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Integrated Care for drug users: Principles and practice

Chapter 3: Accessibility

• Definition of accessibility and why it is important

• Factors that influence accessibility

• Ways to manage waiting times

• Why needs assessment is important

This Chapter examines and discusses the various factors that influence accessibility to drug treatment, care and support services, both in Scotland and elsewhere. These factors will affect (and even determine) the extent to which integrated care can be delivered in any area.

The key sources of evidence that have been drawn on for this Chapter are the research literature, service users' focus groups undertaken by the Scottish Drugs Forum (SDF), the EIU consultation workshops and the EIU Working Group on Accessibility. The Working Group undertook to review the issues that affect the accessibility of services (specifically in the Scottish context) and to identify key principles and elements of effective practice.

This Chapter sets out in more detail:

• the definition of accessibility, its rationale and wider context

• the evidence on factors that influence accessibility

• key principles and elements of effective practice

What is accessibility?

A service is accessible when it is available to all potential users at a time and place suitable to meet their assessed needs and delivered in a user-friendly way. To make services accessible, it is essential to remove the barriers, real or perceived, that individuals experience. These barriers can lead to a lack of engagement and non-attendance. Key issues to be addressed include:

• equity of access for all potential users

• the location and opening hours of services

• the length of time to wait to be seen by a service or to get into treatment

• ensuring an initial (and subsequent) positive experience, as perceived by the user

Above all, a service is accessible when it is designed to meet the needs and aspirations of the individual. In other words, the organisational arrangements should be flexible enough to offer a service that is as person-centred as possible.

The Rationale: why is accessibility important?

Accessibility of services is important to ensure that users get access to the services and interventions most likely to help them, at times when they need them (EIU Working Group 2002, Type 5). This will help ensure that individual users:

• reduce harm to themselves and others

• reduce their drug use

• address other health and social problems

• have an opportunity to rebuild their lives

Ensuring access to effective services will also have an impact on the lives of those who care for drug users, those who are cared for by drug users and the wider community within which they live. Recent survey work on family support needs in Scotland shows that the mental and physical health of those caring for drug users can be seriously affected (EIU 2002, Type 3).

There is a growing evidence base on the range and combinations of interventions that can work with drug users (Simeons 2002, Type 1). Research shows that a range of treatment interventions (with a range of philosophies) may work, but the outcome depends on the individual getting the right treatment at the right time (Department of Health 2002). Ensuring access to a range of interventions and matching interventions to client needs can help promote the effectiveness of treatment (Gossop 1998, Type 3). This relies upon systematic and effective assessment procedures.

As outlined in Chapter 2, it is widely recognised that people who have a drug problem will have a range of other needs. These need to be resolved before that individual can make a full recovery. Interventions which help people to deal with wider problems in their lives and to move on after stabilisation or recovery also show promise and should also be accessible to all users. This highlights the importance of an integrated approach to the treatment, care and support of users.

The assessment process may identify needs for better and more stable housing, help with addressing difficult family relationships, help with addressing debt problems and the need to improve employment prospects. Conversely, a referral may be made to a drug service because there has been a problem in another area of the individual's life, for example, because a tenancy is under threat and a drug problem has been identified.

Overall, the available evidence suggests that (ideally) a broad range of user-friendly interventions that tackle the plethora of health and social needs of drug users should be accessible to those who need them at appropriate junctures. This includes being sensitive to the needs of individuals based on their socio-demographic characteristics. However, service users in Scotland and across the UK appear to have difficulties accessing co-ordinated drug treatment for a number of reasons including: the uneven availability of health and social care services and interventions, poor assessment procedures and lengthy waiting lists (EIU Working Group 2001, Type 5; Audit Commission 2002)

The Wider Context

Accessibility of services is a cause for concern across a number of settings, including primary care. For example, The Scottish Consumer Council Report 'Access to Primary Care Services in Scotland' (SCC 2001, Type 2) demonstrates that accessibility is a key issue for the patient population of Scotland. It stresses that, however effective a service may be, it is only of value if those who need it are easily able to access it. Access can be limited in a number of ways:

• where services are provided

• when services are provided

• how services are provided

Groups in the population who may potentially be disadvantaged in seeking access to primary care services include:

• homeless people

• travelling people

• people from minority ethnic groups

• disabled people

• those with mental health problems

Drug users are also a marginalised group and are disproportionately represented in some of the groups listed above. For example, there appear to be high rates of mental health problems in the drug treatment population. In a prevalence study of co-morbidity among substance misuse and adult mental health treatment populations in England, 40% of the drug treatment population were assessed as suffering from minor depression, 37% with a personality disorder, 27% with severe depression and 19% with severe anxiety (Weaver 2002, Type 3)

It is important that service providers consider the individual needs of service users. There are a number of legislative and good practice initiatives that help to ensure this. In Chapters 1 and 2 we have outlined the Joint Future agenda. This should be a key driver in promoting integrated care in the broader community care field and the drugs field specifically. However, there are other key legislative and practice initiatives.

