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Chapter 7: Overview of Grampian-wide Issues

• NHS Grampian
• Drug-related Deaths
• Grampian Police
• Social Work Criminal Justice Substance Misuse Services
• The Role of Voluntary and Independent Sector Providers
• Feedback from Service Users and Carers

7.1 NHS Grampian

Summary - NHS Grampian

We recognise the difficulties in delivering a service to people with substance misuse problems across three Action Team boundaries. NHS Grampian committed resources to substance misuse services and took an active part in the Action Teams and sub-groups. However, we had concerns about the lack of a strategic overview for health substance misuse services, and the broad remit of senior managers, leaving them little time to devote to substance misuse issues. We noted that NHS Grampian were reviewing some of these arrangements. Health staff have a crucial role to play, working with partners, in the delivery of services to people with substance misuse problems. We had concerns about the inconsistency of governance of staff, and the lack of clarity of roles and responsibilities of some staff, particularly nurses. There were significant gaps in the geographical coverage of some important health services, particularly substitute prescribing, pharmacy services and needle exchanges in rural areas.

7.1.1 Policy, strategic planning and management

Substance misuse was identified as a cross-cutting strategic priority for health improvement and community planning across all three Action Team areas, and featured in current documents such as "Healthfit", Joint Community Care Plans and Community Safety within the wider community planning agenda.

As might be expected, most strategic planning for substance misuse took place in the three Action Team areas rather than at Grampian level. However, a number of senior staff in NHS Grampian and in partner agencies acknowledged that more strategic planning and leadership was needed at a Grampian level to target resources more effectively. NHS Grampian did not have an over-arching strategic framework for substance misuse services. We found that there was insufficient capacity at strategic level to focus on substance misuse services. We were of the opinion that this contributed to inconsistencies in standards of service delivery and deficiencies in performance management across the three Action Team area by health or in partnership with other services.

A senior manager of NHS Grampian acknowledged the need for a Grampian overview of the need for and balance of substance misuse services to enable resources to be targeted where they were most needed. He also recognised the usefulness of a Grampian-wide drug and alcohol strategy, but saw limited scope to develop a local vision due to the agenda being set at a national level, and the individual Action Teams being responsible for driving the local vision.

NHS Grampian contributed significantly to the three Action Teams. At the time of our inspection, two of the three Action Teams (Aberdeen and Aberdeenshire) were chaired by senior NHS Grampian managers, and attendance at meetings of the Action Teams was good, apart from Moray, where involvement was more limited.

There were no clear reporting mechanisms from the Action Teams to NHS Grampian or the three local authorities. This is not uncommon where multi-agency partnerships are set up with a strategic planning remit, but the main partner agencies continue to be accountable for the bulk of the funding. The Chief Executive of NHS Grampian informed us that a mechanism to performance manage the Action Teams through the CHPs was needed as links between the Action Teams and the CHPs were currently in need of strengthening.

We noted the recent development of the Clinical Effectiveness and Reference Group for Addictions ( CERGA). The findings from the inspection suggest that further groundwork on the base-line position of services, as well as the authority and objectives of the group, would be of value in providing a framework which would allow this group to drive continuous improvement. We noted the existence of the blood-borne viruses' strategy and commend the NHS Board on the progress made on the hepatitis screening and immunisation programme. We also welcomed the emergent harm reduction guidance. However, these should form part of a comprehensive strategic framework, to reflect the prominence detailed in the above reports.

The strategic lead for substance misuse sat with the Head of Strategic Planning, who also chaired the Aberdeen JADAT. Both he and other senior managers acknowledged the difficulty of committing the appropriate time within an extensive remit to focus on strategic planning for substance misuse, or indeed, to fulfil the role of JADAT Chair to the extent he saw necessary. A decision had been made to advertise for an independent chair of the JADAT.

Recommendation 17
NHS Grampian should ensure that Action Team partners are clear about its strategic intentions.

