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4 MAKING IT HAPPEN

4.1 Introduction

4.1.1 In this section we address some of the key issues around the subject of what ADATs do in order to influence and put in place services that will make a difference to the problems of substance misuse.

4.1.2 To achieve this, ADATs need a planning and implementation process which successfully delivers and continuously reviews the impact of its activity. A number of stages are required starting with an assessment of needs and moving through other stages to the monitoring of performance which should feedback into re- assessing needs. The stages we identified in this process are:

• Undertaking Needs Assessment
• Determining Strategic Priorities
• Allocating Resources
• Commissioning
• Contracting
• Managing Performance

4.2 Needs Assessment

What is needs assessment?

4.2.1 Needs assessment is about identifying the needs of the target population and planning and delivering services to meet those needs. The aim is to ensure that the required range and capacity of services is available and accessible in a local area.

4.2.2 In the commissioning cycle, the starting point is the assessment of needs. This might be for a particular segment of the population. For example, for 12-14 year olds using alcohol/drugs, the assessment of needs would involve:

• the identification of prevalence and incidence of a condition or conditions.
• Needs as perceived by different agencies - for example intelligence from police, CSPs, schools, GPs, A&E departments.
• Needs as perceived by individual users, carers, communities - involvement of young people, families.

ISD Substance Misuse Team: Alcohol and Drug Misuse

Information Sites

These sites provide information, statistics and research on alcohol and drugs misuse in Scotland. Information is provided at a national and local level. Target users are policy makers, professionals, researchers, employers and the wider community.

What we found and commentary

4.2.3 The predominant sources of information about needs were identified as:

• Prevalence data eg from SALSUS¹ & ISD²
• Trend Data eg from ISD
• Practitioners
• Providers (largely voluntary organisations)
• Partner agencies (sharing information and intelligence)
• ADAT Subgroups
• Any local surveys undertaken.

4.2.4 Public health involvement in ADATs was patchy, and more engagement from public health - a discipline that has expertise in formal needs assessment techniques - might ensure a more robust, evidence based approach. The police collect a large amount of relevant data and intelligence and had the expertise of analysts on their staff and we found some limited evidence of this being used in a collaborative way within ADATs. Most ADATs used a mixture of national statistics and local information to assess need. Some ADATs had commissioned surveys while others used their sub- groups as conduits of locally derived information and intelligence. In rural areas there were comments about the problem of lack of anonymity when assessing the needs of a small rural community.

4.2.5 We found that in most areas local data collection and analysis was being undertaken by one or more of the partners. However, it was rare for partners to pool this information or to try to build a good local picture. We believe that much more effective use could be made of existing local information.

4.2.6 Most ADATs recognised that needs assessment was an aspect of their work that tended to be ad hoc, and over influenced by individuals and agencies making cases driven by their own interests.

Recommendation 16: ADAT partners should use existing resources to develop joint working in the sharing and analysis of local information, data collection, and trend analysis and forecasting.

4.2.7 Capturing the needs of any client group from the perspective of individual service users and their families is notoriously difficult. People have very different life experiences and expectations, and, particularly in the field of substance misuse, families are affected in widely different ways. In addition to these challenges, people abusing drugs and/or alcohol frequently experience chaotic lives that make it even more difficult to ascertain their perspective of their own needs.

4.2.8 Nevertheless, there are techniques that can be used, and organisations, such as SDF, have experience of assessing the needs of those affected by substance misuse. Service providers and practitioners can gather valuable information from those receiving services, although these sources inevitably focus on those already receiving services and may not only underestimate unmet needs but also leave them unidentified.

4.2.9 We found little evidence of systematic input from service users, their families or communities. User/stakeholder consultation and its impact on needs assessment was informal and relatively underdeveloped (see Section 5.2 - Public Engagement). In most ADATs there was a recognition that this was the case.

Recommendation 17: There should be a systematic national approach to needs assessment involving service users and their families, and with better use of analytical expertise at local and national levels.

4.3 Strategic Priorities

4.3.1 Eight ADATs had a current 3 year strategy. Of the remainder, eight had no specific strategy and six strategies were time expired. Most of the strategies, whether current or out of date, addressed both drugs and alcohol. Three ADATs had alcohol strategies only and all were out of date. Only one area had separate alcohol and drugs strategies but both were out of date. Many ADATs indicated they were in the process of revising strategies but were awaiting publication of the updated national strategies on drugs and alcohol. The approach to developing strategies varied from leaving the coordinator and other support staff to develop it, with later input from the ADAT, to the use of development days and full consultation with stakeholders. Despite its limitations (see paragraphs 3.2.20-22), some areas used the CAP as the starting point; in others, the main influencers were the sub-groups and/or local forums.