For example, there are new National Care Standards in Scotland for care homes for people with drug and alcohol misuse problems (Scottish Executive 2001). Responsibility for these standards lies with the new Scottish Commission for the Regulation of Care (SCRC). These standards have been developed with the needs of the client in mind, and set out what they can expect from service providers in a residential setting. However, the standards also clearly articulate what is expected from providers of support and care services.

From April 2003, under the Government's Supporting People initiative, a new funding and policy framework for the provision of housing support services, will come into operation. Under this initiative local authorities will become responsible for the funding, planning and provision of housing support services in their area. The purpose is to make housing support services more accessible to everyone (regardless of tenure), to have services which are more attuned to people's needs and to enable direct payments to be made. The aim is also to improve the quality of services through the registration of providers of housing support services with the SCRC mentioned above. All new service users will be required to undergo an assessment of their housing support needs under the single shared assessment procedure outlined in Joint Future.

A further example is disability legislation. Service providers will need to comply with the Disability Discrimination Act 1995. The Act makes it unlawful for service providers to treat disabled people less favourably than they would treat other people, for a reason related to their disability, when offering or providing goods, facilities, or services. This clearly applies to health service providers, and extends not only to the physical, accessibility of premises, but also to how information is produced and how communication is made.

Similarly, the Race Relations Act 1976 (amended by the Race Relations Amendment Act 2000), makes it unlawful to discriminate against anyone on grounds of race, colour, nationality (including citizenship), or ethnic or national origin. The amended Act also imposes general duties on many public authorities to promote racial equality.

Finally, the National Treatment Agency (NTA) in England is set up as a special health authority to lead the development and monitoring of drug service standards. One of the key concerns for the NTA is the accessibility of drug services for individuals across all DATs in England. The NTA emphasise that a constellation of different services will be required in each area to manage and address the complex needs of drug users, and that these services will need to work in partnership to maximise the use of available resources. For further information about the NTA please see: www.nta.org.uk .

Factors that affect accessibility

We have identified a number of service and individual client characteristics that potentially have an impact on accessibility. These include the needs of specific groups of drug users whose circumstances require additional consideration if services are to be accessible to them:

Service characteristics Individual characteristics

Service Characteristics

1. The range of treatment and care services

As stated earlier, a fundamental feature of accessibility is the provision of an adequate range and capacity of treatment, care and support services to support the changing needs of the client. An effective range of services will be best designed and delivered when they meet identified local needs.

A recent survey of NHS treatment services across the UK showed that a wide range of harm reduction and abstinence oriented interventions is acceptable and available across the UK. However, their availability was limited by a combination of practical, economic, safety and theoretical considerations (Rosenberg 2002, Type 3). There is often a mismatch between what is appropriate and what is available.

A survey of NHS treatment services for opiate users carried out by Aberdeen University in 2001/2002 shows that the availability of different types of pharmacological treatments for drug users varies across Scotland (Cameron 2002, Type 3). This may, at least in part, reflect the different needs of local populations. Psychological approaches, psychosocial approaches and alternative therapies were also available in some areas, usually provided opportunistically by a member of the addictions team who was trained in a specific therapy. A summary of the results from this survey is available in Appendix 5.

Research shows that a range of health and social interventions may work but the outcome often depends on the individual getting the right treatment at the right time. Most drug users will require treatment, care and support from more than one type of service depending upon their drug of choice and their other health and social needs. For example, detoxification followed by relapse prevention, methadone maintenance accompanied by counselling, or symptomatic relief with cognitive behavioural therapy (CBT).

There is also good evidence for the cost effectiveness of treatment interventions.
The National Treatment Outcome Study (NTORs) in England estimates that for every 1 spent on treatment, there is a 3 saving on criminal justice costs (NTORS, Type 3). In particular, NTORs clearly demonstrates the high levels of criminal involvement by drug users before entering treatment. Further information and results from NTORs can be downloaded at www.ntors.org.uk . However, such economic analyses in the drugs field are often partial. They do not account for the increased quality of life for the users and their carers, nor the wider social benefits for the community. As well as 'cost effectiveness' the NTORS study has demonstrated a range of positive outcomes for drug users.

