Updating the NICE NSP Guidance

1. Updating the NICE NSP Guidance Chris Carmona, Public Health Analyst Centre for Public Health

2. Plan • Rationale for the update • The draft NSP recommendations • Changes from the original guidance • Implementation issues • Questions.

3. Updating the guidance

4. Process • Guidance was published in Feb 2009 and was reviewed in Apr 2012 • An expert group considered whether any new evidence or significant changes in policy and practice would be likely to lead to substantively different recommendations. • The proposal of the expert group was consulted on publicly. • On the basis of consultation and expert opinion, NICE decide whether or not to update the guidance.

5. Decision The review process concluded that: • There was no new evidence to contradict the current recommendations • There was new evidence that could add to existing recommendations • There was new evidence that could expand the previous work to more fully meet the scope

6. NICE decided to undertake an update of the existing NSP guidance. • Following the expert group and consultation, the update focussed on: • New evidence related to existing recommendations • Vending machines, outreach, drop boxes. • NSP provision to PIED users • NSP provision to under 18s

7. Drafting the giuidance • CPH commissioned reviews of the evidence. • A public health advisory committee (PHAC) considered the evidence. • On the basis of the evidence and public consultation they drafted new recommendations and updated old recommendations.

8. Original recommendations

9. Recommendation 1 Planning, needs assessment and community engagement • Look at local need and local data on use and geographic spread (including estimating coverage) • Make sure NSPs are configured to meet this need both temporally and spatially • Do all of this in consultation with PWID and local communities

10. Recommendation 2 Meeting need • Commission a range of generic and targeted services that aim to increase coverage (ideally to over 100%) • Develop strategies for disposing of dirty needles safely • Encourage syringe identification schemes • Audit services • Integrated care pathways.

11. Recommendation 3 Types of service • Set up a 3-tier model of service provision • Make sure services are co-ordinated to provide good temporal coverage in each 24 hour period. • Make sure people who are on OST can also get clean needles and syringes.

12. 3 tier model of NSP provision • level one: distribution of injecting equipment either loose or in packs, with written information on harm reduction (for example, on safer injecting or overdose prevention) • level two: distribution of ‘pick and mix’ (bespoke) injecting equipment plus health promotion advice (including advice and information on how to reduce the harms caused by injecting drugs) • level three: level two plus provision of, or referral to, specialist services (for example, vaccinations, drug treatment and secondary care).

13. Recommendation 4 Equipment and advice • Provide people with as many needles and syringes as they need, without arbitrary limitation. • Provide them with sharps bins • Provide them with other equipment they need to safely take drugs • Provide them with information and a gateway to services

14. Recommendation 5 Community pharmacy-based NSPs • Make sure staff are appropriately trained for the level of NSP work they’re doing • Collect used sharps bins • Offer staff Hep B vaccination

15. Recommendation 6 Specialist NSPs: level three services In addition to the above, • Offer a range of needles, syringes and equipment. • Provide harm-reduction services • advice on safer injecting practices, assessment of injection-site infections, • advice on preventing overdoses and • help to stop injecting drugs. • Where appropriate, offer a referral to opioid substitution therapy services. • Offer (or help people to access) a range of health and welfare services.

16. Whats new?

17. Caveat The updated guidance is still not fully signed off so I am unable to share with you the exact wording and content, and anything that I say today may change during the final sign off processes within NICE. The final decisions will be made in mid Feb and the guidance will be published on March 26th 2014.

18. Whats new? • There are two completely new recommendations. • There are some notable additions to recommendations. • The early recommendations have been reorganised to make them more logical.

19. Developing a policy for young people aged under 16 • Requires local areas to develop and implement a policy on providing NSP and related services to young people aged under 18 (including young people under 16). • Asks how local services will achieve the right balance between the imperative to provide young people with injecting equipment and the duty to safeguard them and provide advice on harm reduction and other services. It includes: • the young person’s capacity to consent • the risks they face • the benefits of them using services • the likelihood that they would inject anyway, even if equipment was not provided. • Provide NSP as part of a package of care (esp to under 16s) where possible. • Offers some ideas about the things local areas will need to consider, for example consent, parental involvement, specialist substance misuse services for YP, training needs

20. Provide equipment and advice to people who inject IPED • Ensure needle and syringe programmes: • Are provided at times and in places that meet the needs of people who inject IPED. (For example, outside normal working hours or outreach in gyms.) • Provide the equipment, information and advice needed to support these users. • Are provided by appropriately trained staff • Specialist NSPs with high numbers of IPED users should provide specialist services for them. It includes: • specialist advice about IPED and side effects (stacking/cycling etc) • advice on alternatives (for example, nutrition and physical training as an alternative to AAS) • information about, and referral to, sexual and mental health services and to specialist IPED clinics, if these exist locally.

21. Notable additions • “Not discourage secondary distribution” • “Where possible, provide low dead space syringes” • More points about data collection and monitoring. • Consider drop boxes (in consultation with police and communities) • Consider whether NSVM might be appropriate

22. Implementation

23. NICE Guidance support • Costing and Commissioning tools • Press and dissemination • Linking with national policies and systems- potential collaboration with PHE • Good practice case studies

24. Communications support • Filming – in house filming of a needle exchange program for the NICE website. • Interviews with experts for the NICE website • Opportunities for the press to film on location • Press work with national media channels • Press release Contact lyndsey.unwin@nice.org.uk Lyndsey Unwin: Media Relations lead

25. Into practice: case studies Please contact: mandy.harling@nice.org.ukSenior Implementation Adviser Please let us know about any local work underway where: • It has generated consultation with:BME communities; or men who have sex with men; or emerging populations e.g. people injecting ‘legal highs’ • Local policies/protocols addressing NX provision for young people • Services are delivering needle exchange (NX) for IPEDs users • NX in settings: custody suites; GUM clinics; or A&E depts. • Community pharmacies are integrated into local planning and pathways for NSPs

26. Thank you. Chris Carmona: Lead analyst Chris.carmona@nice.org.uk Mandy Harling: Senior Implementation Adviser mandy.harling@nice.org.uk Lyndsey Unwin: Media Relations lead lyndsey.unwin@nice.org.uk