Addiction Services in Northern Ireland

Public Accounts Committee

Session: Session currently unavailable

Date: 27 January 2022

Reference: NIA 159/17-22

Report on Addiction Services in Northern Ireland.pdf (345.89 kb)

This report is the property of the Public Accounts Committee. Neither the report nor its contents should be disclosed to any person unless such disclosure is authorised by the Committee.

Ordered by the Public Accounts Committee to be published 27 January 2022.

This report is embargoed until 00.01am on 27 January 2022.

Report: NIA 159/17-22 Public Accounts Committee

Contents

Powers and Membership
List of Abbreviations and Acronyms used in this Report
Executive Summary
Summary of Recommendations
Introduction
Harms caused by drug and alcohol use are significant and likely to get worse
A joined-up approach to tackling substance use is essential if the new strategy is to make any impact
Developing the new substance use strategy has taken too long
There is uncertainty around funding for the new strategy and as a result, it may be only partially implemented
Significant deficiencies in data quality and completeness impact the Department’s ability to plan and assess its substance use services
Community and voluntary sector organisations provide effective harm reduction services and should be a priority, yet some of these services have had funding withdrawn
Clearer, more consistent care pathways are needed to ensure people are able to access the right services at the right time
Access to residential rehabilitation beds is inconsistent and a review is long overdue
Misuse of prescription drugs is a significant issue in Northern Ireland, but there is little evidence that interventions to date have made an impact
Links to Appendices

Powers and Membership

Powers

The Public Accounts Committee is a Standing Committee established in accordance with Standing Orders under Section 60(3) of the Northern Ireland Act 1998. It is the statutory function of the Public Accounts Committee to consider the accounts, and reports on accounts laid before the Assembly.

The Public Accounts Committee is appointed under Assembly Standing Order No. 56 of the Standing Orders for the Northern Ireland Assembly. It has the power to send for persons, papers and records and to report from time to time. Neither the Chairperson nor Deputy Chairperson of the Committee shall be a member of the same political party as the Minister of Finance or of any junior minister appointed to the Department of Finance.

Membership

The Committee has 9 members, including a Chairperson and Deputy Chairperson, and a quorum of five members. The membership of the Committee is as follows:

Chairperson: Mr William Humphrey MLA

Deputy Chairperson: Mr Roy Beggs MLA

Mr Andrew Muir MLA²

Mr Cathal Boylan MLA

Mr Maolíosa McHugh MLA

Ms Órlaithí Flynn MLA

Mr William Irwin MLA^{1 4}

Mr David Hilditch MLA

Ms Cara Hunter MLA ^{3 5}

¹With effect from 17 February 2020 Mr Harry Harvey replaced Mr Gary Middleton

²With effect from 31 March 2020 Mr Andrew Muir replaced Mr Trevor Lunn

³With effect from 19 May 2020 Mr Matthew O’Toole replaced Mr John Dallat

⁴With effect from 21 June 2021 Mr William Irwin replaced Mr Harry Harvey

⁵With effect from 18 October 2021 Ms Cara Hunter replaced Mr Matthew O’Toole

List of Abbreviations and Acronyms used in this Report

C&AG: Comptroller & Auditor General

The Department: Department of Health

CVS: Community & Voluntary Sector

SPS: Substitute Prescribing Service

HSC: Health & Social Care

Executive Summary

1. The Public Accounts Committee (the Committee) met on 21 October 2021 to consider the Comptroller and Auditor General’s (C&AG’s) report “Addiction Services in Northern Ireland”.

The main witnesses were:

Mr Richard Pengelly, Department of Health
Professor Sir Michael McBride, Department of Health
Mr Gary Maxwell, Department of Health
Mr Brendan Whittle, Health and Social Care Board
Mr Kieran Donnelly, Northern Ireland Audit Office
Mr Stuart Stevenson, Department of Finance

2. The C&AG’s report highlighted a number of serious issues facing addiction services across Northern Ireland. The level of harm caused by substance use is significant and growing, and the pressures on services, and the wider public sector are becoming unsustainable. There have been failings in joined-up working, both within the health sector and more widely across government. These issues have been compounded by a lack of reliable information and monitoring of services and the absence of an up-to-date substance use strategy for over five years.