The Outcomes Pilot Study, conducted at five drug treatment services across Scotland in 1998/1999, demonstrated a range of positive outcomes for those retained in treatment after just three months (Galbraith 2001, Type 3). These included: a movement away from illicit to prescribed drug use, reduced injecting and sharing, improvements in physical and mental health, reduced criminal activity and improvements in relationships. The study also found:

• 60% of clients were no longer in contact with services three months after initial contact

• 84% of those who were no longer in contact were defaults (i.e. not turning up for appointments)

• 40% of all clients made only one contact with services, highlighting the importance of a positive first contact at drug services.

It is worth noting, however, that loss of contact after one visit may not necessarily be negative. A one-off contact be sufficient to resolve the client's problems. A follow-up to this study is now looking at reasons for presenting for treatment, expectations of agencies and motivations in relation to drug use in order to better understand reasons for retention in or drop out from treatment.

Research shows, however, that more than one treatment episode is frequently required. Services must be able to meet different types and levels of need that an individual may have as he/she progresses through treatment. This is an important consideration when planning and delivering services.

There are a number of predictors that highlight when long-term, or multiple, treatment episodes may be required (Brewer 1998, Type 1). Some of these predictors should be evident at the assessment stage and considered when planning treatment for an individual:

• high levels of pre-treatment drug use

• prior treatment for opiate addiction

• no prior abstinence from opiates

• abstinence or light use of alcohol

• depression

• high levels of stress

• unemployment or employment problems

• association with drug misusing peers

• short length of treatment

• leaving treatment prior to completion

As stated earlier, at initial assessment and when steps have been made towards recovery or stabilisation, a whole range of other needs may become apparent.

The range of services also needs to offer the possibility for individuals to move on to another, appropriate service when they have made progress. Further, the possibility of relapse is a concern. Users commonly feel that support is weighted towards the beginning of the recovery process, jeopardising this process in the long-term (McIntosh 2001, Type 3). The EIU Moving On review highlighted that clients who have moved on to employment needed on-going support to cope with the transition in their lives (EIU 2001, Type 2/3).

Delivering this range of health and social interventions commonly requires effective joint working across agencies including specialist drug services, generic health, mental health, social work, criminal justice and housing services among others. There is evidence of good practice in partnership building across Scotland. For example, the New Futures Fund projects appear to have played a pivotal role in building partnerships between drug services and education, training and employment services (LRDP 2002, Type 3).

2. Client awareness and perceptions of services

One of the barriers to accessing services is lack of knowledge among potential clients of the services available to them and how to access them (EIU Working Group 2001, Type 5). Some drug users will have limited knowledge about the types and range of services available in their area. A number of drug users refer themselves to services and, if they have unrealistic or false expectations of what those services can provide for them, it could lead to a future reluctance to attend any service and potentially treatment failure.

Word of mouth appears to be an important way in which opiate users hear about services and make decisions about whether to approach them (EIU consultation workshops 2001, Type 5). However, qualitative research conducted with stimulant users in Scotland suggests that this may not be a key source of information for them (SDF 2002, Type 4). In general, primary stimulant users have a different profile. In particular, they are more likely to be employed and have social networks outwith other stimulant users.

Services need to consider how best to target information at the groups their service is designed for. In particular services need to be clear to their target audiences about key aspects of their provision. There are examples of how this has been achieved in Scotland. For example, in Argyll and Clyde a handbook has been prepared which includes details of the range of treatment, care and support services and prevention interventions in the area. It also includes information on the local drugs strategy and the list of priorities in the area. This is available at: www.show.scot.nhs.uk/achb/NHSA&C/adat/handbook%20sections.htm

Most of all, services need to be clear about how the service can be accessed (EIU Working Group 2001, Type 5). For example, they need to be clear about whether individuals can refer themselves to the service, or whether they need to access the service through someone else e.g. primary care.

The perceptions clients hold about services will also influence the extent to which they are accessed and when they are accessed. The credibility and knowledge of support agencies and their associated 'image' were highlighted as key factors in engaging with users in the EIU Moving On review and by the EIU Working Group (EIU 2001, Type 2/3; EIU Working Group 2001, Type 5).

3. Location of services

Research carried out to obtain the views of clients about the barriers to accessing services in England shows that the location of services is a major barrier (Audit Commission 2002). Public transport can be a real difficulty, particularly in more rural areas. Further, the cost of transport may exacerbate these difficulties. In the research conducted by the Audit Commission, one study area issued transport passes to their clients. The service users' focus groups suggested that once participants knew where the nearest specialist addiction service was located, they would approach this service first (SDF 2002, Type 4). However, this did pose problems in rural areas because services were sometimes difficult and expensive to get to.

