Tony Duffin

IRELAND’S HEALTH REFERRAL Scheme has come into operation. Under the pilot, some adults found in possession of drugs for personal use for the first time can be referred to health services rather than face prosecution.

Public debate has largely focused on whether the scheme represents progress in drug policy. That is an important question. But there is another issue that receives far less attention: implementation.

In public policy, implementation choices often determine which elements of a reform succeed and which fall short. Eligibility criteria, operational procedures, referral pathways, staff training and data collection may appear to be technical details. In reality, they shape who benefits, who is excluded and whether a policy achieves its objectives. Ireland’s new pilot scheme is a useful example of why that matters.

The government has described the scheme as a health-led pathway intended to support people early, reduce harm and help people make informed choices about their health and wellbeing. Those are worthwhile objectives. The question is whether the implementation choices underpinning the pilot are aligned with them, and whether they will support the people most likely to experience significant drug-related harms.

Who benefits?

The published guidance sets out a number of eligibility requirements. To qualify, a person must be over 18, be a first-time drug offender, admit possession of what they believe to be a controlled drug, be assessed as suitable by An Garda Síochána, and be considered likely to benefit from a health referral. Gardaí must also determine that prosecution is not in the public interest.

Read together, these criteria point to whom the scheme is best placed to reach: someone stopped for the first time, confident enough to admit possession, with no prior record, and stable enough in their circumstances to book and keep an appointment with the relevant health professional. For many people, a student caught with cannabis, or a professional found with a small quantity of cocaine, that is a genuinely good outcome. The question is what happens to everyone else.

The first-time offender criterion is where that question bites hardest. I have worked for more than three decades with people who are street involved: living on the streets or moving between temporary accommodation, hostels, prison, treatment services and periods of rough sleeping, often experiencing trauma and poor physical or mental health. Many of the individuals I worked with, directly or indirectly, had previous convictions for possession. In fact, those experiencing the greatest harms were often the most likely to have a variety of prior convictions, accumulated over years of problematic drug use, homelessness or untreated trauma.

Under the new scheme, many of these individuals would be excluded automatically. That is a striking choice for a scheme whose stated aim is to reduce harm and support engagement with health services. The people with the greatest needs are often those with the longest histories of contact with the criminal justice system, and the least equipped to navigate referral systems, attend appointments and maintain contact with services. That is not a reflection of motivation. It is a reflection of the circumstances in which they are living. The danger is that those with the greatest needs remain the hardest for the system to engage.

Ideally, access to a health intervention should not depend on a person’s willingness to admit to a criminal offence. The published guidance does not clarify what happens to that admission if a referral is later refused or not completed.

Unfair rollout?

The challenge is compounded by the fact that implementation will vary across the country. What is achievable in a city centre, where specialist addiction, homelessness and outreach services are relatively concentrated, may be very different to where specialist supports are tasked with engaging many people across a vast area. The ability to engage and comply will depend in part on where someone lives, and this will impact on the pilot scheme.

The scheme also places significant responsibility in the hands of gardaí, who must weigh whether a person would benefit from a health referral against whether prosecution is in the public interest. It is not an easy judgment to make consistently, case by case, across the country.

The government has committed to having the pilot monitored by the Health Research Board for its first year, with an independent evaluation to follow. That is a welcome commitment, and one that should give the public confidence this pilot will be properly assessed. It would strengthen that confidence further if the published guidance also set out what data will be made available as the pilot progresses, so people can see how it is working in practice.

Related Reads

First-time offenders can now be referred to the HSE when found with drugs for personal use

Dr Ian Marder: What now for the war on people who use drugs in Ireland?

Opinion: A whole of government approach is key to addressing drug use, addiction and recovery

None of this is an argument against the Health Referral Scheme. Diverting people away from prosecution and towards health supports is a positive step.

But policies rarely succeed or fail because of their stated intentions. They succeed or fail because of how they are implemented. The pilot now faces that test. Its success should not be measured by how many referrals are made in year one. It should be measured by whether it reaches people who are currently experiencing significant drug-related harms, whether it operates fairly and consistently, and whether it delivers the health outcomes it was created to achieve.

The introduction of the pilot scheme is an important milestone. It represents an attempt to put into practice a principle embedded in Ireland’s National Drugs Strategy since 2017: that drug use is fundamentally a health issue. Whether that principle translates into better outcomes will depend on the choices made when the pilot was designed, and on whether those choices are revisited, as evidence comes in, to reach those it currently excludes.

Tony Duffin was Independent Chair of Strategic Implementation Group 5 (Alternatives to Coercive Sanctions) under the National Drugs Strategy until it concluded its work at the end of 2024. He leads Progressify, an independent international social policy and public health consultancy practice.