3. It has taken five years to produce a new substance use strategy, which was published in September 2021. In the Committee’s view, tackling substance use has not been enough of a priority for the public sector, and the lack of strategic focus on this area has exacerbated the huge financial costs and significant harms caused to individuals, families and wider society. The Committee hopes that the implementation of the new strategy will be treated with more urgency.

4. The Committee was encouraged by the direction of the new strategy, in particular its emphasis on a collaborative, cross-sectoral approach to tackling the harms caused by substance use. However, commitment on paper must be backed up by actions and funding to implement the strategy. It is clear that on their own, interventions made by the Department of Health (the Department) will not be enough to deal with the large and growing harms, and the Committee calls for joined-up action, led by the centre of government, with a clear objective of reducing drug and alcohol related deaths.

5. The Committee was frustrated by the lack of reliable data on addiction services, and surprised to hear this problem has not been resolved several years after having been identified. The Committee had concerns over how the Department could be sure its services were effective if they are not able to scrutinise them effectively. It is an essential part of the Department’s role to monitor services, and it is vital that future service provision is informed by good quality, outcomes-focused data.

6. The Committee was alarmed by the prevalence of prescription drug use in Northern Ireland, and believes there is much more to be done in this area. The Department’s lack of understanding of prescribing trends is of concern and should be addressed urgently.

7. In order to reduce harms, it is essential that people have access to the right services at the right time. The Committee heard repeatedly about the “bumpiness” of the journey for service users, and the lack of integration between services. This cannot be allowed to continue, and it is essential that the Department works across government and with colleagues in both the statutory and community and voluntary sector to improve care pathways for people who need help.

Summary of Recommendations

Recommendation 1

8. Evidence provided to the Committee showed that Addiction Services has suffered from a lack of strategic attention. Strategy development, and a focus on outcomes demonstrates to stakeholders and service users that the Department is serious about tackling substance use. The absence of an up-to-date substance use strategy for the last five years indicates that this area has not been enough of a priority for the Department.

9. Setting clear objectives for reducing harms caused by addiction is an important part of strategy development. Whilst many of the targets within the old strategy were achieved, these have not effectively addressed the growing impact of substance use. Drug and alcohol related deaths have risen sharply, and are likely to continue without an effective strategy.

The Committee recommends that reducing the harm caused by addiction should be the focus of the Department’s efforts going forward, with a clear objective of reducing drug and alcohol related deaths.

Recommendation 2

10. Attempts at collaboration within the health and social care sector have not always been good in the past and the Committee has some reservations about how successful this approach will be this time around. It is clear that greater connectivity is needed and the Department should lead on this.

The Committee recommends that the Department puts a clear focus on continuing to build and strengthen collaborative work across the Health and Social Care sector to tackle drug and alcohol and use.

Recommendation 3

11. It is clear that actions taken by the Department alone will not be enough to deal with the significant and growing harms related to substance use. The co-production approach to the new strategy is a welcome development, and there is recognition that joined-up action across government is required to tackle these issues effectively.

Given the current pressures on the Health sector, the Committee recommends that consideration is given to the centre of government providing leadership to ensure a genuinely system wide-approach to tackling this issue.

Recommendation 4

12. Implementation of the new strategy will require more than £6 million per annum of additional funding which has not yet been secured. Without this funding the Department will have hard choices to make about which elements of the strategy cannot be fully implemented. Funding the strategy is a clear spend-to-save issue, and additional funding can make a significant contribution to future savings across the public sector.

The Committee recommends that the Department puts forward a robust case for the additional funding needed to fully implement the substance use strategy, outlining its spend-to-save potential, and urges the Executive to ensure that support for the strategy translates into actual budget cover.

Recommendation 5

13. The C&AG’s report highlighted significant deficiencies with the data the Department has on addiction services. Issues with data quality and completeness are a frequent cause for concern with public sector services and it is disappointing to note that these have been ongoing for years. Understanding what works, and the impact interventions have on people’s recovery should underpin future service provision. Resolving data issues, and getting better information on the services it funds and outcomes for service users should be a priority for the Department.

The Committee recommends that the Department addresses issues with data quality and completeness urgently, and that future monitoring has a clear focus on measuring outcomes for service users. Any future strategy and service development must be informed by robust, reliable evidence obtained from services.