Structurally, the Substance Misuse Service was located within the mental health directorate which was Grampian-wide, but was hosted by the Aberdeenshire CHP. Some thought was being given to moving substance misuse services out of the mental health directorate and into the CHPs. Operational responsibility lay with the general manager for mental health services who was also the Clinical Director for the Specialisms Directorate. His managerial portfolio included nine other services. He directly managed all of the health services based at the Fulton Clinic in Aberdeen. This senior manager while operationally involved with this service, was directly involved in the joint commissioning of services in the Action Team area in which he was based.

We were concerned that the extremely wide and diverse responsibilities of these two important posts limited the capacity of the post holders to devote time to substance misuse services. We recognised that proposed changes to the management of substance misuse services were being considered with the intention of improving the situation.

A senior nurse managed nursing staff in both the City and the Shire and was based at the Fulton Clinic. In Moray, a joint manager had been appointed to manage nurses and social workers. The post-holder was a social worker and was managed by the General Manager for Mental Health. We found the level of delegated authority in Moray to be unclear, with some nurses uncertain about governance arrangements. This was one instance of differences in arrangements or expectations where we were unable to obtain clear evidence from senior management as to the systems in place to ensure sound governance. The last comprehensive audit was undertaken in 2003, and a further audit was planned, but the health file reading for Grampian NHS did not provide evidence of nurses' case files being routinely audited.

We recognise the difficulty for NHS Grampian in delivering services across three Action Team areas, and that given the differing needs and circumstances in each area, different practices may develop. However, we were concerned that the practices of staff in health were not equitably managed and governed across the three areas, to ensure that standards of practice were consistent.

We did see good examples of integrated health and social care service delivery which left service users feeling that they had benefited from the enhanced experience, but we had concerns about the following:

• 'Partnership' arrangements between GP practices and SMS nurses which varied widely in the extent to which they constituted joint working. We were told that some GPs referred initially to SMS for assessment and stabilisation and took patients back once this had been achieved, while others did not take them back, but 'hosted' SMS sessions at their practice. We also heard that some GPs would refer to SMS but because they knew from experience, especially in the city, that this could mean months or years of waiting, they would begin prescribing in the meantime. Others would not institute prescribing.
• In some instances the contact between the patient and the GP could be very limited. We heard that a nurse could see the patient, conduct tests, counsel and write a prescription, leaving the doctor to sign it. A recent review of alcohol counselling made available in GP practices in Moray revealed that the most common concern raised by patients was not in relation to the service but the lack of any communication from the GP once they had made the initial referral.
• Non-clinical service providers were frustrated and concerned that people using services could not get access to prescribing services as some local GPs had not engaged in substitute prescribing, leading to what was described as a "post code lottery", and certainly resulted in inconsistent provision of services across Grampian.
• Nurses and their managers were sometimes unclear about whether nurses worked only with people with alcohol problems, or drug problems, or with both, and if both, then what percentage of their time should be spent with each. Historically these had been separated and a gradual change had been encouraged. There was also confusion about whether nurses co-ordinated care packages in conjunction with social work colleagues, and differences in practice in the three Action Team areas about when nurses would undertake home visiting.
• Discrete professional groups, such as pharmacists, reported that they had near daily contact with drug users on substitute prescriptions but some felt quite isolated and 'out of the loop' in their ability to contribute to the care and treatment decision-making process. Others reported a more positive experience.

We therefore had concerns about governance issues in the area of substance misuse. There seemed to be no formal reporting mechanism to the NHS Board which set out the schedule for performance monitoring against targets and standards specific to substance misuse services. We were aware of the structural arrangements within the board to oversee governance, but could find no one in authority who could tell us about clinical governance priorities in respect of substance misuse. In the context of marked variations in practice across the field, we believe that these differences undermine best practice and limit best value from integrated models of care and treatment.

In this regard we found parallels with the NHSQIS report on Clinical Governance and Risk Management Arrangements, which stated that "… corporate decision-making and arrangements for local implementation at NHS Grampian appeared reliant on individuals' relationships, rather than on systems and clear lines of accountability". (2005)

Recommendation 18
NHS Grampian should develop clinical governance arrangements for substance misuse. They should be supported by guidance, standards of performance and reporting requirements.

