Scottish Government

6 Discussion and conclusions

6.1 The purpose of this research was to identify what need there is in Scotland for services for people who become drunk and incapable in public. This has involved not only estimating the size and nature of the problem, but also looking in detail at how the needs of this population are currently being addressed, both in Scotland and elsewhere, and how those needs may be addressed most effectively.

6.2 This chapter summarises the main messages from this research, considers the strengths and limitations of different types of services and offers some conclusions and recommendations.

What need is there for services in Scotland?

6.3 The question, what need is there for services in Scotland, includes two subsidiary questions. The first is, what is the scale of the problem? The second is, what is the nature of the need?

6.4 Considering the scale of the problem first: based on our examination of secondary data sources we estimate that:

• There are between 7,500 - 21,000 drunk and incapable people per year presenting at hospital emergency departments at an estimated cost of between £0.7m and £1.95m per year.
• Across Scotland, there is a relatively small number of people being admitted to hospital with a primary diagnosis of acute intoxication - 1,440 people per year. However, the cost associated with their care in an acute hospital ward is high - an estimated £0.7m per year.
• In addition, there are around 5,500 people per year arrested by the police and charged with the offence of being drunk and incapable. The cost of holding these people in police custody for their own safety is estimated to be around £2.12m per year.

6.5 The data indicated that at least some of the people arrested by the police are repeat offenders. It also seems likely that some people who are arrested by the police as drunk and incapable may also end up in hospital for the same problem on other occasions, or because they're taken there by the police following arrest.

6.6 However, an important finding from the analysis of secondary data is that there is an absence of consistent and robust data on severely intoxicated people. This makes it difficult to obtain an accurate measure on the extent of the problem across Scotland and in local areas. There is no direct source of data on the number of people who are drunk and incapable coming into contact with emergency services who may be eligible for a different type of service. The lack of ambulance service data was also a significant gap. We therefore had to use various proxy measures, such as:

• The number of police charges for being drunk and incapable
• The number of hospital discharges with alcohol intoxication as a primary diagnosis and
• The estimated number of accident and emergency presentations of intoxicated people.

6.7 There are a number of weaknesses with these different datasets, primarily the potential variations in processing, recording and coding of data.

6.8 Therefore, although the data presented in our report provides a useful starting point, it is important that local areas supplement this with locally-gathered intelligence which may provide a more comprehensive and detailed picture of local need.

6.9 From our investigation of services that currently exist to manage the care needs of drunk and incapable people we have identified some common themes regarding the nature of the need in Scotland:

• The first is that there is a need for an alternative service - or services - to reduce the pressure on the time and resources of the emergency services which is caused by severely intoxicated people. Both the police and hospital emergency departments would benefit from alternative services, and both argued strongly for such services.
• Second, there is a need to keep publicly intoxicated people safe until they sober up. Where the individual does not have a responsible person who can look after them, this task must fall to some form of service.
• Finally, there is a need for services to link people more effectively to treatment and support, where appropriate, and / or to deliver brief interventions to reduce drinking levels among binge drinkers. However, the feeling was that people had to be sober first to be able to benefit from such interventions.

6.10 There is also another group for whom some provision may have to be made. These are people who are arrested for an offence (such as assault), but who are also intoxicated and, therefore, vulnerable. Because of the offence these individuals will have to be detained in a cell but they still require to be assessed and monitored. It was beyond the scope of this research to estimate the size of this population. However, the view was that the tasks of assessment and monitoring should not be carried out by the police, but rather by a suitably-qualified medical professional.

What do services look like?

6.11 Both in Scotland and around the world, services for drunk and incapable people tended to fit into one of three models:

• Premises (permanent and temporary) where drunk and incapable people (who are not injured) can be kept safe and their physical condition monitored by trained staff until they are sober and able to go home. These premises can be very basic (mat on floor) or more comfortable (beds and showers). They can operate 24/7, or on certain nights of the week. In the US and Australia, there were examples of these services operating together with a transportation service that collected people off the streets (or from police custody suites), and transferred them to the sobering-up facility.
• Mobile units which provide some level of assessment, triage and first-aid if needed. The target group for these services is usually wider than people who are intoxicated, although intoxicated people generally comprise a large proportion of their clients. These services range from mobile medical resource vehicles to converted buses and can be staffed by ambulance personnel, paramedics and volunteers. They mainly operate at weekends, at special times of the year, or for specific events.
• Custody nurses who provide an assessment of whether people are fit to be detained. Custody nurses can also treat minor injuries in police custody suites. They operate mainly evenings and weekends.

6.12 In Scotland, we also found examples of joint protocols between police and ambulance services for managing the care needs of people who are drunk and incapable in public, and we found cases where technology (cell monitoring systems) was used to support - but not substitute for - visual monitoring by staff.