Recommendation 6

14. Community and voluntary sector (CVS) organisations are key partners in delivering addiction services, and there is clear evidence that they provide successful and cost effective harm reduction and early intervention projects. However, CVS services are often amongst the first to have funding withdrawn when central government is under financial pressure. This kind of short-termism creates significant uncertainty for organisations, their staff and the service users that rely on them for help and will ultimately result in poorer outcomes.

The Committee recommends that the Department commits to working in partnership with Community and Voluntary Sector organisations and strongly encourages the Department to provide more certainty around funding arrangements and contracts for these organisations.

Recommendation 7

15. It is vitally important that people are able to access the right services, at the right time. For many of those suffering from addiction, their first contact with the health service comes either through attendance at the Emergency Department or via general practice. Whilst both of these areas are under intense pressure, it is essential that work is undertaken to ensure that there are effective pathways to refer people to addiction services. Referrals to the wrong type of service can have a serious impact on service users, and can contribute to prolonged waiting times.

16. There is much more work to be done with GPs, in particular raising awareness of Tier 1 and 2 services, and in improving participation in shared care for the Substitute Prescribing Service (SPS). It is clear that the shared care model for Substitute Prescribing has not worked, in part due to a reluctance by GPs to participate. Shared care is an important step in normalising care for patients, and could also reduce pressures on Community Addiction Teams.

The Committee recommends that the Department investigates the failure of the shared care model in some regions and establishes clear plans to increase the number of GPs involved in this care.

Recommendation 8

17. Some people will need more intensive, residential treatment for their addiction. However, there is little in the way of integration for residential rehabilitation services, and two HSC Trusts have no formal access to these beds. This is unacceptable. Although the Department has been aware of the need for a more consistent, regional approach to these services for years, it has made no attempt to review them, meaning that people continue to be treated in the community, even though this may often be inappropriate.

The Committee recommends that the Department should urgently undertake a fundamental review of residential rehabilitation services to ensure consistent and equitable access. Any review should include the provision of aftercare.

Recommendation 9

18. High prescribing rates of some prescription drugs are a significant cause for concern, particularly as these drugs are now involved in the majority of drug related deaths in Northern Ireland. Over the last decade, there have been a number of attempts by the HSC Board to highlight the risks associated Pregabalin, but these have made very little impact, with prescribing rates and related harms continuing to rise sharply. The high prescribing rates of Pregabalin was raised as an issue in 2015 by the PAC in their inquiry into Primary Care Prescribing. Progress in this area has been much too slow and it is very concerning that the Department does not appear to have a clear understanding of why prescribing rates are so much higher in Northern Ireland than elsewhere in the UK.

The Committee recommends that work is undertaken to investigate the sources of these harmful drugs. In our view, this is not just a Health issue, and so a wider response from the centre of government is also required.

Recommendation 10

19. Alternative therapies, such as cognitive behavioural therapy and counselling, can be as effective as prescription drugs for some people. However, there are often long waiting lists for these therapies and, although the Department intends to expand social prescribing, progress has been slow.

The Committee recommends that the Department continues its efforts to make progress on social prescribing and the availability of alternative therapies.

Introduction

20. The Public Accounts Committee (the Committee) met on 21 October 2021 to consider the Comptroller and Auditor General’s (C&AG’s) report “Addiction Services in Northern Ireland”.

The main witnesses were:

Mr Richard Pengelly, Department of Health
Professor Sir Michael McBride, Department of Health
Mr Gary Maxwell, Department of Health
Mr Brendan Whittle, Health and Social Care Board
Mr Kieran Donnelly, Northern Ireland Audit Office
Mr Stuart Stevenson, Department of Finance

Background

21. Substance use causes significant harm in Northern Ireland, to individuals, families and wider society, with impacts on physical and mental health, unemployment, homelessness and criminal activity. The Department of Health (the Department) has itself estimated that the annual cost to Northern Ireland could be around £1.5 billion.

22. Whilst alcohol use remains the most prevalent substance issue in Northern Ireland, the number of people seeking treatment for drug use has grown significantly. The number of deaths relating to substance use is also rising, with drug use deaths more than trebling in the last decade. The effects of substance use are most keenly felt in areas of high deprivation, where deaths related to drug and alcohol use are around four and a half times that seen in the least deprived areas.