We have highlighted issues about joint working in the chapters on the Action Team areas. At this point we draw attention to the fact that people had markedly different experience of partnership working within health and with health colleagues.

7.1.2 Treatment Options and Capacity

Substitute prescribing

Methadone was almost exclusively the substitute prescribed for opiates. We found comparatively rare examples of alternatives being used, either on an individual basis or as part of a pilot.

All three Action Team areas faced challenges in the number and geographical spread of GP practices with enhanced contracts in respect of substance misuse services. This shortage was not unique to Grampian. The problems of GP prescribing have been growing increasingly acute over many years, especially in Aberdeen, and we did not find evidence that these problems had been the focus of strategic planning processes across NHS Grampian. We were aware of current plans to introduce salaried GPs with this prescribing role to relieve pressure in at least two areas.

We were told by senior health managers that the problem with the enhanced contracts was that they were "just not that attractive to GPs". We could not find evidence of any consideration of what would make the contracts more attractive. Quite apart from the financial incentives which have featured elsewhere in Scotland, the GPs we spoke with expected a significant level of support from the Substance Misuse Service and were clear that where this was consistently delivered it worked very well, to the benefit of all concerned.

We heard from doctors that engaging with drug users in particular could be fraught with difficulties. GPs we spoke to had experienced problems of difficult behaviour from some patients. It was clear also, however, that some had worked alongside patients and other agencies to achieve rehabilitation through gradual reduction in methadone dosage. They reported that it was the exception rather than the rule that patients achieved this goal. The picture was much more commonly one of long-term maintenance and some doctors expressed the view that they felt 'backed into a harm reduction corner'.

The expectations of the enhanced contract, apart from prescribing medication and providing testing, are that doctors demonstrate continued development through training, and act as a knowledge resource to colleagues. NHS Grampian had a calendar of training, and GP practices closed one half day a month for training purposes, but both GPs and pharmacists told us that it could be difficult to find the time or the locum cover to allow them to attend some training events.

Moray had not made any improvements in increasing access to prescribing services. National targets on identifying and reporting on new clients in 2005-06 were not met.

Aberdeenshire had increased access to treatment services, reduced waiting times and increased the number of planned discharges and people moving on to employment or further education. The main concerns were the disparities within the area. Services were concentrated in the north, including an integrated Substance Misuse Service, while it had proved difficult to bring GP practices in central and south Aberdeenshire on board with shared care.

Aberdeen had increased access to services and had a high percentage of GP practices signed up to enhanced contracts for drugs, but the overall capacity had been unable to keep pace with the demand for prescribing.

Additional staff resources for prescribing are only part of the solution. We remained concerned that senior SMS staff were unable to articulate a clear strategic workforce and development plan which would avoid perpetuating this bottle-neck.

Recommendation 19
NHS Grampian should increase its efforts to promote enhanced contracts, and provide support to GPs in order to develop more equitable services across Grampian.

Alcohol

Staff involved in substance misuse throughout Grampian reported that alcohol did not have the same public and political profile and developments had lagged behind drug services. Services in Aberdeenshire and Moray were provided to help both alcohol and drug misusers, while those in the city were largely separate. Staff we interviewed had to be prompted to include alcohol in our discussions, as the assumed focus was on drug use. There were plans in Aberdeen for a Community Alcohol Team with a similar structure to the combined SMS/ ICDRS (Integrated Community Drug Rehabilitation Service). Management acknowledged that the development of this service had caused some consternation in the voluntary sector in particular, but provided evidence that there had been extensive consultation. For It's part, the voluntary sector cited this as an example where consultation and conclusions did not seem to progress in a transparent sequence.

