearney spoke about five pillars: supply reduction, prevention, treatment, rehabilitation and research. I did not see much evidence of prevention. Will Mr. Kearney flesh out exactly what was in the previous strategy on prevention? In the assessment done on the previous strategy was Mr. Kearney happy with the level of preventive measures used?

Mr. Gerry Kearney

I will make some opening comments prior to inviting my colleague to speak. The group that is most likely to find itself in serious drug addiction comprises early school leavers and children in severely disadvantaged areas and much of the prevention intervention must focus at those spaces. The quality of the provision of services by State bodies is important as is the role of groups such as the task forces in family interventions or interventions to support children to stay in school either through breakfast clubs or after school clubs. These softer interventions are key. Considerable work is done through the local drugs task forces. Intervention has focused on those more vulnerable groups which are most likely to be at risk of being taken into a drugs lifestyle. Perhaps my colleague, Ms Kathleen Stack, is a little closer to the action and she will speak on prevention.

Ms Kathleen Stack

Under the old strategy, prevention was grouped around a number of issues such as early school leaving because international research suggests that the longer young people are kept in school the better chance there is that they will delay drug use and delay becoming at risk of long-term drug use. Much emphasis was placed on early school leaving and that was reflected in many of the ongoing programmes run by the Department of Education and Science. It also examined school-based prevention programmes, such as On My Own Two Feet. These are prevention programmes that are polysubstance use based and they do not specifically mention drugs or alcohol. They try to get young children to have more self-esteem and confidence so they can say "No" when somebody offers them drugs. We also examined more national awareness campaigns and how effective they are. We also examined broad youth work, particularly in out of school settings where people have left the school system and are involved in Youthreach or other such programmes.

From the work we did on proposals for the new strategy it was felt that much progress was being made on early school leaving, particularly in areas of disadvantage where the heroin problem is still an issue. At the consultation sessions we held much concern was expressed about the effectiveness of the school-based programmes. Concern was expressed that sometimes they are tacked on to the end of a Friday afternoon and that some schools do not give them enough attention and switch the teachers who deliver them. More needs to be done and the programmes done have been evaluated. Implementing those recommendations will be part of the new strategy. Concern was also expressed about broad awareness campaigns. Such a campaign needs to be supported by services. In general a campaign with nothing to support it will not work.

Another issue raised during the consultations was the need for sport and leisure facilities in various areas so that young people have alternatives. Most of those issues are being picked up in the prevention pillar of the new strategy.

Chairman

Quite honestly, I am amazed at Ms Stack's response. Back in 1997 when the original task force was established I was the Minister of State with responsibility for youth affairs and sport. A key recommendation was that we would use sport and recreational facilities as a preventive element. Now, Ms Stack is telling me that it is only being considered. I do not see any evidence of a real involvement with sporting and voluntary groups in communities; they seem to have been sidelined in many areas.

I remember that when the task forces were established in Dublin one was also established in my constituency in Cork because it had a growing problem. The figures I had at the time stated that in 1996 there were four heroin cases in Cork. There were 60 cases in 2006 and in 2008 there were 100 people on treatment and approximately 150 on waiting lists of up to six months. At the time we were criticised by the then Southern Health Board — Ms Crowley is not an agent for it as she was not there at the time — that there was no real heroin problem. The message that prevention is better than cure was missed as was the fact that involvement with sporting and community-based organisations was a key element to deal with what was then an emerging problem in some areas. Many groups that I know would have been prepared to get involved in the fight but were sidelined and the agencies grabbed the resources available and in some cases they were brought in under their own mainstream programmes. The evidence is there to show that the message on prevention being better than cure was missed.

Ms Gretta Crowley

In recent years, our population health department has worked in collaboration with the GAA on an anti-substance abuse programme which targets GAA clubs to work with us.

Chairman

The message at the time was that there would be positive discrimination in areas with an emerging drug problem for the development of facilities and services. That did not happen.

Ms Kathleen Stack

The young people's facilities and services fund, which is very much tied in with the local drugs task forces, was under the aegis of the Department of Community, Rural and Gaeltacht Affairs and is now under that of the Office of the Minister for Children and Youth Affairs. Substantial investment has been made through that programme in youth and community facilities and in sports development officers to target the areas mentioned by the Chairman.

Deputy Seán Fleming

I want to come back to the methadone treatment programme. On reading the report of the Comptroller and Auditor General I concluded that everyone is responsible and nobody is responsible. The Department of Community, Rural and Gaeltacht Affairs is responsible for the national drugs strategy, the Department of Health and Children is responsible for drug misuse and treatment, the Department of Justice, Equality and Law Reform deals with prisoners, the HSE has primary responsibility for implementing the programme, the probation service has a role regarding people before the courts and FÁS has a role relating to this issue of 1,200 spaces. The framework chart on page 78 of the report shows that in addition to all of those there is a national drugs strategy team, a national advisory committee on drugs, regional task forces and local task forces. If every person in each of those bodies dealt with an individual drug abuser there would nearly be enough support. I shudder to think how diffuse the situation is; that is my overall comment. The approach has not been pulled together and I think that is why the witnesses have spoken of a single office.

How many local and regional drugs task forces are there?

Ms Kathleen Stack

There are 14 local and ten regional drugs task forces.

Deputy Seán Fleming

I saw a figure of around 500.

Ms Kathleen Stack

That figure relates to projects the task forces support.

Deputy Seán Fleming

Those 500 projects are linked to——

Ms Kathleen Stack

They are linked to the 14 local and ten regional drugs task forces.

Deputy Seán Fleming

The poor projects on the ground did not even make it into the big chart. The 500 projects are being managed by local drugs task forces.

Ms Kathleen Stack

And the regional task forces.

Deputy Seán Fleming

Has a decision been taken to mainstream a number of projects into the HSE?

Ms Kathleen Stack

There is an ongoing process examining 283 of the projects. Not all will go to the HSE; some will go to vocational education committees, VECs, or FÁS, depending on the nature of the business.

Deputy Seán Fleming

I presume that the main bulk of them will be mainstreamed into the HSE. Ms Stack must be worried that when the HSE comes under pressure for funds these projects will be seen as a soft touch because they are not core activities. I worry about projects being mainstreamed because a shortage in a hospital ward will get priority, then Ms Stack's section will suffer in the budget. It will be a case of last in, first out and these projects will be regarded as the last to join the mainstream HSE; they will be first to be booted out when money is short. What are the criteria for mainstreaming?

Ms Kathleen Stack

An extensive evaluation has been carried out on each of the 283 projects in terms of what they do, whether they respond to the problem in question and the results they produce. All of the agencies would have been involved in the evaluation and the ongoing process aims to move this forward from January 2010.

Deputy Seán Fleming

I understand but I still cannot tell from Ms Stack's response why such a decision would be made regarding a project that has been operating as a local project under a local drugs task force. What is the critical factor in deciding a project is no longer needed and should be mainstreamed into the HSE? What will push the 283 projects from where they are into the mainstream HSE? Why will the other 230 be allowed to stand alone? Are there good projects and bad projects?