23. The Department for Health has overall strategy responsibility for alcohol and drugs. The New Strategic Direction for Alcohol and Drugs was originally launched in 2006. Despite this strategy coming to an end in 2016, the Department did not complete a review of it until 2018. The production of a new strategy was listed as one of the Executive’s priorities in the New Decade, New Approach agreement, however “Preventing Harm, Empowering Recovery” was not published in September 2021. This means that for five years, there was effectively a strategy vacuum.

24. Addiction services face significant and growing pressures including the increasing complexity of care required by service users. Services are under strain, which has been compounded by the impact of the Covid-19 pandemic, and often have long waiting lists. Lengthy waiting lists can deter people from seeking help, prolong risky drug taking behaviours and increase the potential for involvement with the criminal justice system.

25. The C&AG’s report, published in June 2020, highlighted the need for a joined-up approach across government, to tackle this issue effectively. Drug and alcohol addiction are complex problems that do not occur in isolation and recovery depends on a number of overlapping factors including housing, community, family, employment and the criminal justice system. Whilst strategy responsibility lies with the Department of Health, the impacts reach across the public sector. The new strategy outlines a joined-up approach across government, which in the Committee’s view is long overdue and will require strong, proactive leadership from the Department and the Civil Service Board.

26. The C&AG’s report sets out the considerable harms caused by substance use. Rising levels of harm have resulted not only in significant increases in drug and alcohol related deaths over the last decade but also more people suffering and living with addiction. The Committee was concerned to hear evidence that the Department thinks these harms are likely to get worse before they get better, in part because illegal drug availability in Northern Ireland has increased in recent years. This will inevitably lead to further deaths without an effective strategy.

27. The Department’s evidence stated that the majority of the targets it had set for itself in the old substance use strategy were on track for implementation. However, the Committee was concerned that despite the achievement of these objectives, the significant harms caused by drug and alcohol use were actually increasing. The number of both drug-related and alcohol-specific deaths in 2019 was the highest ever recorded.

Harms caused by drug and alcohol use are significant and likely to get worse

Drug and alcohol deaths have increased significantly over the last decade

Type of death	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019
Drug-related deaths	92	102	110	115	110	144	127	136	189	191
Alcohol-specific deaths	260	228	244	206	219	282	289	303	284	336

28. In the Committee’s view, it is not enough to simply track targets – any strategy should aim to prevent harm and reduce the impact on those suffering.

29. The Committee heard worrying evidence that the new strategy would not turn the tide and reduce the levels of harm seen in recent years. Witnesses told the Committee that although they were confident that the new strategy will make a difference, its interventions aim only to reduce, not reverse the trends. The impact of the pandemic would likely make this more challenging for years to come.

The Committee recommends that reducing the harm and deaths caused by addiction should be the key focus of the Executive’s efforts going forward, with a clear objective of reducing drug and alcohol related deaths.

A joined-up approach to tackling substance use is essential if the new strategy is to make any impact

30. The Committee was encouraged that the Department now recognised the importance of a collaborative, cross-government approach to tackling substance use. However, witnesses acknowledged that attempts at collaboration had not been good in the past and the Committee has some reservations about how successful this approach will be this time around. The Committee commends the aspiration, but it is obvious that a more joined-up approach was needed and yet this has taken a long time to come to.

31. The Committee notes that whilst efforts at collaboration are improving, witnesses believed that there was still a way to go on joined-up working. Breaking down the silo mentality that exists in both the HSC sector and across government will be key to the success of the substance use strategy, and the Department has a vital role to play in providing leadership and setting the direction of travel across the whole system. Executive approval of the new strategy and cross-sectoral buy-in are important, but in the Committee’s view, strong leadership will be essential to drive forward a collaborative, cross-sectoral approach to address addiction issues.

The Committee recommends that the Department takes the lead in continuing to build and strengthen collaborative, cross-sectoral efforts to tackle drug and alcohol and use.

Developing the new substance use strategy has taken too long

32. The Department’s drug and alcohol use strategy was out of date at the time of the C&AG’s report. The old strategy was extended in 2012 without a formal review, and was meant to run until 2016. The Department did not review the strategy until 2018, two years after it had expired. A new substance use strategy, “Preventing Harm, Empowering Recovery” was finally published in September 2021, some five years after the previous strategy ended.

33. The Committee heard that the production of this strategy was informed by a co-production approach involving many of those across the sector. We welcome this approach and recognise that it takes time. However, the Committee is concerned that the delay suggests that tackling substance abuse has not been a priority for the Department. Witnesses told the Committee that meaningful, inclusive stakeholder engagement on the new strategy, and subsequent co-production took time, but accepted that they could have been done more quickly.