People with co-existent mental health and substance misuse problems

As identified in the Scottish Executive report, "Mind the Gaps", substantial proportions of people who misuse substances also suffer from mental health problems. Despite the fact that substance misuse sat within the mental health directorate, we were told very little about policies or services for the care and treatment of people with co-occurring substance misuse and mental health problems, as set out in "Mind the Gaps". We heard from many sources that it could be very difficult to access psychiatric care for people who presented with depressive or anxiety-related conditions while they had a substance misuse problem. This appeared to depend on the practice of individual consultants. The availability of services for assessment, treatment and support was often described as a lottery, depending substantially on individuals. We heard about the development of a working group in one of the areas to look at what the barriers were to effective engagement with the "Mind the Gaps" agenda were, but discussion with management in the same area revealed that these difficulties persisted. This is an issue which requires a health-led strategic response across all three areas, and it is concerning to find no clear evidence of the impact of "Mind the Gaps" for people with co-existing mental health and substance use problems.

Recommendation 20
NHS Grampian should review strategy and service delivery for people with co-occurring substance misuse and mental health problems in the light of the objectives and recommendations in "Mind the Gaps". Clinical leadership and pathways of care should be clarified.

Children affected by substance misuse problems

We found a more positive picture in relation to the impact of initiatives to improve services to children affected by substance misuse problems such as Getting Our Priorities Right and Hidden Harm. The health file reading results showed that in 71% of cases where children were living in the same household as the patient, there was an initial assessment of the impact of the patient's substance misuse. The integrated assessment form employed set out data, analysis and any necessary action. From the staff survey, 90% of health staff agreed that their team was proactive in the sharing of information for assessment purposes when patients had children. Ninety seven per cent of staff believed they worked effectively with social work child care colleagues when child protection issues arose. We have referred to this issue in each of the Action Team area chapters.

7.1.3 Pharmacy services

Ninety seven of the 127 pharmacies in Grampian offered supervised consumption of methadone and 12 offered a needle exchange service. The intention was to increase needle exchange and to ensure better geographical spread by targeting areas which did not provide a service. A recent survey of people using services on the content of needle exchange packs had led to some changes, but the decision not to include citric acid was commented on by staff across the sectors and by people using services in our surveys and in our fieldwork.

We heard conflicting accounts of the access to dispensing arrangements for substitute prescriptions in pharmacies. Pharmacists in some areas thought that they were the sole local provider of dispensing services, or GPs thought that access was virtually dependent on one very sympathetic pharmacist, while NHS Grampian reported that there were 300 dispensing spaces available in the city alone. This suggested the need for more robust information and communication systems.

All three Action Team areas experienced challenging issues in respect of access to substitute dispensing services for drug users. The pharmacists we met with during our fieldwork had different approaches and attitudes regarding their work with drug users, but some had clearly gone out of their way to provide a discrete and sensitive service.

There was a specialist lead for substance misuse pharmacy services who was the link with the Action Teams. Some pharmacists expressed the view that they felt isolated from wider substance misuse services. Their main interface was with the prescribing clinician and they said they would welcome more involvement through Action Team structures. We were advised that any concerns about the performance or practice of individual pharmacists would be raised with the specialist lead who would liaise with the head of SMS. There were no routine meetings between these two.

Recommendation 21
Action Teams should improve pharmacists' representation to ensure that their important role is recognised and their experience contributes to the development of integrated substance misuse services of the best quality.

An NHS Grampian audit of methadone prescribing published in 2007 confirmed our findings on a key point regarding the perception of drug users: pharmacists told us that they felt that patients with drug problems were unfairly stigmatised by colleagues from other pharmacies who chose not to get involved in dispensing and supervision. The experience of those who did, in almost 97% of cases, was that they experienced no problems with attitude or behaviour from people on substitute prescriptions. The one area which had seen a slight deterioration from previous audits was in relation to inaccuracies or miscalculations on the actual prescription.

7.1.4 Health staff

We surveyed health staff, but were unable to disaggregate their responses to the three Action Team areas. In common with the three Action Team areas, the positive results from the health staff survey were sometimes at odds with what was repeatedly reported during fieldwork, giving a mixed picture overall. We met with nursing staff, doctors ( GPs and consultants) and pharmacists who had some positive things to say about partnership working in substance misuse, but exasperation from some about the number of GPs who chose not to engage with drug users and substitute prescribing in particular. We also heard from GPs who were engaged in this work that it was not altogether comfortable for them and they felt "backed into a damage limitation corner".