4.3.2 We take the view that all ADATs need to have a shared understanding and commitment to address local needs and national objectives. A Strategic Plan, produced as a result of dialogue between the ADAT partners is an important step in achieving that.

Recommendation 18: All ADATs should develop a 3-year Strategic Plan which sets the direction of travel and is regularly reviewed and updated.

4.3.3 There were some recurrent themes across ADATs in relation to determining strategic priorities:

• The importance of partner involvement at a senior level.
• Tensions among partner agencies in terms of an individual agency's priorities for resourcing.
• Cultural and political differences among partner agencies in terms of how strategic priorities should be determined.
• Getting the right balance between the strategic ADAT and its sub-groups - whether geographic or themed - in terms of agreeing strategic priorities.
• A tendency to focus on treatment services - influenced by what is relatively easily measured and the way that funding streams are directed.

4.3.4 Generally, ADATs reported a reasonable fit between national priorities and local needs and priorities. But the national preoccupation - at least until very recently - with illegal drugs rather than alcohol had not reflected the balance anywhere in Scotland, and in some areas, particularly rural Scotland, problems relating to alcohol abuse far outweighed those relating to illegal drugs. ADATs expressed consequent frustration with the perceived inflexibility of the way in which ring fenced money from SE has been focused on drug services, and the way in which the CAP demanded data that bore little relationship to local priorities. In particular, the CAP did not provide an appropriate focus for alcohol services.

4.4 Resources

4.4.1 ADATs have three potential sources of statutory funding:

• Scottish Executive ring-fenced money which currently goes to ADATs via local NHS Boards.
• Money already spent within individual agencies on substance misuse, for example:
• a local authority may be funding a local voluntary organisation to provide support for people with substance misuse problems;
• a health board may be providing a specialist health team for people with substance misuse problems.
• Additional money from agencies not ring-fenced nor currently spent on substance misuse services. This might come from the agency's efficiency savings or from additional general allocations from the Scottish Executive.

What we found and commentary

4.4.2 There was variable transparency regarding the way in which resources were allocated, although some areas reported it was improving. A few ADATs had the assistance of a financial expert from one of the partners which had been helpful. Virtually all the funding that was allocated to the ADATs for decision was the ring-fenced funding which came through the Health Board. Many ADATs complained that the restrictions on the ring-fenced money made it difficult to meet locally agreed priorities, for example, where alcohol had been determined as a greater priority than drugs. Some however described their creativity in terms of ability to "bend the spend", for example by shifting emphasis from drugs to alcohol where this was felt to be more of a local priority. But not all ADATs felt able to do this. Despite the restrictions on ring-fenced funding, some ADATs felt that the protection ring-fencing gave to drugs and alcohol money was very important as they felt that they would receive very little if it were left to the local NHS/ LA to decide between other competing priorities. A few took the view that ring-fenced funding let the Health Board "off the hook" because they regarded the ADAT money as the limit of what is needed rather than as a lever to bring in more.

4.4.3 It was envisaged at the outset that the existence of the ring-fenced money would encourage the partners in an ADAT to put up for joint discussion and decision some or all of their respective, core expenditure on substance misuse. However, few ADATs had their ring-fenced money supplemented by additional resources from partners although a few did receive "in kind" support in the form of staff or accommodation.

4.4.4 In some areas, decisions tended to be governed by waiting times and other NHS priorities. In one area we were told that the Health Board had established a practice of top slicing the ring-fenced funding from its ADATs to fund alcohol treatment services. There appeared to have been no consultation with the ADATs about this. In some ADATs, there could be a conflict of interest, for example when an influential sub-group was chaired by a practitioner with a vested interest in the direction of spend.

4.4.5 The evidence suggests that ring-fenced funding is needed to ensure the prioritisation of expenditure on drugs and alcohol services. However, the balance of what is and is not inside the ring-fence is generally unhelpful and inhibits more comprehensive discussion and decision making by the ADAT. One area described the ADAT ring-fenced funding as "the icing on the cake" when they felt that the ADAT should have been dealing with the whole cake.