Given the current pressures on the Health sector, the Committee recommends that consideration is given to the Executive providing leadership to ensure a genuinely system wide-approach to tackling this issue.

There is uncertainty around funding for the new strategy and as a result, it may be only partially implemented

34. Witnesses told the Committee that the new substance use strategy requires more than £6 million per annum in additional funding which has not yet been secured. They confirmed that in the absence of this funding, parts of the strategy cannot be fully implemented. In the Committee’s view it is essential that the Executive supports the Department of Health in seeking adequate funding for the strategy.

35. Whilst there is uncertainty around the additional funding required for the Department’s alcohol and drug strategy, the Committee notes the publication of a new, ten-year drug strategy in England. “From Harm to Hope” is backed by a new investment of almost £780 million for treatment - the largest ever increase - bringing total spending on drug enforcement and treatment to more than £3 billion over the next three years. The new investment will be ring-fenced so that the money is spent only on this agenda. The strategy also sets a clear intention of reducing the number of drug-related deaths for the first time in a decade.

36. The Committee heard compelling evidence that funding the strategy in Northern Ireland was a spend-to-save issue, and additional funding will help to offset the wider costs of alcohol and drug use. Witnesses said that every pound spent on proper and effective implementation of the strategy will be returned four, five or even up to six-fold in future savings to the health and justice sectors. In the Committee’s view, it will be a significant missed opportunity to make a difference if funding is not secured, potentially risking further lives lost and considerable costs across the public sector.

Significant deficiencies in data quality and completeness impact the Department’s ability to plan and assess its substance use services

37. The C&AG’s report highlighted that the Department had very limited performance data on addiction services, and that there were significant issues with the quality of the data that it did manage to collect. The limited data the Department collects is not outcomes focused, counting how many people have used addiction services, rather than the impact services are having on people’s lives. It was unclear to the Committee how the Department had been able to assess the outcomes of its previous strategy and develop a new strategy without reliable, quality evidence on the services that it funds.

38. The witnesses told the Committee that they accepted the C&AG’s findings on data quality without reservation. However, the Committee was surprised to hear that issues with data quality and completeness have not been resolved and are still a concern several years after they were first identified. The Committee is frustrated by the lack of urgency in this area by the Department.

39. Whilst witnesses referred specifically to problems with data from Tier 1 and 2 services, which are mainly delivered by community and voluntary sector organisations, the C&AG’s report said that concerns with data quality existed across all levels of addiction services, including an absence of regional data collection for Tiers 3 and 4, which are delivered by the HSC sector. The Committee is alarmed that the Department does not have comprehensive data on the services delivered by its own HSC Trusts.

40. While witnesses agreed that data quality is still a long way from where it should be, the Committee notes that they did not provide any details on their plans or a timeframe to improve this situation. The Committee is concerned that resolving these issues, and getting better information on the services it funds, does not appear to be a priority for the Department. This is simply not acceptable.

Community and voluntary sector organisations provide effective harm reduction services and should be a priority, yet some of these services have had funding withdrawn

41. Reducing harm caused by substance use should be a key priority for the Department. The C&AG’s report presented clear evidence that Tier 2 services, mostly provided by the community and voluntary sector (CVS), provide successful and cost-effective harm reduction and early intervention projects. Witnesses acknowledged the strong value added by CVS organisations to addiction services. The Committee was therefore alarmed to hear evidence that these services are often amongst the first to have funding withdrawn when central government is under financial pressure. In the Committee’s view, this is short-sighted and creates significant uncertainty for these organisations and the people that rely on their services.

42. CVS organisations provide essential addiction services and the Committee believes that they should be considered key partners in delivering the substance use strategy. The Committee therefore welcomes the Permanent Secretary’s commitment to refreshing and renewing the collaborative approach to services with the CVS.

Clearer, more consistent care pathways are needed to ensure people are able to access the right services at the right time

43. The C&AG’s report highlighted the need to improve referral pathways and relationships between sectors and tiers, in particular the need to build a better understanding of CVS services within the statutory sector. It also underlined the impact that inconsistent referral processes can have on both waiting lists for services and people seeking treatment. It is the Committee’s strong view that whilst there should be no wrong door, it is vital that those who seek help are able to access the right services as quickly as possible.