Ms Kathleen Stack

If one goes back to the nature of the drugs task forces one sees they were always about piloting initiatives. It was felt statutory agencies might not respond as quickly as a community project. The idea was always that pilot projects would be mainstreamed if proved successful; the main criteria is the impact in dealing with a drug problem. Some projects deal with family issues and provide counselling services; it is a question of assessing the impact a project has in dealing with a drug problem in a particular area.

Deputy Seán Fleming

I will allow Mr. Kearney to come in but I am even more confused as a result of the answer given. I will try to make my question clear. Many of the 500 projects were pilot projects. Are successful projects mainstreamed and does that mean we will continue with the 230 that were not successful? Or is it the case that the successful projects are left alone and the failures amalgamated with the VECs and the HSE? Between the good and the bad, the total comes to around 500 projects. Why are some being mainstreamed? It is not just about the nature of the work. Some of the projects fulfilled a role and other did not; why are some mainstreamed and others not?

Mr. Gerry Kearney

On mainstreaming, one of the benefits of local drugs task forces is that they can intervene in what we call "minding the gap". If they see a gap that is not being filled by statutory bodies they can identify a service needed and pilot it. However, in terms of control and accountability, the Government cannot sustain hundreds of projects that are piloted all over the country. The projects must either continue under an explicit mainstream umbrella or be discontinued for not proving their worth. The purpose of this is to take objectively assessed good practice and bring it into the mainstream.

My next point relates to confusion around structures and vulnerability on the funding issue, as mentioned by Deputy Shortall. In future, in terms of the totality of drugs budgets, there must be a horizontal ministerial view on spending. It should not be fragmented between various Ministers. To make this meaningful and real there must be a single point. Rather than putting sums together for a meeting of an inter-departmental group or the Committee of Public Accounts we should add up the total on an annual basis. This would make the protection of projects more meaningful. When we provide funding to the HSE for mainstreaming we expect it will be preserved and not lost. I am giving a general overview. There are issues of accountability and control and there are also responsibilities facing local statutory agencies; they must engage with projects because it cannot be done centrally.

Deputy Seán Fleming

I get the impression from what Mr. Kearney has said that the 283 projects have been useful and have proved themselves and will, therefore, now be integrated. Did Mr. Kearney imply the other 230 projects were not useful and may be closed down? The successful ones are being mainstreamed and the others are left hanging; that is what I inferred.

Ms Kathleen Stack

To clarify, the 283 projects are those of local drugs task forces; the remaining projects relate to regional drugs task forces and have not yet been evaluated.

Deputy Seán Fleming

The regional drugs task forces have not yet been dealt with.

Ms Kathleen Stack

That is so.

Deputy Seán Fleming

Out of the projects that have been examined, how many did not meet the criteria for success and should not continue?

Ms Kathleen Stack

They are in various categories but around 250 were found to operate successfully.

Deputy Seán Fleming

Are they being mainstreamed?

Ms Kathleen Stack

Yes.

Deputy Seán Fleming

Ultimately then, the idea is to mainstream. Did all of the projects have an office, a computer, a phone system and an administration?

Ms Kathleen Stack

Some of them did but they are not all individual, stand-alone projects.

Deputy Seán Fleming

I will return to the idea of having just one Minister responsible with a clear budget. The report estimates a figure of €140 million but there are many caveats attached to that; they cannot quite be sure because people do not prepare their budgets in this manner. Most of the money is being spent through the HSE. Is it necessary to have a strict budget line? It would be a cliché to say one must have a clear budget line, lines of responsibility and reporting structures. However, my understanding is that the HSE's cancer strategy does not have a clear budget line, as such, in terms of the HSE budget. As most of the spend is in the HSE, should the drugs strategy have a clear budget line and stand alone, or should it operate within the HSE similarly to the new cancer strategy, which seems to work without a defined budget line? This definition of a budget line might sound a big thing to us at a meeting of the Committee of Public Accounts, but perhaps there are other ways of doing it. I am using the cancer strategy and the HSE as an example. I keep hearing that it does not have a specific budget but much work is being done.

Mr. Gerry Kearney

A point made strongly by the Comptroller and Auditor General is that if we want to consider seriously outcomes, effectiveness and cost we must be clear at the outset about the budget and the public resources going in. We also need to join up our budgets. The difference with cancer is that it is core HSE business. Many of the dealings to do with drugs, historically and currently, have not been central. Where something is not central but is shared across Departments——

Deputy Seán Fleming

How many people die from drug abuse each year? Mr. Kearney is saying that drug addicts are not a core business.

Mr. Gerry Kearney

The last recorded figure, from around 2005, is about 400 recorded deaths per annum, so this may be increased by around 50 per year.

Deputy Seán Fleming

How can anyone suggest that is not a core function of the HSE, the Department of Health and Children or the Department of Community, Rural and Gaeltacht Affairs? I cannot even let Mr. Kearney complete a sentence if he is going to talk like that. Four hundred deaths are core to everything.

Mr. Gerry Kearney

I will be quite clear about it; I am not saying it is not a core function. I am talking about what are regarded by organisations as their core functions.

Deputy Seán Fleming

So those 400 people who passed away are nobody's core function?

Mr. Gerry Kearney

I do not think so. As public servants——

Deputy Seán Fleming

Which organisation?

Mr. Gerry Kearney

It is a shared responsibility across those bodies.

Deputy Seán Fleming

That is similar to my opening comment that everybody is responsible and nobody is responsible. We have gone full circle.

I would like to move back to the issue of methadone treatment because I would like to follow up a couple of issues. We know it needs to be more tightly focused.

Chairman

The conclusion we have reached is that we might talk about co-ordination but it is crying out for leadership. Somebody has to take the thing by the scruff of the neck and pull it all together. I am surprised the HSE is incorporating some projects under its control when we have a Minister of State with responsibility for drugs strategy. Surely this should be a role for that Minister.

Deputy Róisín Shortall

Many of the projects that were mainstreamed are now being cut because of budget cutbacks.

Deputy Seán Fleming

I suspect the witnesses do not have an answer on the issue of methadone treatment. What is the longest timescale for methadone treatment? On the question of a personal identifier, do people not have PPS numbers when they come to the clinics? Perhaps I am missing something, but I thought everyone had a PPS number. Why can we not know if a person has been in the system before? The witnesses say there are data protection issues, but I do not understand the problem with the HSE knowing somebody's PPS number.

Ms Gretta Crowley

I will ask Mr. Doyle to deal with this.

Mr. Joe Doyle

As part of the methadone protocol, all patients receiving methadone are monitored. We have not been able to extrapolate the information to answer the Deputy's question but we are doing an exercise to identify that. The methadone protocol and the central treatment list were set up to monitor safe prescribing for clients. That was the reason for it; however, we were able to obtain information as a by-product of the system. We are looking into that.

Deputy Seán Fleming

Are there people out there who have been on methadone treatment for six or ten years?

Mr. Joe Doyle

There could be, yes.

Deputy Seán Fleming

It is a lifelong thing. Is that good or bad, bearing in mind that they are not on heroin?

Mr. Joe Doyle

The international evidence would suggest that being on methadone is a good thing. It is an individual——

Deputy Róisín Shortall

Not indefinitely.

Mr. Joe Doyle

I personally agree with the Deputy. However, for some people that is a life choice.