4.4.6 Most ADATs had little influence on the core funding streams of partner organisations. There were examples of "behind the scenes" influence that was difficult to quantify - a sense that the ADAT - usually through its support workers - was making some difference to the priorities of individual partners. It was felt that the influence varied according to which agency the Chair came from. Thus an NHS Chair was likely to have greater influence on the NHS than on the local authority.

4.4.7 ADATs found it difficult to get a complete picture of local allocations and expenditure on drugs and alcohol services. In addition to the ring-fenced funding for ADATs, Health Boards, local authorities, police, court services and prisons also spend significant sums on substance misuse. Some of this is hard to quantify where it is part of a service not dedicated to substance misuse, such as Accident and Emergency provision. But there is also significant expenditure on dedicated provision for substance misuse about which the ADAT is given no information. This includes national funding for Drug Treatment and Testing Orders and Arrest Referral and local expenditure on police campaigns as well as the more obvious expenditure by Health Boards and local authorities.

4.4.8 We believe that the role originally envisaged for ADATs is the correct one. The partnership should be the place where joint decisions are made about the most effective use of shared and complementary resources. To achieve this, however, needs greater transparency about the resources provided to and spent by the ADAT partners. Partner organisations should be required, with assistance from the Scottish Executive if necessary, to identify the resources that they spend on dedicated substance misuse services and put them up for joint discussion in the ADAT. ADATs will need appropriate financial expertise, possibly provided by one of the partner organisations, to monitor these resources.

Recommendation 19: Partner organisations in ADATs should be required to identify all dedicated expenditure on substance misuse activity and make it available for discussion and joint decision in the ADAT.

4.4.9 A few ADATs generated additional income and funding as a result of partnership working. There were examples of the following in several ADATs:

• Joint funding of a post eg between the ADAT and a Community Safety Partnership.
• Input of different resources to achieve a single goal.
• Access to charitable funding - usually through trusts eg Lloyds TSB Foundation, Big Lottery.

4.4.10 Some areas were good at stocking a "bottom drawer" with worked up proposals that could be taken out at short notice should Scottish Executive or charitable funding become available. Others gave no thought to this.

4.4.11 Funding is problematic in particular for voluntary sector organisations who find it difficult to access. Concern was expressed about the emphasis by the Scottish Executive and other funders on new and innovative approaches, often at the expense of existing and effective services whose budgets were frozen or discontinued. Often there is an unrealistic expectation by funders that services will somehow become self funding. Sometimes the voluntary organisation finds an alternative source of funding in the hope that the services will eventually be mainstreamed into the statutory sector. There are few examples across Scotland of this happening. As a result some voluntary sector organisations are financially precarious because they have to constantly chase funding from numerous resources to sustain services. The constant search for funding is time consuming and a diversion from client care obligations. Additionally, funding is often insufficient and short term. (See also Section 4.6 on contracting.) This can lead to the loss of experienced and qualified staff who require a secure, stable and structured environment in which both themselves and their organisation can progress.

4.4.12 Rapid turnover of staff and uncertainty about future or continued funding can undermine the quality of services. ADATs can address this by committing to providing longer term funding, of at least 3 years duration, subject to regular and satisfactory performance reports. Performance reporting should be rigorous but realistic in terms of the time commitment required to complete it and appropriate to the amount of funding being provided.

4.4.13 Many of the voluntary sector ADAT members receive funding from charities such as Lloyds TSB Foundation Partnership Drugs Initiative. However, many ADATs reported that they did not have a clear understanding or knowledge of funding coming from charitable or other sources. Sometimes, when that funding ran out, ADATs were expected to provide continuation funding even where they had had no say in determining whether the purpose of the funding fitted with the priorities of the ADAT.

4.4.14 There is no doubt that voluntary organisations play a valuable role in ADATs. They are often better placed to provide particular services and may be able to access funding that would not be available to the statutory partners. ADATs should recognise this potential. However, where there is an expectation that the ADAT may be required to match fund or in due course fully fund particular projects or services, then decisions about their development and applications for funding to operate them should be taken in the context of the strategic priorities of the ADAT. Decisions should be strategy, not funding, led. It follows that voluntary organisations have to be able and willing to participate fully in ADATs.

4.4.15 Where the ADAT partners have agreed that an application for external funding should be supported by the ADAT, partners should be prepared to demonstrate their support by formally endorsing the application or, if necessary, providing supplementary funding.

Recommendation 20: ADAT partners should be prepared to demonstrate their support where applications for charitable funding or funding from other external sources for the provision of projects and services in relation to substance misuse have been agreed with the ADAT, ADATs and partner organisations should aim to provide funding to voluntary sector organisations which is of at least 3 years duration, subject to satisfactory performance reports.

