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6. Provision of services

Aims:

• To provide equitable, accessible and inclusive services to address the needs of those who experience problems with alcohol and those affected by others' alcohol problems.
• To improve awareness of sources of help and support for those affected by alcohol problems.

Key actions to date

• Development of an alcohol problems support and treatment services framework to help local areas assess needs and plan to meet these needs.
• Improved understanding of what works in treating and supporting people affected by alcohol problems.
• Allocation of an additional £10 million for alcohol services in both 2005/06 and 2006/07.

Identifying effective practice and developing services

6.1 Over recent years we have seen a significant expansion in our knowledge of how to meet the treatment and support needs of people affected by alcohol problems and what services are being delivered at local level. Key developments have included:

• The HTA - Prevention of relapse in alcohol dependence, published in December 2002 by HTBS, which provides an analysis of the clinical and cost effectiveness of pharmacological and psychosocial interventions, and also covers organisational issues and patients' needs and preferences.
• Sign guideline 74 - The management of harmful drinking and alcohol dependence in primary care, published in September 2003 by SIGN which provides advice on the treatment of people with alcohol dependence, hazardous or harmful drinking within primary care (general practice and community nursing) and A&E departments. It makes specific recommendations on the detection and assessment of alcohol problems as well as the delivery of brief interventions in general practice.
• Mind the Gaps: Meeting the Needs of People with Co-occurring Mental Health and Substance Misuse Problems, the report of the Joint Working Group of the Scottish Advisory Committees on Drug and Alcohol Misuse, published in October 2003.
• A Fuller Life, the report of the expert group reviewing services for people with alcohol-related brain damage, published in April 2004, makes recommendations covering health promotion and prevention, challenging stigma and discrimination, planning and delivering better services, standards, training, information, and evaluation and research.
• Alcohol and Ageing - Is alcohol a threat to healthy ageing for the baby boomers?, the report of NHSHS Alcohol and Ageing Working Group, published in May 2006, makes recommendations on age-based sensible drinking limits, research needs in relation to ageing and alcohol, the information and education needs of older people in relation to alcohol and the need to improve training of health professionals to assess for, and react to, excessive drinking in older people.

6.2 The formation of NHSQIS has brought together several different approaches to the process of quality improvement and is allowing us to improve the quality of services for people with alcohol problems.

6.3 In December 2004, NHSQIS held a discussion forum, involving those working within alcohol services, which explored the implementation of quality improvement issues. The main issues identified from this forum were the need for:

• the development of minimum data sets;
• awareness and implementation of the HTA and SIGN guidelines; and
• greater involvement of primary care.

6.4 The National Treatment Agency for Substance Misuse issued guidance on addressing racial equality in the commissioning of drug and alcohol treatment following the introduction of the Race Relations (Amendment) Act 2000. The National Resource Centre for Ethnic Minority Health is providing support to NHS organisations in Scotland in implementing the Act and training is available through STRADA on understanding drug and alcohol issues in black and minority ethnic communities. ADATs have been asked to satisfy themselves that existing and planned drug and alcohol services meet the requirements of the new legislation.

6.5 The Executive's Review of Drug Treatment and Rehabilitation Services: Summary and Action Plan, which was published in October 2004, made several recommendations for improving the quality and consistency of substance misuse services around Scotland, including the development of a quality standards framework. A steering group of representatives from drug and alcohol partner agencies has been formed to progress this and a challenging timescale for the development of the framework set, with a workable draft already agreed.

Primary care

SIGN/ HTA Guidelines

6.6SIGN guideline No 74 on the Management of Harmful Drinking and Alcohol Dependence in Primary Care published in 2003, and HTA on the prevention of relapse in alcohol dependence published in 2002 highlighted that:

• the use of appropriate screening tools improves the detection and treatment of alcohol problems within primary care, A&E, pre- and antenatal settings;
• brief intervention in primary care - (a 5-20 minute counselling session with onward referral if appropriate) - can reduce total alcohol consumption and episodes of excessive drinking in hazardous drinkers, for periods lasting up to a year; and
• evidence shows that two drugs and four therapies are effective in preventing relapse in people who are alcohol dependent.

6.7 The Executive has undertaken a high level survey of NHS Boards to identify barriers preventing full implementation of the SIGN and HTA guidelines. Most report making progress in taking forward particular recommendations but that:

• access to specialist services and support is problematic;
• there are real problems in engaging GPs and other primary care staff;
• there is a shortage of staff trained to deliver the recommended interventions; and
• full implementation requires additional resources.