Deputy Seán Fleming

There is a reference in appendix A of the report to street methadone. What is that? The appendix is useful for us lay people in separating heroin, methadone, cocaine and cannabis and the different issues involved. The appendix states: "Methadone is a synthetic drug that is widely used as a controlled substitute for heroin, but may also be used on a non-prescribed basis (‘street methadone')."

Ms Gretta Crowley

Street methadone is methadone that has been prescribed and given to a patient but is traded.

Deputy Seán Fleming

That is what I suspected. I now return to the issue of what happens a person when he or she goes for treatment, which the witnesses explained well earlier. It is stated in the report that normally the initial phase of methadone maintenance is in a clinic. The person starts at the clinic and is stabilised and he or she may then move to a GP or pharmacist. I refer to paragraph 4 of page 39 of the report, which states: "Once a stable situation has been achieved, the misuser may be permitted to take away a few days' supply of methadone at a time." There must be a risk that this will be sold. Is that what we are referring to?

Ms Gretta Crowley

Yes, but the judgment is made that if a person is stabilised——

Deputy Seán Fleming

What is the formula? Is it a tablet or a liquid in a vial? I presume, early on, when the person starts in the clinic and is stabilised over several weeks, it is given intravenously or orally. In what form is the four or five days' supply of methadone?

Ms Gretta Crowley

It is a liquid in a sachet. That is part of the issue with progression. Methadone is an opiate, so we must be careful about——

Deputy Seán Fleming

Did the penny not drop that there are people who are on this for ten years who may be calling in to collect it and then going away to sell it? I do not want to be unfair to the genuine people out there, but this must be an issue.

Ms Gretta Crowley

There is always that possibility, but the assessment process when a person progresses to this stage would mean that he or she would be unlikely to do that as there would be a relationship there. Some people, when they start, come back on a daily basis until they have proven their bona fides and it is felt they will not sell the methadone. The possibility is there but we take all due care not to promote that. The alternative is to keep them in the clinic, and the longer we keep them in clinics, the longer the waiting times.

Deputy Seán Fleming

Because of the data protection issue, is it possible that a person could be going to two different GPs or pharmacists?

Ms Gretta Crowley

No. Every person who is prescribed methadone has a card which is issued to a specific GP and pharmacist. These are named on the card, so there is protection against that. One cannot go to several pharmacies and get double doses and then sell the extra.

Deputy Seán Fleming

The last topic I wish to deal with is the waiting time for methadone maintenance, which is also covered in the report of the Comptroller and Auditor General. When this report was carried out in April of last year, there were waiting times of 13 to 14 months in the midlands and 18 months in the south.

I would like to go through the information that has been put before us today, as I am trying to put it all altogether. The witnesses reported progress in their opening statements, but I will have to take them up on that. It is not as rosy as they have painted it. On page 44 of the report there is a chart showing the number of people waiting for methadone treatment in April 2008, when the report was being finalised. The total was 461. The witnesses have just told us the figure is now 545. Thus, in the past 15 months, the number of people waiting for treatment has increased by more than 20%. The figure in the report is 461, but the witnesses told us a few minutes ago that the number on the waiting list now is 545, which is an increase of 84 people, or more than 20%. The number on the waiting list has increased by over 20% in the year. I take some of what Ms Crowley has said with good intention but also with a pinch of salt.

That report also states that there were 68 clinics in 2007. The chart on page 40 shows methadone maintenance provided by HSE area in 2007. There were 61 in Dublin and seven in the rest of the country, making a total of 68. Ms Crowley has told us there were 69 so I take it that in two years the HSE has opened one clinic. I cannot see how Ms Crowley regards that as progress. The waiting time has gone up by 20% since the report was drafted yet Ms Crowley says she will bring it down to three months. I applaud her intention but I cannot see that happening. I hope she can understand my scepticism. I would like to hear about the increases.

Ms Gretta Crowley

In the period to which the Deputy refers one was opened and we plan to open more this year. We have also increased the number of treatment places in that time within the existing clinics.

Deputy Seán Fleming

I am puzzled that the waiting list has increased by over 20% in 15 months. Ms Crowley has presented the good side of it which we want to hear but I am reading the large figures.

Ms Gretta Crowley

I accept the Deputy's point but we are working carefully on the definition of waiting times and there may be differences in those.

Deputy Seán Fleming

Ms Crowley will exclude the people who have not got onto the waiting list the next time she gives us figures. She will stop people getting on the waiting list so that they will not be included in the figures. I am being sceptical but we have seen that done before. That is how waiting lists are improved around here.

There are two charts, on pages 40 and 44, which refer to the number of clinics. Ms Crowley told us that the waiting list in the southern region has gone from 100 to 106 in 12 months and there is one clinic. How can there be only one clinic in the southern region, our Chairman's region, and 61 in the Dublin region? The midlands is just as bad, there are only two clinics and 100 people on the waiting list.

Ms Gretta Crowley

For a long time in the former Southern Health Board area there was no heroin problem. This is an emerging trend. We are responding to the availability of heroin in the Cork area and plan to open two more clinics there before the end of the year.

Deputy Seán Fleming

Is that in the HSE service plan for this year and is the money ringfenced or has it been approved yet?

Ms Gretta Crowley

We are doing that within our existing resources. We have not received additional funds this year but we have received assistance——

Deputy Seán Fleming

Ms Crowley can understand why I am a bit hard on the point about the waiting list. I am again reading the report produced in April 2008 which shows an 18 month waiting list but Ms Crowley is saying that three years since that list commenced this is an "emerging" problem. The average waiting list 18 months ago was 18 months in the southern region so 18 months ago many people had been waiting over 18 months. I get worried when I hear this being described as an "emerging" problem in Cork. I find it hard to reconcile that with a waiting list that is at least three years long. I do not understand how it takes maybe four years to get somebody into a clinic. What is the problem? Ms Crowley says that it is a matter for the GP to choose to take up the service but can she understand the frustration people feel when they see that it can take over four years to get a GP to manage a second clinic in what was the southern health board region? That is a lack of determination not lack of a doctor. If somebody in the HSE wanted that to happen it would have happened.

Ms Gretta Crowley

I am from Cork and we worked hard to get that clinic established. In the first quarter of this year we had a 40% increase in patients treated since the end of last year. We plan to open two other clinics.

Deputy Seán Fleming

Has the HSE been successful in getting medical professionals for the centres it hopes to open before the end of the year or is it still in a recruitment phase and will the same problem arise again?

Ms Gretta Crowley

We are working very hard and we have a liaison GP who is actively recruiting GPs. She targets GPs in the area and works with them to develop shared care, to build their confidence in treating patients on methadone. We are confident that we will do that.

Chairman

Ms Crowley said there was a six-month waiting period in Cork but on page 44 of the Comptroller and Auditor General's report the waiting period is given as 18 months. Will she please give us an up to date average waiting period in the other areas outside Dublin, starting with the midlands?

Ms Gretta Crowley

In the midlands, Portlaoise, it is 5.6 months as of 30 April this year, in Portlaoise, 3.8 months——

Deputy Seán Fleming

Ms Crowley has mentioned Portlaoise twice.

Ms Gretta Crowley

Portlaoise-Athlone. In the south west of Dublin, the Aisling clinic has none, Castle Street has none, Cork Street has 2.5 months. I can give the committee a copy of all the lists.