In some areas mobile services and outreach work have been organised to tackle some of the difficulties posed by locating a service centrally. For example, there are a variety of ways in which needle exchange facilities are provided, including static services, mobile units and backpacking. This range of methods of distributing injecting equipment may reach injectors early in their injecting careers as well as users who would not normally access traditional needle exchange facilities.

The extent to which out of area referrals for residential rehabilitation are made is variable across Scotland (Cameron 2002, Type 3). This survey of NHS services for opiate users suggests that there are about 250 NHS out of area referrals for substance misuse each year in Scotland, mostly for residential detoxification. It should be noted that these figures also include alcohol misuse in some areas. Out of area referrals were commonly made when local services had been exhausted and the referral had the support of the clinician responsible for addictions. It is worth noting that the evidence base on the effectiveness of residential rehabilitation is not as strong as for community based interventions for opiate use (Simeons 2002, Type 1). Further research on the effectiveness of residential rehabilitation approaches is required.

4. Opening times of services

For many people it is difficult, if not impossible, to organise attendance at a service at a set time. Individuals who have children may have particular problems because of school hours or childcare responsibilities. Services need to be flexible in their opening times to allow these individuals to access services at times convenient to them.

It is also important to consider when specific groups of users can best attend. There is evidence to suggest that the majority of primary stimulant users are in employment and would find it hard to attend during normal office hours. This is also the case with steroid users. So, services to cater for these groups should be accessible out-with standard working hours.

Further, as an individual makes progress towards recovery it may be appropriate and useful for them to attend an employability project, attend training, undertake voluntary work or indeed enter employment. If individuals still require support from a treatment provider (e.g. for methadone) opening times need to be flexible enough to accommodate the needs of the client at that stage in their recovery.

Some services across Scotland offer evening sessions and a small number offer 24 hour access to maximise their contact with drug users. For example, a service for steroid users in Dundee operates in the evening to accommodate the majority of their clients who work during the day. The Glasgow Drug Crisis Centre offers a 24 hour drop-in service that includes a needle exchange, a one stop service and residential rehabilitation.

5. Waiting times

One of the keys to a successful outcome from treatment is a prompt and appropriate response when an individual seeks help. Lengthy waits are demotivating and discourage entry into treatment. (National Treatment Agency 2002, Type 3; EIU Working Group 2001, Type 5).

Waiting times for access to drug services is a problem across Scotland and the wider UK for both drug users and for service providers across health, social work and voluntary agencies. (EIU Working Group 2001 Type 5; SDF 2002, Type 4). Information from DAT Corporate Action Plans indicates that there are wide variations in waiting times for clients seeking help with drug problems, from a matter of days to several months. For drug users, long delays for and during assessment, delays following the initial assessment, and delays in referral cause frustration and may lead to reduced motivation. For services, lengthy waiting times have a demoralising effect on staff who can feel constantly under pressure. They may also feel that their performance is judged solely in this one area.

"I was made to go for weeks...one day a week for assessment. You just became despondent. They were trying to see if you were motivated. But you saw people come and go in the time you were there and you were just like - when do I get my turn?.... It was murder."
SDF Focus Group Respondent 2002

The length of waiting times can be due to a number of factors. Work on waiting times by the National Treatment Agency (NTA) and by the EIU Working Group in Scotland suggest that the following factors are the main causes of the problem with waiting times:

• availability of services does not meet demand

• capacity within and across services does not meet demand

• assessment procedures are numerous and variable, leading to delays

• treatment regimes are not flexible enough

• workforce constraints (in particular too few skilled staff)

• joint working arrangements could be better developed (referral / discharge procedures)

• criminal justice initiatives (e.g. DTTOs, drug courts) increase demand on services

• there is an increase in client demand at services with good outcome records

Sustaining the client's motivation to enter a service can be difficult when there is a waiting time. A number of interventions have been tried to minimise drop-out from waiting lists. However, evidence of their effectiveness is scarce. A randomised controlled trial to evaluate the effectiveness of a motivational intervention to reduce drop out from publicly funded treatment waiting lists in the United States did not enhance treatment entry, completion or outcome among treatment-seeking client (Donovan 2001, Type 3). The authors suggested that alternative strategies such as contingency management and case management may help. However, this is unlikely to be as effective as providing direct access to services.

A study which examined the relationship between waiting times and outcomes of over 2000 clients in Warwickshire between 1983 and 1998 clearly demonstrated that those who completed treatment waited less time (on average) between assessment and admission than those who did not complete treatment (Georgakis 1999, Type 3).