6.8NHS Dumfries & Galloway have developed and implemented a SIGN pilot involving 3 GP practices; and appointed a counsellor and detoxification nurse to support general practice staff to screen and deliver brief advice/interventions and provide a practice based counselling service. Funding for this was met from within existing allocations and has led to around 550 patients being opportunistically screened for alcohol consumption. After a practice-based brief advice and information session, 59% of those seen again 3 months later had reduced their alcohol consumption, and 46% showed improved liver function. The pilot will be rolled out across the whole region over the next 1 to 2 years.

General Medical Services contract

6.9 The new GMS contract includes alcohol services as a specialised national enhanced service. Those practices signing up to provide this enhanced service need to maintain a register of patients with an alcohol problem, offer screening and brief interventions, assist with follow up treatment and provide an annual review of their services. As a result, information about alcohol use should be more widely available from GP practices in the future. STRADA are developing generalist GP training on the integrated care of people with drug and alcohol problems and this should lead to better assessment and care in the community.

Quality and Outcomes Framework

6.10 Further measures within the new GMS contract at a UK and Scottish level to improve the delivery of brief interventions are under consideration.

Delivering for Health

6.11 In Delivering for Health, work is underway to look at improving the physical health of people with mental illness. This will include support and advice on alcohol.

Keep Well Programme

6.12 This pilot Programme, first announced as part of Delivering for Health in October 2005, has been established to increase the rate of health improvement in deprived communities by enhancing primary care services to deliver anticipatory care - identifying and targeting those at particular risk of preventable serious ill-health; offering appropriate interventions and services to them; and providing monitoring and follow up. The Programme will consist of two waves of pilots, the first of which are now being established in 5 CHPs in Dundee, Edinburgh, North Lanarkshire and Glasgow (North and East). The main focus of the Programme is to identify and treat those in the 45 - 64 year age groups who are at risk of Cardiovascular Disease. Alcohol will feature as part of the lifestyle discussions with those individuals who participate in the pilots and, where appropriate, the assessment format as recommended by SIGN will be applied.

Local Pharmacies

6.13 A pilot study looking at Drinking Interventions in Pharmacies Study - funded by AERC - has been running in Glasgow to assess the barriers faced by community pharmacists in providing screening, brief interventions and, where appropriate, onward alcohol service referral for targeted pharmacy clients. The work includes undertaking a baseline evaluation of pharmacists' readiness to fulfil this role and a training programme designed to fully equip them to do so; and forms part of a larger pilot project to evaluate the feasibility and acceptability of the provision of interventions on alcohol issues in community pharmacies.

Local provision

6.14 Our knowledge of local service provision has also increased since the original plan was published. Local service provision is identified within the annual Corporate Action Plans submitted to the Executive by Scotland's 21 ADATs. These plans identify a range of excellent work to develop support and treatment services including the implementation of single shared assessment, development of community involvement, shared service protocols and integrated community addiction teams, and provision of training and education for a range of staff. They also help to identify the areas where there is the greatest need for additional resources including specialist psychiatric services, specialist services for children and families, counselling services, respite and rehabilitation services and services for people with alcohol-related brain damage. Annual reporting through local plans is being used to assess priorities for future investment in services and will be further developed into an accountability framework which will allow for service improvements in each area of Scotland to be tracked, and progress towards national priorities assessed.

6.15 We will consider whether an independent audit of service provision is needed in future should the national collation of information provided by ADATs prove ineffective.

6.16 A wide range of funding streams now support people with alcohol problems. These include the Supporting People programme which helped over 2,200 people with alcohol problems in 2003/04 (Statistical Bulletin HSG/2005/2) and the Community Regeneration Fund, which amounts to £31.8 million over 3 years and supports the development of safe, strong communities, employability projects, health promotion and activities designed to engage young people.

6.17 Other funding opportunities include the Executive's Local Action Fund, the New Opportunities Fund's Better Off programme and Lloyds TSB Foundation for Scotland Partnership Drugs Initiative.

Local Alcohol Councils

6.18AFS is undertaking a consultation review that will aim to explore and identify how the contributions that Local Alcohol Councils make in supporting the service delivery agenda can be further enhanced. There is a network of local alcohol agencies throughout the country which provide one-to-one free and confidential counselling to anyone affected by either their own alcohol problem or that of someone close to them. The findings from this exercise will be considered when available.