Deputy Seán Fleming

Ms Crowley outlined the figures clinic by clinic rather than by region.

Chairman

We want the figures for the clinics outside Dublin because the situation in Dublin is different. Will Ms Crowley start please with the midlands?

Ms Gretta Crowley

The waiting time in Portlaoise is 5.6 months and in Athlone, 3.8 months.

Chairman

What about the mid-west?

Ms Gretta Crowley

Limerick, Clare and north Tipperary, one week; Galway, Mayo and Roscommon, six months.

Chairman

That has increased from three to six months.

Ms Gretta Crowley

There are 20 on the waiting list in Galway, Mayo and Roscommon.

Chairman

What about the south east, the Waterford-Wexford area?

Ms Gretta Crowley

The waiting time in Waterford is two years, and Carlow 28 weeks.

Chairman

What about the southern region?

Ms Gretta Crowley

The waiting time for Arbour House is ten months.

Chairman

What about those who are waiting to go on the waiting list? As Deputy Fleming said, that was how the hospital figures were presented — I will not use another word.

Ms Gretta Crowley

For the southern area, the total inclusive figure is reported. There are 97 on the list. We have had an average of two contacts per week for new assessments in the Cork area. That is the rate at which people are coming onto the waiting list.

Chairman

How many people are on the waiting list?

Ms Gretta Crowley

Two new people join the list every week in Cork. We hope to open two more clinics before the end of the year which will take at least 40 people off the list.

Chairman

Why has the south-eastern waiting list gone from 18 months to two years?

Ms Gretta Crowley

That was because we relied on GPs travelling from Dublin and making time available. We are actively recruiting more GPs in that area and increasing the clinics. We will put an extra clinic into the Waterford area before the end of the year.

Deputy Thomas P. Broughan

I welcome our guests and thank them for all the work they are doing in this area. The Comptroller and Auditor General's report states that we have a total of 23 beds available for detoxification. This is a critical element for those addicted to heroin or other opiates but the Comptroller concludes that 63 beds are needed for medical detoxification and stabilisation for drug users, or 2.7 times the current number of in-patient beds based on the six week detoxification programme.

In 2007, the Comptroller notes that only two thirds of the available bed-days at the two facilities were used for treatment. Given that detoxification is such a critical area to help people move out of addiction, why is this not a bigger part of the programme that is offered?

Ms Gretta Crowley

We recognise the need for the detoxification programmes and we are working to increase the number of beds. There is an issue with the resources available; we must work within the constraints of the current financial position. The additional resources have not been forthcoming to allow us to fill the number of beds but we are working in partnership with the community and voluntary sector to increase the number of detoxification beds. We are also working on community-based detoxification that does not require a residential bed. Looking at the figures, to end 2008, we had 539 successful detoxifications. Those figures are average. In 2007, 554 completed detox, while in 2006 there were 377, in 2005 there were 423, in 2004 there were 319 and in 2000 there were 204 who successfully completed detoxifications.

Deputy Thomas P. Broughan

What is the waiting time for a detoxification bed?

Ms Gretta Crowley

In terms of residential detoxification, the average waiting times range between two weeks and four months for a residential bed. I do not have the figures for detoxification in the community but that is done at a point in time. We have seen significant numbers detoxify in the community. It is part of the ongoing treatment programme so detoxification takes place in collaboration with the GP and a community-based team.

Deputy Thomas P. Broughan

A much more aggressive approach by policy makers to this area would involve taking the Comptroller and Auditor General's conclusions in this area seriously to secure greater availability of beds and staff.

Ms Gretta Crowley

Yes, I agree, and we are actively working with our partners to maximise the use of beds for detoxification. We will work with our client cohort in any way we can to support them in availing of them.

Deputy Thomas P. Broughan

Could resources be reallocated from other less critical areas into the detoxification area?

Ms Gretta Crowley

Within the drug and alcohol area?

Deputy Thomas P. Broughan

We are spending €140 million per annum on the whole area. Is there scope for moving more resources into the first step to get people who are utterly addicted out of their addiction?

Ms Gretta Crowley

In the current climate, looking at reallocating and reconfiguring of existing resources is constantly on our radar and we will try to get money from everywhere. A difficulty with disaggregating the costs of the drug treatment is that people will use all the resources to the best of their ability and it is hard to separate one area. We are working on a specific programme to look at where there are beds available in other residential treatment centres and if we can dovetail with them to provide methadone detoxification in those centres. We are actively working with our partners on that programme.

Deputy Thomas P. Broughan

A key experience of everyone who works in this area is that people who suffer addiction often have other major problems. It is extraordinary that we have not established a system of care where there is a mentor or care manager for every single client. Are we working towards that?

Ms Gretta Crowley

We are. Recently we have appointed, within existing resources, the national coordinator for rehabilitation and a national implementation committee for the rehabilitation strategy that sets out the framework to progress the care management, case management and key worker approach. That must be an interagency approach because the different aspects of their care may involve education, housing and family counselling, so we are actively working on that.

Deputy Thomas P. Broughan

At the moment, of the 8,000 people that were mentioned, how many would have a care manager with a care plan and progression plan?

Mr. Joe Doyle

That is part of the work that the national drug rehabilitation implementation committee is doing at the moment. We have the rehabilitation and integration service in the northern area. That approach differs from HSE area to area so we are trying to standardise it and develop a national framework.

Deputy Thomas P. Broughan

We are familiar with this on the other side of the Department today, with mentors for those who are not working in the partnership and Leader areas. Do we have that in drugs?

Mr. Joe Doyle

Mentoring problems?

Deputy Thomas P. Broughan

A single key worker.

Mr. Joe Doyle

Most of the voluntary and statutory sectors would say they have key workers. I could not say what percentage of clients exactly have them but it would be the view of the rehabilitation committee that everyone should have a key worker and a case manager, particularly the more complex cases because there will be a number of interventions occurring with one individual. That is where case management is important.

Deputy Thomas P. Broughan

Could the committee get information about that area? My colleague referred to the number of deaths from this horrendous plague over the past few decades which make it clear this is an important intervention.

Mr. Joe Doyle

Yes.

Deputy Thomas P. Broughan

There are a few references to alcohol at the beginning of the report. It is notable that young people who progress to opiates go through a stage of alcohol addiction. There is a new programme on the misuse of drugs and a new strategy will be in place in 2010. Should we give more attention to alcohol abuse? I was recently struck that the distinguished company and Dublin institution, Arthur Guinness, is celebrating 250 years. I remember asking Diageo on numerous occasions if it would provide more alcohol-free beverages but it refused absolutely. Is there any emphasis as alcohol as a stepping stone into the use of opiates?

Ms Gretta Crowley

Yes. From the consultation process for both the national drugs strategy and our experience of service users, alcohol is recognised as a gateway or disinhibitor to allow people to experiment with drugs. We have advocated for a stronger line to be taken on that. That is something we want to progress. In some parts of the country outside of Dublin our addiction services combine drug and alcohol services, unlike the greater Dublin area where there is a separate focus on drugs. There are fears that people will say the inclusion of alcohol will swamp the dedication to drugs. That is something we are trying to address cautiously. We have advocated and will try to address alcohol issues wherever possible.