There are some management processes that (while put in place for good reason) may contribute to increased waiting times. For example, some substitute prescribing services require that the majority of their clients are on supervised consumption regimes. There can be requirements for weekly drug tests or regular meetings with key workers. For some clients and for a period of time, these conditions are entirely appropriate. However, universal application may be costly and will reduce the number of clients who can be treated by that service. Further, if regular reviews are not carried out, the continuation of the practice for individuals whose needs are largely met may prevent others from entering the service. This can lead to long waiting lists, increased waiting times and high priority clients struggling to get the support that they need. It may also have a negative impact on clients who are ready to move on to another stage in the rehabilitation process.

The NTA Guidelines 'Making the System Work' (NTA 2002) highlight that working practices and joint working arrangements are particularly important in tackling waiting lists. Some services in Scotland operate a duty system so clients do not have to wait for a first appointment. Other services have learnt through experience that referral to another provider may be more appropriate than further care in their service after stabilisation has occurred. Research conducted for the EIU Moving On report suggested that many treatment services were reluctant to 'let go' of their clients, even when they had been stabilised and were (at least in some cases) ready to progress to the next stage of rehabilitation (EIU 2001, Type 2/3).

There may also be problems with managing non-attendance. This will in turn increase the waiting times for others if the appointment cannot be allocated to another client. In some cases, the appointment systems are not designed to reflect the needs and lifestyle of the clients who have serious drug problems. To overcome this difficulty, some services operate on a drop-in or a one-stop model.

The EIU Working Groups and service users' focus groups highlight the problems associated with allocating priority to those on waiting lists. In particular, drug users' perceptions of what they need to do, or be assessed as, to be prioritised for treatment and care. There is a general consensus among users that you need to be referred through the criminal justice system, or be injecting to stand any chance of prioritisation.

A study was commissioned by NTA in 2002 to examine waiting time strategies in 4 DAT areas with zero to low waiting times. They shared a number of similarities:

• spread existing resources further

• use new approaches and interventions

• utilise new information systems and technology

• improve the integration of local services

• manage the movement of clients through the drug treatment system and minimize unnecessary delays

• keep services open for longer and later

• increase performance in the key areas of assessment, dosing, and care management procedures.

Annex 3A sets out a three-stage approach to addressing waiting times.

6. Staff

Staff will play a crucial role in attracting and retaining drug users in services. For drug users, staff members are the 'face' of the service. Staff members have a clear role in promoting the credibility and image of the service. Further, their attitude at first contact is likely to have a significant influence on whether the drug user will continue to attend (EIU Working Group, Type 5).

Currently there seems to be a national problem with recruiting and retaining staff in the substance misuse field in Scotland and the wider UK. A UK wide mapping exercise of the drug and alcohol sector conducted by Healthworks UK found that many staff working with users were well qualified, but their qualifications were not specific to the work they were undertaking (Healthworks 2001, Type 3). Recent developments in the criminal justice sector (e.g. DTTOs) offering offenders referral to treatment services have increased demand for services and, consequently, on staffing. The Executive is working with Drug Action Teams to identify and resolve staffing issues.

When qualified staff are in post, they need support networks and supervision to help them to reflect on their professional practice and provide support in dealing with difficult situations. Staff also need effective management support to help them manage their case loads and to access and undertake continuing professional development (EIU consultation workshops 2001, Type 5). Finally, administrative support is crucial to support the work of professional staff to ensure they are able to spend their time on the professional tasks they are qualified to practice.

Training is the key to ensuring that staff members have the opportunity to maintain and improve their skills and gain new competencies. In the context of integrated care services, there is a particular value in multi-agency training to promote and encourage mutual understanding of the role and working practices of other service providers. Access to appropriate services can be reduced because staff members do not know where to direct clients when they might benefit from another service or be ready to progress.

STRADA now provides training in a number of aspects of drug misuse and treatment for staff in a range of agencies. More detail is set out in Appendix 7.

7. Assessment

The assessment process is a key factor in making services accessible. Effective assessment practice can help ensure access to appropriate treatment within a time period that will allow the provider to capitalise on the individuals motivation. The judgement on what is the right treatment approach for an individual will be made largely as a result of the quality of information gained at the initial assessment. This is discussed further in Chapter 4. This Chapter provides information that supports the design and delivery of effective assessment processes including examples of assessment tools.