Protecting children

6.19 " It's Everyone's Job to Make Sure I'm Alright", the Report of the Child Protection Review, was published in November 2002. The report raised a number of concerns about the care and protection of children in Scotland and made recommendations to improve the practice and management of child protection services. In responding to the report, Ministers announced a 5 point Action Plan to help deliver improvements which formed the basis of the Executive's 3 year reform programme for child protection services. Since then, the Minister for Parliamentary Business has announced the Executive's "intention to legislate on information sharing to protect children at risk and we are seeking to make provision for this in the Protection of Vulnerable Groups Bill". A Charter for Children and a Framework for Standards have been published and a Code of Practice for the Joint Inspection of Services to protect children and young people is now in use. This will be reviewed in the autumn and will help inform the production of a Code for the joint inspection of wider children's services which will be ready for use in the pilot sites for Joint Inspections of Children's Services in 2007.

eCare Framework

6.20 In April 2006, the Minister for Finance and Public Service Reform set out the key priorities for a new multi-agency local data sharing partnerships (based around the 14 health board geographies). These partnerships will be responsible for leading the local work on personal data sharing. Chairs for all of the partnerships have now been appointed and the Executive's Data Sharing and Standards Division is now working closely with the partnerships to support them in their initial phase of activity.

6.21 One of the key priorities for 2006/07 is to support the sharing of information for children at risk. Centrally, work is underway to define the data and technical standards necessary to support the national rollout of the eCare child protection messaging system, which is being piloted in Lanarkshire.

6.22 The Data Sharing and Standards Division is also currently working to support Getting it Right for Every Child ( GIRFEC). The GIRFEC Implementation Plan, published on 22 June 2006, states that, "a 'prototype' of an IT solution to facilitate information sharing will be available from April 2007 for national roll out and testing with a wider group of children. We also intend to have developed the system specifications necessary to enable agencies' operating systems to be adapted to support the single assessment, record and plan".

6.23Getting Our Priorities Right, published in February 2003, outlines the expectations on a range of agencies in relation to referral, information sharing, service provision and monitoring for families where parents or carers misuse substances, including alcohol.

6.24Hidden Harm, a report by the Prevention Working Group of the Advisory Council on the Misuse of Drugs, published in June 2003, highlights the size and seriousness of the harm caused to children by parental drug use. The Executive published its response to this report in 2004 and an action plan entitled Hidden Harm - Next Steps in 2006, setting out a number of commitments for action to ensure that services are responsive to the needs of parents with substance misuse problems; and that the interests of the child are paramount in any decisions made regarding their future care and well-being.

Pregnancy

6.25Hidden Harm - Next Steps confirms that drug and alcohol use should be routinely recorded at ante-natal clinic and linked to stillbirths, congenital abnormalities and subsequent developmental abnormalities. At present, national statistics on drug use in pregnancy are available from the maternity record ( SMR02) and the Scottish Birth Record ( SBR). Evidence suggests that current practice in recording this information is variable. In order to improve the recording of these data and the detection of problem drug and alcohol use in pregnancy, research into current practices is being commissioned.

6.26 Linked to this is the development of the Scottish Women Held Maternity record and its associated electronic record, which should also contribute to a more accurate and consistent recording of this information; and the use of appropriate screening tools to improve the detection and treatment of alcohol problems within pre and antenatal settings.

Criminal justice services

6.27 Six Executive-funded arrest referral pilot schemes were established in Scotland during 2004 to offer a voluntary path into treatment services for individuals arrested for certain "trigger" offences or who displayed signs of drug or alcohol-related problems. Although primarily aimed at drug misusers, several of the pilots have an additional focus on alcohol use. To date over 500 individuals have been referred into alcohol services as new clients or to continue their ongoing treatment. The pilots were subject to independent evaluation by the University of Stirling and the evaluation report was published in July 2006. Ministers have confirmed continuation to March 2008 of funding for the existing schemes and additional funding to allow a new arrest referral scheme to be established in Aberdeen and extension of arrest referral to all appropriate police stations in Glasgow.

6.28 Certain offenders may be repeatedly arrested for being drunk and incapable. Intoxicated individuals need to be carefully monitored and early detection and intervention applied in cases where intoxication leads to a compromised airway. The Executive supported a pilot of the Life Signs monitoring system at Albyn House in Aberdeen and a working group led by AFS is exploring options for delivery of such provision in both urban and rural settings.