Deputy Thomas P. Broughan

Our staff has given us information on other jurisdictions. Some of my colleagues may have referred to that. A comparison between Scotland and Australia in terms of return to misuse of drugs by people who have exited from programmes shows that Australia seems to have had better outcomes. There are many other aspects to this issue that we, as a committee, will examine. Enforcement is a key one. In Sweden, enforcement on the supply side seems to have been a major factor in its progression. We have the ROSIE study in Ireland, but are there things on the strategy side or on the health management side that we could learn from other countries?

Mr. Gerry Kearney

Yes. One of the points touched on in the report of the Comptroller and Auditor General and raised repeatedly in discussions here this morning is that rather than being about addressing individuals presenting with a problem it is about addressing individuals as having a multiplicity of social and other problems and needing that kind of individualised care worker to carry them through. There are models abroad that we need to bring in and they are reflected to a degree in the proposals as agreed in the new strategy. That is one of the first points.

The second point has been the issue of the methadone maintenance story, parking people on methadone maintenance and, maybe, being more explicit around our expectations. We need to be careful on this. On the one hand many of the individuals with whom we are dealing are in extraordinarily chaotic circumstances and, as reflected in previous conversations, certainly in the UK, it is an achievement to get somebody on to a methadone programme and to stay there for three months, because heroin is a drug that leads to constant relapse. We must benchmark progression through and from methadone by reference to international standards. They will be extraordinarily low. We know that from our own experience and otherwise, but we need to do that.

Deputy Thomas P. Broughan

I suppose the outcomes are very bad.

Mr. Gerry Kearney

The outcomes are very bad. However, we look at it from two levels. What one wants to do in the first instance is to reduce the chaos that individuals cause to themselves, to their families and their communities by heroin addiction. That is the first step. The second is to get them into a programme that stabilises them and that enables them, or some of them at least, to progress to where they can live proper lives free of methadone and other dependencies. That is taken as read. By way of context, though, there are 1.7 million heroin users across the European Union so we fit into that frame and of course we have much to learn from practice in other jurisdictions.

Deputy Thomas P. Broughan

How do we fit in terms of our overall population? Are we high up the table, are we midway, or towards the bottom?

Mr. Gerry Kearney

My recollection is that we tend to be mid-table but the impression as well is that on the cocaine piece we are somewhat higher up the chain.

Ms Kathleen Stack

We are about mid-table. The nature of the drug problem changes as one goes across the EU. In eastern Europe, in places such as the Czech Republic there are problems with amphetamines which traditionally has not been a problem in western Europe. When one comes across to western Europe there are problems with drugs with which we would be more familiar such as heroin, cocaine and the like. The pillar approach we have in the strategy is very much in keeping with the European action plan and generally would reflect the way most western European countries would target their drug problem. Some countries would have a greater emphasis on things such as supply reduction and the whole criminal justice end, whereas other countries would be more towards the harm minimisation end which is where we would see ourselves fitting in. Some countries have taken that a step further. The Dutch and the Swiss have gone the road of providing prescription heroin and heroin injecting rooms. Our approach is to target the problem from several different angles. That is where the pillar approach comes in.

Deputy Thomas P. Broughan

Are there any estimates of the number of people who are not involved in treatment or perhaps were in treatment but who need treatment? Is that known?

Ms Gretta Crowley

That is a hard question. Given the nature of drug use we could not be very explicit.

Deputy Thomas P. Broughan

It could be another 8,000?

Ms Kathleen Stack

There has been an increase in treatment places in recent times. The focus is on trying to get more and more people on to methadone so that hidden population to which the Deputy refers would not be that sizeable.

Deputy Thomas P. Broughan

Are there any estimates from people who liaise with you? To take a very basic point I could certainly say that in my constituency there would be places where in perhaps an hour's time one will see people gathering not for a service provided by the HSE but for alleged distribution of opiates and other drugs. One hears these allegations about various locations. One sees people. Obviously they are law enforcement areas but it prompts the question whether any work has been done in that regard. One could take the DEDs. When one looks at the statistics here one sees that, while the problem outside Dublin is increasing, the problem in the greater Dublin area seems to be an appalling problem with 80% of clients involved in programmes. Should we not have some way of determining the real size of the problem?

Mr. Gerry Kearney

There is a study under way at present the findings of which I anticipate will be published this autumn. These will give us firmer figures.

Ms Kathleen Stack

This is a study being done on the prevalence of opiates across the country. The results will be available in the autumn. It is more difficult when we are talking about the hidden population to which the Deputy referred. It is even difficult to visualise how one would go about getting such statistics.

Mr. Gerry Kearney

To put a framework on it, because the questions the Deputy asked is entirely reasonable, my recollection is that the figure for opiate use according to previous surveys was of the order of 14,000. The bulk of those, approximately 12,000, would have been based in Dublin. We would anticipate some modest increase in Dublin, based on preliminary figures but probably a sustained concentration in particular areas and the very visible manifestation of that. Equally worrying is the increase in heroin use outside of Dublin, particularly in the Leinster towns. That data will be available this autumn and we will be happy to make it available to the committee.

Deputy Thomas P. Broughan

We do not have those figures yet.

Mr. Gerry Kearney

We do not have them today.

Chairman

Arising from the discussion, I note there has been a 20% cut in the budget for the local task forces and a 23% cut in the budget for the Government's advisory body. What impact will that have on services?

Mr. Gerry Kearney

By way of clarification, the cut to task forces is not of that order. I can only speak for the Department of Community, Rural and Gaeltacht Affairs. The task forces have seen their budget increase from €17.8 million in 2005 up to €33.5 this year, which is close to a doubling of resources.

Chairman

What about last year?

Mr. Gerry Kearney

Last year the budget was higher at €35.5 million.

Chairman

So there is a cut.

Mr. Gerry Kearney

Very definitely. There is a cut of the order of 6% to 8% depending on the spread of the task forces. The actual drugs budget generally, including other initiatives under our subheads and capital, would have increased from €19.7 million in 2005 up to €44.3 million last year. The amount has fallen back to €40.6 this year.

Chairman

Is there a 20% reduction?

Mr. Gerry Kearney

A 10% reduction.

Chairman

What impact will the cut of 6% to 8% have on services at local level?

Mr. Gerry Kearney

This is a very difficult space. We are currently in discussions with the task forces. We have notified them of their revised budgets for the remainder of the year and we are discussing with them how they will manage with those reduced allocations for projects. Certainly it is going to affect projects.

Chairman

In regard to what has been described here as an emerging problem in areas outside of Dublin and areas in Cork which have a major problem but will have an even greater problem in a short time, how can Mr. Kearney reconcile that with cutbacks?

Mr. Gerry Kearney

As reflected by the assistant national director, the Department is making available resources directly to the HSE this year to proceed to open additional treatment clinics. We have recognised that as an absolute priority. We need to distinguish between getting the HSE to put additional resources into treatment clinics and work that is undertaken by the drug task forces through their projects.

Chairman

Could it be said that the Department is stripping local voluntary groups in preference to statutory bodies?

Mr. Gerry Kearney

No. We do not normally fund other statutory bodies. On an ad hoc basis we——

Chairman

Is it true that the cut at local level is being offset by extra allocations to the HSE?