44. For many of those who seek help, Primary Care is often their first port of call. The Committee welcomes innovations such as multi-disciplinary teams, which have the potential to meet the needs of those seeking help and the use of GP time more efficiently. However, given the current demands on Primary Care, access to GPs remains greatly restricted. With this in mind, the Committee has asked the C&AG to investigate access to Primary Care in his forward work programme.

45. In addition to resolving issues around access, the Committee believes that there is more work to be done with GPs, in particular raising awareness of Tier 1 and 2 services, and in participating in shared care for the Substitute Prescribing Service (SPS). It has been a long-held ambition that GPs should share care for stabilised SPS patients. This is not only an important step in normalising care for these patients, but would also reduce pressures on Community Addiction Teams. However, the Committee noted huge variations in the delivery of shared care model across the HSC Trusts, and in one Trust only 3 per cent of SPS patients are cared for by their GP. When questioned, witnesses were unable to provide clear explanations for these variations. In the Committee’s view this warrants more investigation.

The Committee recommends that the Department investigates the failure of the shared care model in some regions and establishes clear plans to increase the number of GPs involved in this care.

Access to residential rehabilitation beds is inconsistent and a review is long overdue

46. Residential detoxification and rehabilitation treatment is required for individuals with the most complex needs, where community based care is not appropriate. Residential rehabilitation is provided by two independent sector providers, and under the current model two Trusts do not have formal access to these beds, meaning their patients often have to be treated in the community, when this may not be the most appropriate setting.

47. The Committee was concerned by evidence that there is currently no effective integration within residential addiction services. Whilst witnesses assured the Committee that all Trusts can access beds, the Committee felt this was largely down to goodwill, rather than any proper regional planning by the Department. The Department has been aware of the need for a more consistent regional approach to these services for several years, and witnesses referred to the need for a strategic plan for residential services, with the aim of creating a smoother journey for service users. However, the Committee heard very few details on how or when any review might happen, and is concerned about the potential ongoing impact on service users.

48. Addiction treatment is not the end of the recovery journey and so the Committee was also troubled to note the absence of consistent aftercare for some Tier 4 services, when this is such an important part of the recovery process. All were in agreement on the need to ensure support is in place to help people in the long-term.

Misuse of prescription drugs is a significant issue in Northern Ireland, but there is little evidence that interventions to date have made an impact

49. Prescription drugs are now involved in the majority of drug related deaths in Northern Ireland, and the number of people seeking treatment for misuse of prescription drugs is significant. Deaths related to Pregabalin have increased sharply.

Pregabalin was involved in 40 per cent of drug-related deaths in 2019

	2013	2014	2015	2016	2017	2018	2019
Number of related deaths	1	5	7	9	33	54	77

50. Pregabalin, Tramadol and benzodiazepines are among the most commonly misused drugs. Prescribing rates for some of these drugs are much higher in Northern Ireland than elsewhere in the UK. Whilst the Committee accepts that there are other means of acquiring these drugs than on prescription, it was not convinced that the Department has a clear understanding of why prescribing rates are so much higher in Northern Ireland, or how people are obtaining these drugs. In the Committee’s view, the Department must do much more to tackle these issues.

51. The Committee has particular concerns about the prevalence of Pregabalin and its increasing involvement in drug related deaths. The high prescribing rates of Pregabalin was previously raised as an issue by PAC in 2015 in their inquiry into Primary Care Prescribing. High levels of prescribing risk normalising the use of potentially very dangerous drugs and lead to people underestimating the associated dangers. Witnesses told the Committee that given the pattern of prescribing Pregabalin over the last number of years, there is room for improvement. In the Committee’s view, this is a serious understatement.

52. Whilst the Committee heard that the HSC Board had attempted to highlighting issues with Pregabalin, the Committee considers that this has been ineffective and progress has been much too slow. We agree with the Chief Medical Officer’s assessment that these is much more to be done on this issue.

53. Alternative therapies, such as cognitive behavioural therapy and counselling, can be as effective as prescription drugs for some people. However, there are often long waiting lists for these therapies and so the Committee had concerns that prescribing rates would continue to rise in the absence of these alternative services. Witnesses stated that there needs to be an expansion of social prescribing in relation to alcohol and drug addiction and told the Committee that they had not made as much progress as they had hoped in this area.