8. Referral arrangements

Strengthening referral and discharge arrangements is key to the provision of integrated care. Referrals to drug services are frequently made by a wide range of agencies and by drug users themselves. This reflects the diverse needs of the client group. Arrangements at a local level should ensure that referrals can be easily made by a wide range of care providers including health, housing, employment and criminal justice services.

In some cases, drug users simultaneously attend a number of services either through self-referral or through referral with no apparent co-ordination (Audit Commission 2002, EIU consultation workshops 2001, Type 5). Sometimes service providers will not know that the individual is being seen by other services in the area, or indeed within the same service. The result is uncoordinated and potentially ineffective treatment, care and support.

Another problem is reluctance by some service providers to refer their clients onwards. This was one of the barriers to helping recovering drug users to move on to training and employment provision identified in the EIU Review "Moving On" (EIU 2002, Type 2 and 4; EIU Working Group Type 5). It can arise from lack of knowledge and confidence among staff about the role of other providers and the services that they can offer.

There must be effective and efficient referral arrangements to ensure that individuals get access to services when they need them and their motivation is high. The referral arrangements also need to take into account the individual's need for support to make the transition.

Individual Characteristics

1. Gender

Women make up one third (32%) of the drug treatment population in Scotland (Scottish Drugs Misuse Database 2000/01). Difficulties in accessing services may mean, however, that women are under-represented in treatment. The experience of drug addiction appears to be different for men and women. For example, women who have problems with drug use are more likely than men to have a substance misusing partner and to have experienced domestic violence (Gilbert 2000, Type 3; Powis 2000, Type 3). Other difficulties may include: a history of sexual abuse (Wallen 1992, Type 3); low self-esteem and poor emotional health (Swift 1996, Type 3; Gilchrist 2002, Type 3); and the greater stigma attached to drug use among women.

Strategies to improve accessibility of services must take into account the particular experiences and circumstances of women. Barriers to entering treatment may be real or they may be perceived. Services may be perceived as being male orientated (if more men than women attend), or women may simply be unaware of the services that exist. In response, active recruitment and outreach can encourage women into treatment. Even when women do engage with treatment services, they may not sustain attendance, thereby reducing the chance of a successful outcome. Further, the design and delivery of services needs to take account of women's roles and responsibilities as mothers. While having children can be an important influence in the decision to seek treatment, child care or family commitments can act as a barrier to accessing services. A lack of child care provision within services can be a very real barrier to accessing treatment services. Providing child care facilities can increase attendance (Marsh 2000, Type 3). Whilst women are more likely to have child care responsibilities, it should be recognised that child care may also be an issue for male drug users.

For drug using mothers, the fear of their children being taken into care can present a psychological barrier to approaching services (Allen 1995, Type 3). Providing women with information can assist in overcoming their fears and drawing them into services. Explaining the confidentiality regulations of the agency and the reporting requirements for child abuse and neglect in a way that demonstrates that the worker has the women's welfare in mind can assist in establishing trust (Kumpfer 1991, Type 3).

Being away from their children as a condition of treatment may discourage women from entering residential services (Marsh 1985, Type 3). Allowing women to live with their children during residential drug treatment enhances retention in care, potentially improving the mother/child relationship and post-discharge treatment outcomes (Hughes 1995, Type 3).

An example of this is the Aberlour Childcare Trust residential rehabilitation facilities in Edinburgh and Glasgow. These projects also address the women's personal and social development and provide support to move on to training and employment.

For women who are pregnant, access to drug treatment and wider healthcare services, is particularly important. The Women's Reproductive Health Service (WRHS) at Glasgow's Princess Royal Maternity Hospital (formerly based at Glasgow Royal Maternity, Rottenrow) identified a range of barriers to the use of ante-natal services by pregnant drug users (Hepburn 1997, Type 3). Fear of encountering judgmental staff attitudes was often the primary reason for non-attendance. There were other barriers. Women found it difficult to get access to services because of referral procedures. Traditionally access to ante-natal care is by GP referral. There was no opportunity for self-referral. It was difficult to get to services because of distance and time constraints arising from their other responsibilities. Women were also concerned they might be made to have an HIV test and, if positive, be forced to have a termination.

Women's relationships with their partners also have an impact on their likelihood of approaching services. Research shows that women who have drug problems are more likely to have a substance misusing partner (Lex 1991, Type 3; Powis 2000, Type 3; Pivnick 1994, Type 3). Drug using sexual partners can exert an important influence over women's drug misuse, with most female injectors having been given their first injection by a male sexual partner (Powis 1996, Type 3). As noted previously, they may also have experienced physical violence or sexual abuse. Having a partner who uses drugs decreases readiness to enter treatment (Riehman 2000, Type 3). Similarly, there is research evidence that women who engage in treatment with, rather than without, their partner have better outcomes (Kim 1994, Type 3).