Mr. Gerry Kearney

It is not extra allocations. Each year we reserve a level of funds, particularly on the capital side, to invest in the development of an extension of facilities where we can get buy-in by, say, the HSE that after that capital asset is developed it will commit to fund, support and service that project. That is what we are talking about.

Chairman

Will Mr. Kearney present the committee with details of the type of cuts that will be experienced by local task forces as a result of the 6% to 8% cut?

Deputy Thomas P. Broughan

May I add a tiny postscript to that? Does the Department receive any funding from the fight against drugs in terms of the proceeds of the CAB or any kind of hypothecated taxation from misuse of drugs? Does any funding come to the Department or the task forces from the criminals on the other side?

Chairman

We have not been in receipt of funds from the CAB. Arising from the Dormant Accounts Fund, considerable resources have been made available in the context of RAPID and drugs task force initiatives to support the work of community groups across the country. On thedormant accounts side yes, but not on the allocated funds.

Deputy Thomas P. Broughan

Has the Department received any funds from the CAB?

Mr. Gerry Kearney

No. The Department of Finance official is present. I understand there is a fairly strong resistance to what is called the hypothecation of resources and it also regards it as a fairly unstable resource of funds that would not be available with any certainly particularly on a year to year basis.

Deputy Jim O’Keeffe

On the issue of collaboration with pharmacies and drug treatment, I note that Mr. Kearney told the committee there are 496 pharmacies participating in the methadone maintenance scheme. The pharmacies have a major role to play from the point of view of the programme to provide access to harm reduction and needle exchange services, particularly in the country. Clearly it has a significant role to play from the point of view of health and social gain for drug users and the community at large. I am concerned at the impact of the present confrontation between the Minister for Health and Children and the pharmacies. What impact will it have on that collaboration and are there any stand-by arrangements?

Ms Gretta Crowley

We hope it will not have an impact but a significant number of pharmacies have submitted their resignations from the GMS scheme but the methadone protocol operates outside of that scheme. We are keeping our fingers crossed that unlike the previous iteration when they withdrew for a while last year, we will be able to maintain the service throughout the negotiations between the HSE and the pharmacies in regard to their mark-up costs. We are looking at contingency arrangements for general prescription of medicines. A working group has been established to identify sites for alternative dispensing if it comes to that. In regard to the methadone protocol we had a contingency plan in place. If we had to re-implement what we did previously, it would put us to the pin of our collar in the current climate. We had a successful contingency arrangement on the last occasion and while it was disruptive to service users we will do everything possible to avoid such a scenario. It is dramatic for them to have to go back into a clinic setting where the security arrangements and so on are much more chaotic. We have collaborated with the IPU in terms of the needle exchange programme and have identified 65 pharmacies throughout the country that it has agreed to. I have been reassured by the IPU that it is separating that collaboration from the current difficulties but I cannot predict what will happen in terms of the negotiations with the HSE.

Deputy Jim O’Keeffe

Can Ms Crowley be certain as of now that we will escape the direct consequence of the confrontation with the Minister and the pharmacies?

Ms Gretta Crowley

From our experience on the last occasion when they withdrew, we have a contingency arrangement in place. It will be a matter of reactivating that arrangement. That will not be without its challenges to find spaces to bring everybody back to our clinics. That will be significant for us if it comes to pass.

Deputy Jim O’Keeffe

Does Ms Crowley reckon she will be able to cope even if put to pin of her collar?

Ms Gretta Crowley

The last time we felt we had to do everything and everybody got their treatment and we pulled it off at a significant cost. Without the co-operation of many staff members who worked day and night and beyond the call of duty it is going to be a very difficult challenge.

Chairman

I will take the last question from Deputy Shortall.

Deputy Róisín Shortall

What is the cost of maintaining a person on methadone?

Ms Gretta Crowley

The current cost for somebody on a community scheme is €2,427 per patient.

Deputy Róisín Shortall

What is the cost per GP?

Ms Gretta Crowley

That would include all the GP fees and the ingredient costs.

Deputy Róisín Shortall

What is the difference in costs in respect of a person attending a clinic and a person attending a GP?

Ms Gretta Crowley

Given that our clinics do other treatments we do not disaggregate the costs. Those costs are more difficult for us to find but I will go my best to get a reasonable estimate of them. It is not possible to do that at present.

Deputy Róisín Shortall

Could it be that there are financial incentives to use of certain types of treatment over others?

Ms Gretta Crowley

In regard to methadone, the Suboxone pilot study is looking at that issue. The ingredient costs of Suboxone are significantly higher than methadone. Methadone is very cost effective in terms of the cost of the drugs for the people. If that cost had to be replicated in other drugs the cost would be significantly higher. We have started the evaluation programme with 80 clients in both a clinic and community setting. The pilot will run for a year and at eight months we will do an evaluation of the costs and outcomes for the clients in that group.

Deputy Róisín Shortall

I find it difficult to get an overview of exactly where the HSE is going in regard to drug treatment, the costs involved and the different aspects of it. At this stage in an eight year strategy I would have thought a more analytical view would be taken in terms of approaches and costs.

Ms Gretta Crowley

One of our difficulties in the Health Service Executive is that many of our general ledger and accounting systems are different and therefore it takes——

Deputy Róisín Shortall

When will all that work be done? A number of issues have been raised here and the response is that the HSE is in the process of doing or intends doing that. Why has it not been done to date at the point of spending €140 million per year on treatment alone? Why do we not know what is happening with that money?

Ms Gretta Crowley

We know the total of the spend on dedicated drug services, which is €101.87 million. They are the facts as we have them at the moment.

Deputy Róisín Shortall

Yes, but there must be a way of measuring whether that money is being spent effectively and whether we are getting value for it. Has the cost-benefit ever been worked out in terms of maintaining somebody indefinitely or up to eight, nine or ten years on a methadone programme compared to providing intensive support, getting them into a residential detox programme, providing counselling and rehabilitation to enable that person to come off drugs, go into training, get a job and live independently? There seems to be an attitude of containing the problem and a complacency about certain sectors of the community having large numbers in treatment on an indefinite basis. From society's point of view and from a cost point of view, is there a case for taking a different approach with the aim of getting somebody off all kinds of drugs or substitutes in as quick a period as possible to enable those people to become self-sufficient again?

Ms Gretta Crowley

I agree with the Deputy. The nature of heroin addiction is that people relapse. They go on a programme, relapse and come off it. The very nature of the addiction——

Deputy Róisín Shortall

It is very easy to say these are chaotic people. They are chaotic but——

Ms Gretta Crowley

We have significant numbers that are stabilised, holding down jobs and doing other——

Deputy Róisín Shortall

There is not much point in telling the committee that there are significant numbers. Can Ms Crowley produce the data in respect of the numbers of people who have gone through methadone maintenance programmes, how long they were in methadone maintenance and what they are doing now?

Mr. Joe Doyle

One of the difficulties we have is the unique identifier. That has been identified in the formation of the new strategy. I am not dodging the Deputy's question. We have looked at the——

Deputy Róisín Shortall

We have heard all the excuses for not knowing what is happening.

Mr. Joe Doyle

We have looked at the central treatment list because the central treatment list gives us the reason people exit the list. Looking at the exit list from the central treatment list, CTL, we identified that approximately 450 people who exit the central treatment list have not successfully completed their treatment. On a yearly basis, therefore, approximately 400 people leave the central treatment list.