6.29 Prison provides a real opportunity to provide high quality treatment services for people with alcohol problems. Since the publication of the original plan, the Scottish Prison Service ( SPS) has:

• further integrated drug and alcohol education and health promotion for prisoners;
• been working towards better detection of people with alcohol problems through its core screening of all prisoners on reception since May 2004;
• introduced individual care planning, including specific alcohol assessment from September 2004;
• improved post-release links with community health, social care and alcohol services;
• ensured alcohol services are augmented by service provision from Alcoholics Anonymous delivered to all Prisons in Scotland;
• begun work in 2006 to monitor prisoners' alcohol problems and alcohol-related offending through better management and care information; and
• ensured delivery of training to SPS staff by STRADA.

Employment for people with alcohol problems

6.30 Pilot services to help people with alcohol problems into work are available, under Jobcentre Plus' Progress2Work Link Up programme, in Fife and Forth Valley. Since October 2003, the Pathways to Work pilot has been encouraging people with a health condition or disability, but who want to and are able to work, to find, remain and progress in employment. The pilot recognises that there are mutual benefits between improving people's health and their return to, or remaining in, employment; and that this requires joint working between Jobcentre Plus Personal Advisors and NHS Condition Management Practitioners. For a large proportion of incapacity benefit claimants in the pilot areas in Scotland - Renfrewshire, Inverclyde, Argyll and Bute - alcohol problems are one of the factors that prevent them moving into work. For a fairly small number of people, it is the major factor, while for many others it is a coping mechanism which they use to handle their other difficulties. The pilot has demonstrated the need for Jobcentre Plus and NHS staff to be able to refer clients to specialist alcohol services, both before and during the work-focused condition management programme that is central to Pathways to Work. This joint working will be key to helping people with alcohol problems in the new pilot areas: Glasgow from October 2005 and Lanarkshire/East Dunbartonshire from April 2006.

6.31 Additionally the Executive launched, on 12 June 2006, Workforce Plus, an Employability Framework for Scotland. This forms part of the Scottish Executive's Closing the Opportunity Gap approach to tackling poverty, and is based on the principle that for the vast majority of people in Scotland, work is the surest way of achieving a better quality of life and avoiding disadvantage. People with substance misuse problems, whilst relatively small in number, represent some of the hardest to reach for any employability programme. Critical to any future success on issues of employability will be the relationship between ADATs and Community Planning Partnerships who will be responsible for planning, managing and delivering the Closing the Opportunity Gap targets; and the effectiveness of these relationships at local level will be explored further as part of the planned best value stock-take of ADATs.

Drinkline

6.32 The UK Drinkline information line has been operating since April 2003 from two call centres based within Scotland; and is currently structured to deliver telephone advice to those who are seeking help and support for alcohol-related problems. The service itself is not promoted and as such the client group who are using it are, by their very nature, self selective.

6.33 The service, as stands, offers advice on all health and social issues relating to alcohol; provides information through public health leaflets; and makes onward referrals to local services as appropriate.

6.34 Future national communications activity on alcohol in Scotland will aim to challenge the social norms influencing people's lifestyle and choices, and in particular to challenge the complacent attitudes towards alcohol which encourage or tacitly endorse harmful drinking by others. Work is also underway with partner organisations to develop a national suite of publications that will target specific sectors of the population. Topics will include issues such as excessive drinking, alcohol and the law and recognising alcohol problems in yourself and others. The Drinkline service will be promoted through all campaign activities.

6.35 In addition to the Drinkline service being proactively marketed within Scotland, it is proposed that we explore how a telephone helpline service can be utilised to deliver a form of brief intervention - based on the methodology featured within current SIGN guidelines - that can be supplemented with a web based support tool to allow clients to self assess their progress and track any reductions in their alcohol consumption levels. This approach would also serve to divert people away from services which are in high demand; and provide a further opportunity to implement an evidence based approach to reducing harmful consumption behaviours in Scotland.