Some female drug users are involved in criminal activities. Prostitution and its associated dangers are of particular concern. This may be another barrier to accessing services. However, there have been some services specifically set up to address the health and social care needs of this group of women, such as Base 75 in Glasgow (see example).

Finally, for those working in drugs services and other agencies, improved inter-agency collaboration and a co-ordinated approach to service delivery should help assist in meeting the diverse and complex needs of women problem drug users (Becker 2002, Type 3).

2. Ethnicity

In 2000/01, only 27 people (0.3%) reported to the Scottish Drug Misuse Database were of ethnic origin other than White. The comparable figure for 1999/00 was 15 (0.2%). This is a lower proportion than the proportion of ethnic minorities in the total Scottish population. Surveillance and surveys suggest that drug use in the UK is more prevalent among white people overall. While this may be the case, there are likely to be substantial numbers of minority ethnic drug users, with geographical variations and differences in the type of drugs used.

Minority ethnic drug users have traditionally been reluctant to access existing services. Service providers must be more sensitive to the needs of minority ethnic groups. This involves providing materials and support in languages other than English, providing services to address the drug of use (e.g. not just opiates) and working with families with different cultural backgrounds and values.

Different models of service have been developed and tried across the UK. Some of these are mainstream services with an attached worker to address the specific problems faced by minority ethnic users. In other areas (usually with a high prevalence of use among minority ethnic groups) dedicated services have been developed. Local needs assessment will help to guide decisions about the most appropriate service models.

A national scoping study of drug prevention and drug service delivery to minority ethnic communities conducted in 6 DAT areas in England in 2000/2001 (Sheikh 2001, Type 3) showed that 'symbols of accessibility' were important. This means showing explicitly that minority ethnic groups are welcomed by a service, e.g. posters, leaflets, cultural-specific newspapers and magazines (Sangster 2002, Type 3).

However, it was emphasised this was only one aspect of what was required to ensure access to culturally sensitive services. Others include a shift away from delivering services for opiate injectors to the development of services with a holistic, therapeutic and social focus, the importance of 'cultural competence' and gearing mainstream service towards meeting the needs of diverse minority ethnic groups. The full report is available from the Drug Prevention Advisory Service (DPAS Paper 16), or at: www.drugs.gov.uk/ReportsandPublications/Communities/Blackminorityethniccommunities

3. Residents in rural and remote areas

Drug users who live in rural and remote areas encounter a number of problems, some of which are covered in the earlier section on the location of services. In recent years, the increasing problem of rural deprivation and the associated problems of drug use have been recognised (Scottish Executive 2001). Inadequate and expensive public transport, lack of training and employment opportunities and limited childcare provision are all features of rural deprivation. People with substance misuse problems were identified as one of the groups most affected by poverty and social exclusion in the 2001 report. In particular, there is a problem for people with substance misuse problems in reintegrating into the community.

There are a number of factors that affect accessibility for people in rural areas. The range of accessible and available services is often a problem. Very few rural areas seem to have carried out an adequate or accurate assessment to establish the real scale of the problem. National databases record activity of existing services that are largely urban based. Opiate use may not be the main problem. There is some anecdotal evidence that there is more opportunistic drug use (e.g. of manufactured substances such as amphetamines or readily "found" substances such as veterinary preparations).

There has also been an assumption in the past that people from rural areas would travel to the nearest town (as a 'hub'). This may happen in 'dormitory' areas, but there is evidence that many people will not travel to get services (EIU Working Group 2001, Type 5). Sparse populations, long distances to travel and in some cases long standing rivalries between towns and villages mean that the characteristics of the services and who provides them may differ from those in urban centres.

There are frequently problems maintaining anonymity in small communities (EIU Working Group 2001, Type 5). There is little or no evidence to support the assertion that there is more mutual support and assistance within rural communities. The difficulties of disproportionately low levels of confidentiality and high levels of stigma require that substantial efforts be made to engage with communities and improve understanding of the nature of drug problems and their impact.

Different service models can be used to tackle the problems specific to rural areas including home visits and mobile units. Outreach workers in particular can be used to good effect to provide services such as needle exchange, methadone maintenance and home detoxification. Alternatively, premises are found that can function as satellites to the central static sites that will inevitably be difficult for rural users to access. Research has shown that even city-based users were unlikely to travel more than a mile to access needle exchanges (Stimson 1988).