Deputy Róisín Shortall

Is that a good performance?

Mr. Joe Doyle

We have nothing to compare it against. If we look back over the time line, initially in 2000 we identified that 254 successfully completed their treatment. It increased to 446 in 2008.

Deputy Róisín Shortall

Does Mr. Doyle know the average length of time people spent on maintenance?

Mr. Joe Doyle

The difficulty we have arises from the systems in place to monitor that.

Deputy Róisín Shortall

When will the systems be changed? Why have they remained inadequate for so long?

Mr. Joe Doyle

In our submission on the development of the new national drugs strategy we supported the need for a unique identifier. That would give us all the information required.

Deputy Róisín Shortall

Without disclosing identities, Mr. Doyle still has access to the data which will tell him the number of people who are on methadone maintenance. He should be able to produce figures telling us the average length of time people are on methadone maintenance and the outcomes. A key aspect identified for the new drug strategy was that there would be proper measurements for outcomes for all of this effort and all of the public money being spent. Why is it that at this stage we still do not have a way of measuring the outcomes? It can be done on an anonymous basis. We do not want to be able to identify the people but Mr. Doyle has the data. Why can he not analyse it in such a way that will provide us with answers to questions?

Mr. Joe Doyle

I do not understand what the Deputy means about us having the data. I am sharing the data we have. The difficulty we have with the CTL is that it records people's last episode of treatment. For example, when the pharmacy dispute arose in 2007 many people exited their regular treatment provider and switched back. The central treatment list shows their last treatment episode but that is a bit of a cog in that system. We are looking deeper into the central treatment list to see what it can tell us. As I said earlier, it was initially set up around the methadone protocol. It was not set up to do what we are looking to do out of it. What needs to happen——

Deputy Róisín Shortall

That was initially but in the interim why have changes not been made? One excuse after another is being given for us not being in a position to assess the cost effectiveness of the approach to drug treatment. We are not in a position to do that now.

Ms Gretta Crowley

I take the Deputy's point but we have tried to focus on getting as many people into treatment as possible. I agree we have work to do——

Deputy Róisín Shortall

Ten years on we should be in a position to be more analytical about it and to be able to reach conclusions.

Deputy Thomas P. Broughan

Of the 400 people mentioned, do we know if they will reappear later? Can Mr. Doyle say that those 400 are now clean and leading a stable life? Do we know that?

Mr. Joe Doyle

No. One of the difficulties we have is that once people successfully exit from treatment they do not necessarily want to engage with us again. It is the nature of the beast. In fairness, in answering the questions the members put to us we point to the ROSIE study and the fact that we have increased our numbers year on year. That in itself is a positive indicator. We——

Deputy Róisín Shortall

Yes, but that is one element. The key aspect at the start of all of this was to ensure that treatment was available. In fairness, a great deal of progress was made in increasing the capacity, even though there are still many areas where much work needs to be done, but it is difficult to understand how we could have a two year waiting list at this point and the reason the HSE has been unable to shape up to the kind of demands on it. We still do not know at this point the optimum way of treating drug abuse, how we are performing compared to other countries and whether we are getting value for money for the €140 million spent on drug treatment every year. We cannot answer those questions and it seems to be one excuse after another.

Mr. Joe Doyle

Having responsibility for overseeing the rehabilitation strategy, I can talk about that. There is a specific action in the rehabilitation strategy that is examining the same methodology taken up in the ROSIE study. We are picking out a cohort of people who successfully completed their treatment and doing a similar longitudinal study on them. There is a rehabilitation strategy in place that was produced by the Department in 2007.

Deputy Róisín Shortall

How long will we have to wait for the results of that?

Ms Gretta Crowley

One of the issues is that we are facing very difficult times. That rehabilitation strategy set out a requirement for €25 million in additional funds to implement the recommendations of the strategy. In the current climate, therefore, it will be very difficult to make progress but we are doing what we can in the context of the resources.

Deputy Róisín Shortall

In fairness, the current climate is a fairly recent phenomenon. Money is very tight but for many years there was a great deal of money available. We are not just talking about the past six or nine months. We are talking about in recent years and it is not acceptable that after building up so much experience in the drugs area we are still not in a position to say how successful the approach is and whether we are getting value for money.

Chairman

Moving away from that issue, will Mr. Moloney indicate if the Department of Finance has evaluated the effectiveness of the programme?

Mr. David Moloney

It would not be within our remit to conduct an evaluation. The Comptroller and Auditor General has conducted a value for money review which the committee is looking at today. We take a keen interest in what is being done in terms of the value for money aspects. It must be recognised that there are major challenges in terms of drug treatment because there is a huge range of activities that contribute to drug treatment. We have invested substantial sums of money in research, particularly through the national advisory committee on drugs, in terms of a longitudinal study. It has clearly indicated that the money invested in drug treatment has had the benefit of reducing cost to society of drug misuse and reducing the drug use of those people.

Deputy Róisín Shortall

Where are the figures in that respect?

Mr. David Moloney

They are published. The national advisory committee on drugs had a study——

Deputy Róisín Shortall

Surely the most cost effective way of dealing with this problem would be to get people functioning normally and back into employment.

Mr. David Moloney

International evidence as I understand it — the Department would be more expert on this — suggests that different approaches will work for different categories of people who are addicted to different drugs. There is some success in some areas with detoxification approaches, but in the main most countries do not have the experience that detoxification would work for everybody. That gives rise to the difficult issue that many people remain on methadone maintenance for prolonged periods. While not regarding that as a success, it is far preferable to the chaotic lifestyles from which they have come. The point is well made in the Comptroller and Auditor General's report, which we also support, that there should be a greater emphasis on person-centred care planning around an individual's pathway through drug misuse. The report concentrates exclusively on drug treatment. We spent approximately €140 million on drug treatment but we spend much more than that on drug related services if account is taken of not only treatment but other services provided in terms of the national drugs strategy. There is a major investment in that respect. I accept that there is a challenge in putting the money beside those outputs. The development of indicators is really the only way we have of fully meeting that challenge.

Deputy Róisín Shortall

The concern is that the emphasis has been on numbers, getting people into treatment and then basically leaving them there. There is not the same kind of urgency as there was at the start of this process in keeping a focus on the need to keep people moving through the system to ensure there would be a recovery and a life after drug abuse. Too many people get stuck on treatment. I asked earlier what percentage of the budget is being spent on counselling and rehabilitation.

Ms Gretta Crowley

I would be happy to provide that to the committee afterwards.

Deputy Róisín Shortall

Ms Crowley does not have that information with her. May I ask a final question?

Chairman

Before the Deputy does so, I wish to intervene. Ms Stack said that a new strategy has been prepared, that it is currently being printed, and the Department will have it by the autumn. Has the new strategy addressed the issues Deputy Shortall raised and does Ms Stack have answers in that respect?

Ms Kathleen Stack

Two of the pillars under the new strategy are treatment and rehabilitation. A number of the issues on which Deputy Shortall touched are reflected in the way in which the new strategy will be rolled out. One of the objectives on the treatment side is to develop a national integrated treatment and rehabilitation service that would provide drug free and harm reduction approaches for problem drug users. It seeks to address the issue of moving people on and not having them parked on methadone, as it were. Many of the issues are picked up in that respect.