4.5 Commissioning

What is Commissioning?

4.5.1 Commissioning is the mechanism that translates strategic priorities into services on the ground and levers change, driving up quality and efficiency. It takes into account evidence of effectiveness of interventions, quality of services, and quantity required regardless of whether the provider comes from the statutory, voluntary or private sector. At the commissioning stage, the ADAT should agree where it should focus its partnership energy to effect maximum impact. It may agree that a service sits largely or wholly within one agency and should continue either to be the sole responsibility of that agency or that the delivery should be led by that agency. This may be appropriate where:

• Responsibility for the service clearly rests with a single agency eg blood testing for abnormal liver function.
• The ADAT partners agree following review that a service is currently running effectively and is not in need of change at present.

Thus an important aspect of the ADAT's work is to focus its energies on priorities that demand the added value of a partnership approach.

What we found and commentary

4.5.2 We found a few examples of service redesign that could be described as commissioning. (See Case Study 4.). Overall, there was little evidence of ADATs taking a "level playing field" approach to providers, in as much as the voluntary and, to a much lesser extent, the private sectors were required to tender for services; while statutory providers continue to be funded for services without the challenge of external competition. The key issue here is that services should be delivered by the agency best suited to do the job, and that there should be no presumption that statutory service providers are better able to deliver. Nor should a history of being the provider be an influence on future service delivery decisions.

Case Study 4: Direct Access Service

The evidence base supporting this development was summarised within a number of local and national publications including the national guidance document Integrated Care for Drug Users - Principles and Practice,EIU 2002. Local need was highlighted by a variety of service providers. Evidence suggested that stimulant users would be more likely to access a "Direct Access Service". Prevalence figures estimated that in this ADAT area there could be around 1400 "hidden" problematic drug users (ie users who were not in touch with any services.)

The Direct Access Service would offer a range of interventions including assessment, social care and onward referral from multiple access points across the ADAT for people with problems relating to drug misuse or for those affected by another's use, such as families and carers. It would also expand the nature of service interventions available to individuals who were unable or unwilling to access the services on offer locally. The service would cater for all age groups and cover all drugs. The service would have flexible opening times and would support up to 300 new clients a year with an additional capacity to offer information, assessment and onward referral.

Key deliverables were identified as:

• Increased new clients in the system
• Reduced waiting times - maximum referral to assessment of 72 hours.
• Widened range of interventions
• Following a bidding process, a voluntary organisation was commissioned to develop the service which has been in operation since March 2007.

Recommendation 21: ADATs should be prepared to consider all providers - statutory, voluntary and private - when commissioning and be prepared to move inefficient and/or poor quality services away from existing providers. There should be a level playing field among providers - statutory, voluntary and private.

4.6 Contracting

What is contracting?

4.6.1 A contract is an agreement - usually written and legally binding - that specifies the terms of the agreement between the purchaser and the provider. It defines the parties, the value of the contract and what each party agrees to. It should clarify which risks are to be borne by the purchaser and which are the responsibility of the provider and establish reasonable risk sharing. The process of moving effectively from a service specification to a contract, or a range of contracts, is specialised work, and the relevant experience may only be available to the ADAT through one or more of the partner agencies.

4.6.2 The term 'service level agreement' is sometimes used interchangeably with contract but it is more correctly used to describe the obligations within a contract that set out the service, required levels of service, responsibilities and priorities. An SLA is also often used as a performance management tool especially in internal markets where one part of an organisation (the commissioning department) agrees with another part of the same organisation (a service department) a performance framework for delivering services. An SLA can be an effective tool for creating a common understanding between two parties regarding services, expectations, responsibilities and priorities.

What we found and commentary

4.6.3 Much of the contracting between ADATs and providers was in the form of Service Level Agreements ( SLAs) usually with voluntary organisations, and rarely with statutory services. However, we found that few ADATs had the skills to tender and negotiate contracts effectively, and we would not expect this specialism within an ADAT support team. Some ADATs resolved this by using the contracts teams of partner agencies, such as the local authority or health board. This highlights the more general point that ADATs need to be supported by partner agencies for a range of specialisms including finance, contracting, needs assessment etc. In addition, as ADATs are not legal entities, they were unable to enter into contracts and where contracts were required, these were held in the name of a partner agency.