4. Homelessness

In 2000/01, 2.7% of all 'new problem drug users' in contact with services reported to the Scottish Drug Misuse Database had a living situation described as of 'no fixed abode'. The comparable figure in 1999/00 was 3.1%. However, this excludes individuals who are living in insecure or temporary accommodation. Further, the homeless population are probably less likely than the drug using population as a whole to access services.

Homelessness and the problems associated with insecure accommodation appear to be very common among the drug using population. A review of the Rough Sleepers Initiative in Glasgow suggests that about half of rough sleepers between the age of 25-34 years and about one third of rough sleepers between the ages of 16-24 years were dependent on heroin (SWSI 2001). Similarly, a study of 200 drug users in Glasgow and Dundee demonstrated that approximately one third (32%) were currently homeless and two-thirds (68%) had experienced homelessness at some stage (Neale 1999, Type 3).

A report on street homelessness in Glasgow by the Homelessness Task Force emphasised the need to deal with drug problems and wider health and social problems alongside homelessness. The report identified the barriers faced by homeless people when seeking health care (Scottish Executive 2000):

• a poor reception and inadequate treatment at accident and emergency departments

• difficulty in registering and continuing to access general practitioners

• negative self image and lack of self esteem result in a lack of confidence to access services

• difficulty in tackling health problems when living in poor accommodation and with a lack of social support

Further work to review the causes and nature of homelessness in Scotland, to examine current practice in dealing with cases of homelessness and to make recommendations on how homelessness can best be prevented and tackled is underway. For further information please see their home page at http://www.scotland.gov.uk/homelessness/

These and other barriers are also highlighted by the Scottish Executive's Health and Homeless Guidance (2001). The purpose of this Guidance is to emphasise the importance of delivering on the target to end the need for people to sleep rough, and on the broader aim of delivering services to people whose life circumstances affect their access to care. A full copy of the guidance is at: http://www.scotland.gov.uk/library3/health/hahg-00.asp .

The guidance highlights the following:

• the criteria for accessing a service can be a barrier e.g. requirement to be drug or alcohol free

• unwillingness of some GPs to prescribe for homeless drug users due to fear of overdose and safe storage of substitute medication

• mobility of the homeless population means they may frequently move away from the area where they are registered with a GP

Overall, the research evidence points to the need for an integrated strategy of addressing the broader reasons for the homeless situation and drug use (though of course these can sometimes be difficult to disentangle). A study of good practice with homeless drug users suggests that there are a number of key elements that promote good practice (Kennedy 2001, Type 3). These include:

• devoting time and resources to ensuring easy access

• devoting time to establishing trust

• tailoring support to an individual's needs

• incorporating users views into service design and delivery

A number of service models have been developed to address the needs of homeless people, many of whom are drug users. These include one-stop services and outreach work. These services are commonly provided by a partnership of statutory and voluntary providers. Frequently these services offer a range of provision including: community care and supported housing assessments, housing advice, access to primary health care teams and drug and alcohol workers and advice on temporary accommodation.

5. Non-opiate use

Research shows that the socio-demographic profiles of non-opiate users can be different from opiate users, and that a range of support and treatment must be available to address the diverse needs of this group. However, there is likely to be a substantial proportion of stimulant users who are also opiate users. A recent report from the Psychostimulants Working Group in Scotland established by the Scottish Advisory Committee on Drug Misuse (SACDM) in 2001 suggests that there are four main categories of stimulant users, each with their own set of needs (Scottish Executive 2002):

• youthful experimenters

• regular stimulant users

• problematic stimulant users

• opiate / stimulant co-users

It is clear from both the research literature and the service users' focus groups (SDF 2002, Type 4) that stimulant drug users perceive existing drug services to be the domain of opiate users. This affects the perceived accessibility of services for non-opiate users. In the case of opiate users who also use stimulants, this can mean that only their opiate use is being addressed by services. It is clear that decisions on how to re-configure or redesign services to meet the need of stimulant drug users should be based on local needs assessments among non-opiate users and co-users.

Overall, there is limited evidence about the effectiveness of drug services designed to meet the needs of non-opiate users, and in particular stimulant users (crack, cocaine, amphetamine, ecstasy). However, a combination of pharmacological (in the main symptomatic relief) and psychological / psychosocial interventions is likely to be appropriate. In particular, evidence on the use of psychological and psychosocial interventions among stimulant users appears promising (Scottish Executive 2002). However, availability of these services and interventions for stimulant users is currently limited.

The full report of the PSWG can be downloaded at: http://www.drugmisuse.isdscotland.org/publications/abstracts/sac-psycho-report.htm

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