Chairman

Perhaps we will return to this matter in the autumn when the new strategy has been printed. Ms Stack may come back to the committee to give us an outline of the new strategy.

Deputy Thomas P. Broughan

That strategy covers the period up to 2016.

Ms Kathleen Stack

Yes.

Chairman

I think it is almost essential that Ms Stack would back to the committee to discuss the new strategy.

Deputy Róisín Shortall

Given the importance of counselling and rehabilitation, it is difficult to understand that the HSE cannot put a figure on how much is being spent on that area. How much of the budget of €140 million is being spent on that area? That would lead us to believe that adequate emphasis is not being placed on that aspect of the services, that the emphasis is on containment rather than on treatment and recovery.

In regard to the principal areas identified in the Comptroller and Auditor General's report on the need to provide a key worker for each drug user and to have an individual care plan, about which Deputy Broughan asked, the representatives have said that they hope to do that in the future. Why has that not happened? Can the representatives tell us how many people at this point have an individual care plan? What percentage of HSE's clients have an individual care and key worker? Can the representatives give us that information?

Ms Gretta Crowley

All those receiving services from the HSE have an individual care plan for the services. A person's case management is an overall plan that would take account of his or her housing, educational and employment needs. Mr. Doyle referred to that in terms of an inter-agency agreed care plan that would be understood by all those involved in providing any element of treatment or rehabilitation to a care worker. The national rehabilitation implementation committee is working on that and on agreeing protocols between the various agencies in the areas.

Deputy Róisín Shortall

When does the HSE expect to be in a position to be able to report that everybody concerned has an individual care plan and key worker?

Mr. Joe Doyle

We have to develop the framework first to ensure we all agree on what is agreed. I have no timelines for this. There are approximately 40 recommendations in the rehabilitation report. I need all the other Departments concerned to roll in around it. They are interdependent in this respect. The committee is currently on this.

Deputy Thomas P. Broughan

Some of that work is happening currently. In regard to the mentoring programme in terms of jobs, mentors in my area refer people to the drugs task force and vice versa. Why is it such a step up to get a comprehensive care plan for each person concerned, irrespective of which part of our infrastructure discovered that the person has a range of problems and that the person's drug use complicates matters and makes his or her situation much more difficult? Why is it so difficult to have a point of contact for that person?

Mr. Joe Doyle

Currently, there are some models of good practice, which was picked up in the Comptroller and Auditor General's report. Some areas have pushed ahead with care planning and management systems. There is the rehabilitation and integration service. In other areas there is nothing in place in that respect. We have to develop a system to have a seamless transition for the individual once he or she accesses treatment right through his or her continuum of care. That is the challenge.

Deputy Róisín Shortall

Is that not the kind of hole that the local drugs task forces have been plugging? To return to the point I made initially, are those task forces not trying to make up for the shortcomings of the statutory agencies where they, and in this case the HSE in particular, are not playing a full part in tacking the problem?

Mr. Joe Doyle

It is stated in the rehabilitation strategy that there is a role for the task forces in terms of their treatment and rehabilitation subcommittees being in a position to co-ordinate that activity within their locality. Some of the difficulty we have encountered is that not every task force has a treatment and rehabilitation subcommittee.

Deputy Róisín Shortall

I am making the general point that in many cases it is the local drugs forces that drag the statutory agencies, in particular the HSE, kicking and screaming to the table.

Mr. Joe Doyle

I would not necessarily agree with that. The HSE participated in those structures.

Deputy Róisín Shortall

To a greater or lesser degree, but it varies enormously from task force to task force. The kind of process that Mr. Doyle is outlining is mind-blowing where he has to get agreement on agreement. He is still not in a position to tell us when he will able to implement the key recommendations in the Comptroller and Auditor's General's report.

Mr. Joe Doyle

There is a rehabilitation report that I have been asked to implement. I chair the committee in that respect. The report identifies the need to have ten case managers and ten co-ordinators who will specifically co-ordinate the case management and they will oversee the cases. As Ms Crowley alluded to, resources are the issue. I have said to the committee that we need to be solution focused and to examine how we can do this without the resources identified in the report. That is what we are currently working through. Examining how to do this is where we are now.

Deputy Róisín Shortall

Mr. Doyle does not know when that will be in place.

Chairman

We will be returning to this matter in the autumn. We will bring in other agencies. In view of today's response, we will need to talk to the HSE's representatives again. Much of the focus should be on evaluation because there does not seem to be adequate evaluation of the success of programmes, as has been shown. I would also return to the question of leadership: there needs to be strong leadership to drive all the strands of the strategy. In view of the fact that we do not have possession of the new strategy nor the survey, referred to earlier, of the number of people who are not in treatment but who should be, we need possession of both the strategy and the evaluation by September as well as some progress on what we have just discussed. We will also be bringing in the Prison Service, the probation service and the Courts Service on this issue in September.

Deputy Thomas P. Broughan

Mention was made of the 400 deaths that we know of. Do they include deaths through violence? Is there any follow through or database in that regard? We will be discussing that at other meetings later on. The other side of the coin is that in the constituencies that the Chairman, Deputy Shortall and I represent, we have had a number of horrendous assassinations, which are directly related to the criminal side of this issue. Is it known how many of these deaths resulted from violence?

Mr. Joe Doyle

There is the national drug-related deaths research that was conducted by the Health Research Board. It provides year-on-year figures and will give accurate data.

Deputy Thomas P. Broughan

That is where it is available?

Mr. Joe Doyle

Yes.

Ms Kathleen Stack

I understand that does not include the sort of deaths to which the Deputy referred. It concerns deaths that are directly related to drug use.

Chairman

Does Mr. Buckley wish to comment on what we have been listening to?

Mr. John Buckley

Yes. I would like to summarise and reflect on a few matters. One of the themes coming through is that the best prospect for effective treatment is to move promptly as soon as the client presents for help. Therefore, prompt assessment and treatment are obviously very important. Better record keeping will be needed to evidence that this is being delivered.

A multiplicity of problems are being presented in the person of the client, including social and psychological ones. There are also interactions the client has with his or her family and various other people. The integrated individual care plan is an obvious answer, which will allow treatment to be tailored to the needs of clients. It is central to any kind of meaningful interventions. It is also central to value for money because only by having a tailored individual care plan, can one ration the bag of resources necessary for individual cases in any kind of rational way. The other theme that emerges is that it all needs to be administered in a situation where there is a national framework for care planning.

Moving to cost effectiveness, a possible suggestion is that with the planned creation of the new office at central government level to co-ordinate the programme better, there is an opportunity to demonstrate more transparently the costs and to link them to the measures of output and achievement. One possible suggestion is to use something along the lines of an output statement, which is currently used by Departments for their own mainline services in order to link inputs, outputs and outcomes.

Chairman

Thank you, Mr. Buckley. I wish to thank everyone who has contributed to the meeting, including members of the committee and witnesses. We will be returning to the issue in September when, as I said, we will ask the Prison Service, the probation service and the Courts Service, as well as today's witnesses, to return when we renew our deliberations.

The witnesses withdrew.

The committee adjourned at 1.05 p.m. until 10 a.m. on Thursday, 17 September 2009.