4.6.4 Across Scotland we heard that work was in progress either to introduce SLAs where there were none, or to improve the effectiveness of existing SLAs. Some ADATs were working collaboratively with their providers to develop meaningful outcome measures.

4.6.5 The role of the ADAT in monitoring SLAs was variable from no input to total responsibility for writing the agreement and monitoring it. Monitoring was not always a clear or standardised process. In one area, accountability was monitored according to the requirements of a partner, whilst in others the ADAT required quarterly update reports. Overall the accountability arrangements varied and those concerned did not necessarily fully understand them.

Recommendation 22: ADATs should make use of commissioning and contracting expertise available within partner agencies.

4.6.6 The relationship between ADATs and the voluntary sector is relevant here. We heard repeatedly of frustration among voluntary organisations in relation to commissioning and contracting. There were three main concerns. First, voluntary organisations felt that they were subject to much more stringent monitoring arrangements than statutory providers, and that contracts tended to have unreasonably short timeframes, with annual renewal, often not confirmed until the last moment. Second, local voluntaries that had enjoyed a close relationship as providers without SLAs found themselves competing with larger national voluntary organisations as tighter commissioning arrangements came into play. Thirdly, there was a presumption that the voluntary sector should be a cheaper option. Some voluntary organisations found themselves penalised by an expectation that they should not recover their full costs despite the recommendations of the Strategic Funding Review carried out jointly by central and local government and the voluntary sector in Scotland. Some voluntary organisations also found that when statutory agencies were experiencing serious financial constraints voluntary sector providers were the first to have their contracts revised to their financial detriment.

Recommendation 23: Commissioners should contract for services with the voluntary sector on a level playing field basis; and should pay the full costs of service delivery.

4.7 Performance Management

What is Performance Management?

4.7.1 Performance management is a strategic approach to managing an area of work. It aims to improve organisational effectiveness and add value by enhancing existing capabilities and building new ones. It is largely concerned with continuous improvement of the organisations broad strategic capabilities and the specific capabilities of individuals and teams. Within ADATs, it deals with the broader issues that agencies have to face in the ever changing environment of drug and alcohol misuse and gives general direction for ADATs to achieve longer term goals. Performance management provides a real opportunity for ADATs to be proactive and innovative in influencing strategy and contributing to the way in which service delivery meets local need.

What we found and commentary

4.7.2 In a few ADAT areas there had been reviews of performance and an evaluation of the service provision. This encouraged continuous improvement, ensuring that the right services are offered, delivered and reported upon. However, there were also some areas where there were no competing services and the existing ones were funded year on year. In some areas, due to a lack of performance monitoring services were unable to demonstrate clearly their success criteria.

4.7.3 Annual performance monitoring in all of the ADATs was carried out mainly through use of the Corporate Action Plan ( CAP) (see also paragraphs 3.2.20-22). However, this document was not viewed as being a robust means of monitoring outcomes. It was perceived as being neither an effective monitoring tool nor a planning tool.

4.7.4 Across Scotland there was a strong desire to place more emphasis on local compared to national targets. It was perceived that the national accountability through the CAP diverted the energy of ADATs and reduced the time that they could spend on addressing the realistic local issues that were of concern to the community. A few ADATs had supplemented the CAP with local performance monitoring, whilst others had sought assistance from specialist research and evaluation agencies to assist with needs assessment and monitoring and evaluating services.

4.7.5 In some areas the assistance of a financial advisor had been sought which had been of benefit to the team. In some areas, local action plans reflected ongoing activity, links with other strategies and on-going progress. Many local performance measures concentrated more on activity reporting than outcomes. In a few areas, the ADAT priorities were reflected in the corporate plans of the relevant partners and monitored through them, reporting back to the ADAT.

4.7.6 There was some evidence of staff appraisal and development schemes but the extent to which they were linked to the planning cycle was variable. In a few ADATs there was some understanding of how staff objectives aligned with corporate objectives and performance appraisal. Most ADATs were less able to demonstrate evidence of a link between performance management and staff appraisal as a tool of staff governance.

4.7.7 Support is needed at a national level to enable ADATs to undertake more effective monitoring through a performance management framework. This would enable individual partners to remain accountable in respect of their contribution at a local level to the achievement of targets on substance misuse which might help to drive up performance nationally. Most ADATs recognised that they needed continuously to improve performance and outcome measurement but had found this process difficult and would have welcomed more guidance and support in this regard.