6.13 In general, stakeholders felt that the best way to manage the needs of drunk and incapable people would be to provide a place of safety where individuals can sober up under the care of trained staff. There was strong support for the idea of a permanent sobering-up facility with dedicated premises operating round the clock. However, this was seen as expensive, in part because of possible under-occupancy during weekdays, and in part because it would cater for a relatively small number of people, after taking into account that some people will still have to be taken into custody (because they have committed an offence), or to hospital (because they are injured). There is also evidence from Scotland and elsewhere around the world that such services can end up being used frequently by a small number of alcohol-dependent drinkers.

6.14 Some people felt that mobile resource units and triage points were less expensive and might be better suited to meet the needs of intoxicated people in busy city centres. They can also deal with a larger volume of people. What was reported to be missing in the Glasgow pilot was a holding area for drunk people. In Edinburgh and Aberdeen, the triage services had access to space where people could wait until they were sober. In England, there has been some success in using specially adapted buses that have space to allow people sit and wait for short periods of time.

6.15 The use of custody nurses was not widespread across Scotland. There were some positive reports of this model of service. However, if other services for drunk and incapable people are not also made available, the use of custody nurses does nothing to divert people from police custody who do not really need to be there.

6.16 The issue of service funding was a recurrent theme in this study. There is clearly a need for a new approach to funding services. In both Inverness and Aberdeen, the funding for the designated place was under severe pressure. Where there have been temporary services, funding has been provided only on a short-term basis, with no guarantee of the service being repeated or extended.

6.17 One of the main difficulties seems to be that no one agency feels responsible for the provision of services for drunk and incapable people. This was seen to have an impact on funding. The findings of this research suggest that a multi-agency approach to funding will be required. In Scotland, this should at the very least involve the local authority, NHS (community and acute services), ambulance service, police and the voluntary sector. Both professionals and service users also argued for the licensed trade to be involved as well - not only in terms of discouraging excessive alcohol consumption by customers, but also in contributing towards the cost of it when it occurs.

What is seen as good practice?

6.18 A report published by HM Inspectorate of Constabulary for Scotland argues strongly that a police cell is not the best place for holding an individual who has committed no offence, but who is merely drunk and incapable of looking after themselves. ⁹⁶ Stakeholders, including service users, unanimously agreed with this view.

6.19 Therefore, one aspect of good practice in meeting the needs of drunk and incapable people at a local level is to ensure that alternative services are provided to divert severely intoxicated people from police custody. The experience of Australia shows that the introduction of sobering-up services can have a dramatic impact on the number of intoxicated individuals held in police custody.

6.20 Evidence from Scotland and around the world suggests that good practice in providing services for this vulnerable population requires:

• Locally-based needs assessment to get a more detailed picture of the local population of drunk and incapable people
• Multi-agency support, both at the planning and delivery stage
• Flexibility in commissioning services, as needs are likely to vary from one area to another, and they are likely to change over time
• Multi-disciplinary staff trained in first-aid and in the ability to recognise when more specialist clinical input is required
• Clear referral, admission and safety protocols and procedures
• Some form of brief intervention or referral to longer-term services providing treatment and / or housing support when the person is sober.

6.21 The latter point was emphasised, not only by professional stakeholders, but also by service users. It is the latter point that provides the link between harm reduction (keeping people safe) and prevention (encouraging a reduction in dangerous levels of drinking).

6.22 On the other hand, it was also recognised that it may take many attendances before an individual is willing and able to respond to interventions. One of the advantages of an overnight sobering-up service is that it provides an opportunity for engaging with service users in the morning when they are sober. In any case, there was a clear consensus among stakeholders that there should be more intensive efforts to try to help chronic drinkers, in particular, break the cycle.

What are the options for services?

6.23 The findings of this study suggest that a one-size-fits-all approach to services for drunk and incapable people is unlikely to address all the needs. Therefore, this study does not recommend that local areas should adopt a certain model of service. Different service models have different strengths and limitations, and it may be that the best approach will be a combination of models.

6.24 In deciding what type of service will best suit the circumstances of a particular local area, it is important that the objectives of the service be clarified. From our evidence we would suggest that there are three interlinked objectives:

• To keep vulnerable people safe
• To reduce the pressure on emergency services (police, emergency departments and ambulance service)
• To deliver interventions that will encourage people to reduce their drinking and prevent recurrence.

6.25 Arguably, the last of these objectives makes service design and delivery more complex and requires involvement from a greater number of agencies. The interventions would be different depending on the client. For binge drinkers, particularly young binge drinkers, the focus may be on brief interventions, advice and education. For chronic drinkers, the interventions will need to be more intensive and longer-term.

6.26 In considering the options, the issue of cost is obviously important. However, local service planners should also bear in mind the existing costs already incurred by the police, emergency departments and ambulance service in responding to the needs of severely intoxicated people. Ways of minimising costs might include:

• Providing premises for a place of safety and using those premises for other purposes during the week, e.g., health, social care or information services for problem alcohol users.
• Providing a place of safety within existing premises, e.g., police cells, hospital, social work or community centres, but ensuring that the monitoring function is provided by suitably trained staff.
• Installing life monitoring systems in police cells.
• Increasing the number of custody nurses available to assess and treat people intoxicated by both alcohol and drugs.
• Using mobile units which could be taken to different locations as needed at weekends when the problem is greatest, and deployed for other duties during the week.