Future priorities

6.36 Backed by the additional resources resulting from the Partnership Agreement - the document setting out the principles that guide the current Scottish Labour and Liberal Democratic coalition government in developing and implementing policies for Scotland - this plan aims to deliver equitable, accessible and inclusive services throughout Scotland. This will be achieved by:

• supporting the delivery of person centred services which meet the needs of individuals and their families and children;
• supporting the implementation of existing guidelines for the treatment and support of people needing alcohol services;
• working with partners to assess local capacity, need and service gaps against the established four tier service framework, and tracking growth of capacity as a result of increased investment;
• linking additional resources to service level agreements with local partners which accept responsibility for expanding high quality services in line with national priorities;
• supporting the further development of well trained staff at all levels in alcohol services throughout Scotland; and
• ensuring that we are able to respond to the ways in which an increasingly ageing population might affect the demand for alcohol services in Scotland.

Specific actions:

Nationally

23. We will work with partners across the drug and alcohol fields to develop a quality standards framework for drug and alcohol services in Scotland.

24. We will, during the next three years, assess the impact and cost effectiveness of expenditure, target new funding at filling service gaps and work with ADATs to consider opportunities for re-prioritisation.

25. We will explore through STRADA, NHSNES, NHSQIS, AES and NHSHS the funding of a national training resource to support implementation of SIGN and HTA on the prevention of relapse guidelines. The first stage is an audit of current implementation, which will be developed and commissioned by spring 2007.

26. We will reinforce the expectation that SIGN and HTA guidance underpins all activity delivered within NHS Boards. We will incentivise GPs to manage harmful drinking and alcohol dependence in primary care and to prevent relapse. This includes NHS Board Local Delivery Plans and measures through GMS.

In primary and secondary care settings

27. We will monitor the number of NHS Boards commissioning an enhanced service for alcohol misuse and the take up of services by those practices providing this enhanced service.

28. NHSQIS, in conjunction with STAG, are carrying out an audit of patients presenting in A&E departments with an alcohol component to their condition. This will develop a focus for statistical information and explore subsequent pathways to care beyond the A&E intervention.

29. We will consider and, if appropriate, introduce the recording of waiting times for access to alcohol services and ensure this forms part of a national accountability framework for alcohol services.

30. Working with NHSQIS, NES, STRADA and NHSHS, we will ensure that both SIGN and HTA guidelines are translated into a series of priority actions for use by health professionals in the delivery of primary and secondary care services.

31. We will develop a research project to assess the impact of alcohol interventions on the overall Keep Well Programme target group.

In the community

32. We will pilot, in 2007/2008, a telephone based brief intervention service that will aim to apply the principles of the SIGN guideline, opportunistically identifying harmful or hazardous drinkers at an early stage, and providing appropriate support; allowing individuals to track their consumption levels by means of self assessment, using web and telephone based follow up.

33. We will commission research to be undertaken into practices used for capturing data on problem drug and alcohol use in pregnancy to improve methods for data capture, input and reporting.

34. We will strengthen links between alcohol and mental health, in terms of alcohol as a risk factor for mental health problems, mental illness and suicide; and how alcohol is used as a way of dealing with adversity, stress, emotional and mental health difficulties. In relation to wider substance misuse issues and the mental health agenda, attention will be given to taking forward the recommendations of Mind the Gaps and A Fuller Life. We will develop guidance for joined-up services by spring 2007.

35. We will support and evaluate a pilot project in Dundee, exploring how services can best meet the multiple and complex needs of women (and their children) affected by substance misuse (including alcohol) and domestic abuse.

36. We will support and evaluate a pilot project in the deprived areas of Renfrewshire, East Renfrewshire and Inverclyde, exploring how services can best meet the multiple and complex needs of deaf people with alcohol problems by developing specialist counselling services for this severely disadvantaged group.

37. We will explore whether the pilot study looking at Drinking Interventions in Pharmacies can be rolled out nationally as a future activity within the scope of the public health service element of the new community pharmacy contract.

38. We will raise the profile of the Drinkline service by working with partner agencies to feature the Scottish telephone helpline number on all "topic specific" alcohol publications in Scotland as well as on a national Scottish alcohol information website.

39. We will support ADATs, AFS and others in raising the profile of alcohol agencies and issues amongst equality and diversity groups, drawing on the experience of Glasgow Alcohol Action Team in this area.

40. We will work with partners to develop and implement a strategy for the provision of places of safety within Scotland.

41. We will ensure that ADATs work with Jobcentre Plus, the Scottish Centre for Healthy Working Lives and NHS Condition Management Practitioners in supporting people with alcohol problems, who want to and are able to, find employment or return to work.

42. We will explore how local Councils on Alcohol can be more fully utilised in the delivery of harm prevention and reduction programmes at local level.

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