4.7.8 We have already recommended (see Recommendation 4) that the Scottish Executive should work with ADATs to revise and replace the CAP with an Annual Delivery Plan ( ADP). This Plan should be designed so that it meets the performance management needs of ADATs and the Scottish Executive. The Annual Delivery Plan would be the means by which ADATs would implement the priorities in their 3 year strategic plan. The ADP would also form the basis of the annual accountability meeting with the Minister. (Recommendation 9 refers.)

Recommendation 24: The Annual Delivery Plan should meet the performance management needs of the ADAT and the Scottish Executive and should form the basis of the annual accountability meeting with the Minister.

National Quality Standards for Substance Misuse Services

4.7.9 The National Quality Standards for Substance Misuse Services and accompanying guidance were published in September 2006 with the aim of improving the consistency and quality of substance misuse service provision in Scotland.

4.7.10 In November 2006, a request was made to ADAT support officers to obtain information from service providers as to their readiness for the implementation of these Standards. This was viewed positively and 14 ADATs participated in the baseline exercise, which was intended to measure the ability of services to demonstrate that they meet the Standards and identified common themes and support needs.

4.7.11 The baseline exercise highlighted the following issues:

• Variation among ADATs in their involvement in commissioning and performance management of services and duplication of information required for monitoring and management purposes.
• In some areas there was over-reliance on verbal understanding of service policies and procedures.
• The absence of a strategic approach to service planning and development, including poor needs assessment, commissioning practice and performance management was found to affect the ability of services and ADATs to demonstrate compliance with the Quality Standards.
• A lack of a shared understanding about user involvement, and little consistency in family/carer involvement.

However, it was stated that further guidance would be welcomed. The report on the baseline exercise made a number of recommendations including that the role and expectations of ADATs in relation to implementation of the Quality Standards should be stated formally as soon as possible.

4.7.12 As part of the key findings of the Alcohol User Involvement survey, there was evidence that in most areas clients had received a personal care plan and that those clients with alcohol problems who moved between services did so in a positive way that was planned and structured by service workers. However, the SDF User Involvement Report found that services for clients with drug problems were not joined up and there was little evidence of continuity of service provision for clients who moved to another area. Both the need for service users to have personal care plans and the need for a wide range of providers to ensure that their services work together to benefit the service user are covered in the National Quality Standards.

4.7.13 In the course of the Stocktake, some ADAT staff reported that it was too early to draw conclusions but they felt that the Quality Standards would be beneficial in helping them to document and support much of their work and that this would lead to consistent standards and co-ordinated services which would meet a full range of service-user needs. However, at the time of the Stocktake there was generally, a low awareness of the Quality Standards across the country.

Recommendation 25: ADATs should promote the adoption of the National Quality Standards. The guidance framework to be developed for ADATs (Recommendation 2 refers) should include an explicit statement about the role of ADATs in relation to implementation of the Standards.

Value for Money

4.7.14 The Local Government in Scotland Act 2003 places a duty on local authorities to secure Best Value which is defined as continuous improvement in the performance of the local authority's functions. The objective of Best Value is to ensure that effective management delivers better and more responsive public services. It is about local authorities:

• balancing the quality of services with cost
• achieving sustainable development
• being accountable and transparent, by engaging with the local community
• ensuring equal opportunities
• continuously improving the outcomes of the services they provide.

4.7.15 There is no requirement for ADATs to operate in accordance with Best Value which does not in any case apply to other ADAT partners although they may have a commitment to similar approaches. It would therefore be inappropriate to measure the performance of ADATs in strict accordance with the Best Value regime. Nevertheless, the principles of Best Value are relevant to the delivery of efficient and effective services and they provide a good template against which to consider the performance of ADATs.

4.7.16 There were few examples of ADATs having programmes of review of services in place to identify alternative action or justify retention of services. In some areas there was an over reliance on verbal and informal understanding of service policy and procedure as opposed to written documentation. However, in a few areas, stakeholders were consulted to identify issues of concern and to influence future approaches regarding overall needs assessment and these processes although informal seemed to work well. There was some evidence of providers being compared on an informal basis with others to identify and stimulate good practice.

4.7.17 Overall the majority of areas established local targets and standards for at least some of their services. However, many reported on performance in terms of activity rather than outcome measurement. There were few examples of the use of recognised quality management tools and benchmarking tended to take place on an informal and ad hoc basis. In some areas ADAT support staff met informally and shared information with each other. This seemed to work well and allow for some sharing of good practice

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