6.27 Table 6.1 on the following page summarises the strengths and limitations of the three main service models we identified in Scotland and elsewhere, and compares their relative cost.

Table 6.1: Strengths, limitations, good practice and relative cost associated with sobering-up services, custody nurses and mobile units

6.28 In considering the best option(s) for different local circumstances, the following factors should be taken into account:

• The target group: Is the service primarily to ensure the health and safety of drinkers who occasionally become drunk and incapable and need immediate care before sobering up and returning home? Or will it offer a more intensive, perhaps more medical intervention for people with a serious, long-term problem?
• The location: Ideally, the service should be near to an emergency department, or a first-aid post, but it is also worth considering proximity to the main centre of population where drinking is mostly likely to occur, and to police custody suites. There is also the question of transport: how will people arrive at the service, and how will they leave it?
• Capacity: How many clients are likely to use the service? Static premises may only be able to accommodate limited numbers. A mobile facility may offer greater flexibility but that will be contingent on a short stay which may not be suitable for all clients. A mobile unit linked to a "holding centre" may be able to address some of these difficulties.
• Level of comfort: If it is a building , will it provide beds or mats on the floor, showers, food?
• Hours of operation: 24/7 or mainly at weekends and other times of peak demand? If the latter, what will happen at other times?
• Number and level of staff: Staff should have a mix of skills but should at minimum have first-aid training, including at least one member of staff with paramedic-equivalent training. Staff should also be able to provide brief interventions and onward referral when appropriate. If the service aims to address the problems of chronic drinkers in a more systematic and sustained way, it may require more highly trained or specialised staff.
• Admission and exit criteria: These criteria need to be agreed with other agencies that will refer or bring people to the service. For example, will the service be able to accept people with minor injuries?
• Links to other services: To ensure that the service works as it was intended to work, it will be important to establish good working relationships with other agencies at an early stage. This includes not only the agencies that might refer people to the service (police, ambulance service, emergency department), but also agencies that might provide follow-up / brief interventions, and longer-term treatment and support.
• Funding: This should be through a multi-agency partnership, involving all relevant stakeholders, including the local authority, NHS, police and ambulance service.
• Service delivery: Will the service be provided by the statutory or voluntary sector?
• Monitoring and evaluation: This allows service planners and providers to ascertain whether the service is meeting the needs it was intended to meet, and to determine whether local needs are changing.

6.29 Funding emerged as a key issue in this research, particularly in relation to the funding of designated places. It may be that funding would be more readily available if the link to treatment was better structured. However, service providers may feel at risk if they cannot meet targets of referrals / access to treatment. Commissioners and planners should therefore discuss with service providers realistic aims and objectives for meeting the immediate care needs of clients and whether, and how, that can be combined with further intervention with those people who have chronic alcohol problems.

Recommendations

6.30 There should be a strategic and partnership approach at local level to planning and funding services to meet the care needs of drunk and incapable people.

6.31 The findings of this study suggest that in some local areas, there have been difficulties agreeing who should take responsibility for planning and delivering services for drunk and incapable people. In our view, the strategy for addressing the care needs of drunk and incapable people should be part of a wider local alcohol strategy, and Alcohol and Drug Partnerships are therefore best placed to take the lead on this. ⁹⁷

6.32 Local areas should undertake a local area needs assessment prior to planning services for drunk and incapable people. Locally-gathered intelligence may provide a more comprehensive and detailed picture than it has been possible to provide here.

6.33 The provision of services requires the involvement of a range of agencies but should include at the very least, health, social work, the police, the ambulance service and the voluntary sector. There are potential cost savings to be made in shifting the balance of care from high-resource-intensive emergency services to services that are specifically targeted at this population.

6.34 At the same time, the NHS, in particular, should take a much greater role in the establishment and running of services than they do at present in some areas. NHS input is needed not only to address people's acute care needs when they are intoxicated, but also the longer-term care needs of alcohol-dependent people.

6.35 Local strategies for responding to the needs of drunk and incapable people should include interventions that help to prevent people from becoming drunk and incapable in the first place. Examples of the use of taxi marshals and the Street Pastor initiatives around Scotland are perceived to be beneficial and should be considered more widely.

6.36 Some people will have to be detained in custody because of the other offences they have committed. The care needs of these individuals should be assessed and met by a suitably trained individual.

6.37 At the same time, the use of technology, for example through cell monitoring systems, may provide an additional (not an alternative) support for monitoring intoxicated people in custody.

6.38 Protocols should be developed between the police, ambulance service, emergency department and any alternative services set up to manage the care needs of intoxicated people. These protocols should clearly specify the target group for the alternative services, how people are referred to them, how the services operate, and how they can make referrals to other agencies to address longer-term care needs.

6.39 Finally, services need to have an effective way of linking people to treatment and support. However, commissioners and planners should discuss with service providers realistic aims and objectives for meeting the immediate care needs of clients and whether, and how, that can be combined with further intervention with those people who have chronic alcohol problems.