Almost all of staff who responded to our survey agreed that they enjoyed their job. Where there were established shared care arrangements and where pharmacists felt they were included in the communication loop, experience on the ground was reported on favourably. It was also acknowledged that NHS Grampian provided opportunities for multi-disciplinary training. Nursing staff reported that individual supervision had appropriate priority from their line manager. They had access to a psychotherapist for confidential support, and this person then reported to the senior nurse with "themes" should any arise.

Nursing staff generally appeared to feel that the work that they did and the difference it made were key motivators. The dissatisfaction we encountered from some seemed to be related to feeling "out on a limb" and more keenly felt in a particular area where drug misuse services were perceived to be more "nurse-led".

Ninety one percent of staff reported that more effective partnership working by the agencies represented on the Action Teams had resulted in improved outcomes for people using services. Of partnership working with other services on the ground the most positive relationships were reported to be with social work. Only a minority of health staff felt they had an effective working relationship with housing or other local authority departments, or with the independent sector. Just over half responded positively about their relationship with the voluntary sector which was a concern, given the important and substantial role of the latter across the Grampian area.

More than half of staff agreed that there were clear guidelines about the appropriate sharing of information, but even where teams were working to an integrated service model, most health workers could not access all the records of current and mutual service users. The majority of staff felt that they were proactive in sharing information for assessment purposes where service users had parenting responsibilities.

Sixty five percent of respondents in our survey agreed that morale had been good in their team for the last six months but almost half disagreed that working conditions were likely to improve in the coming year.

7.2 Drug-related Deaths

From the beginning of 2006 to mid December there were 45 confirmed and two suspected drug related deaths in Grampian: five in Moray, 14 confirmed and one suspected in Aberdeenshire, and 26 confirmed and one suspected in Aberdeen City. This was a significant increase from 2005 - almost 100% - but the 2005 figure was unusually low. Grampian has had approximately 11% of drug-related deaths in Scotland since 2001 with the exception of 2005.

We found no mechanism in Grampian for systematically reviewing drug-related deaths. We noted from the Moray Corporate Action Plan ( CAP) that the DAAT was to set up a local group to review drug-related deaths, while in the city CAP it was stated that a sub-group of the recently-established Clinical Effectiveness and Reference Group ( CERGA) would in 2006-07 "review current policies and make recommendations for a comprehensive strategy for tackling drug related deaths and local implementation of the SACDM reporting into preventing drug related deaths".

CERGA is to have a Grampian-wide remit and it would be more appropriate if this group took forward these objectives on behalf of all three Action Teams in the form of a Standing Group, consistent with Scottish Executive guidance on Taking Action to Reduce Scotland's Drug-related Deaths.

An overhaul of current arrangements for reviewing alcohol or drug deaths where the person was known to services, was also needed. There was currently no formal procedure for examining these deaths. There was an informal arrangement where they were reported to the specialist substance misuse consultant who linked with the police, sought information from SMS about treatment status, and, if in treatment, a decision was taken with the lead clinician as to whether a critical incident review should take place. NHS Grampian was reconsidering this process following concerns raised by the Mental Welfare Commission.

Recommendation 22
NHS Grampian and Grampian Police, in consultation with Action Team partners, should establish a standing group for the monitoring and prevention of drug-related deaths and should develop formal procedures for the review of drug related deaths where the person was known to services. The three Action Teams should agree a definition of alcohol-related deaths and include those deaths with drug deaths.

7.3 Grampian Police

Strategy

Action Teams had highlighted different aspects of partnership working with the police in their Corporate Action Plans and Self-evaluation Questionnaires, and these were explored in the area chapters. It seemed clear from the evidence presented in these documents and from discussions during fieldwork, that the police were generally regarded as a good multi-agency partner in the field of substance misuse. The police described themselves as "an active consultative partner involved in the preparation of Action Team strategies".

The force was represented on all three Action Teams and there appeared to be strong links with community safety structures, which had led to a number of joint initiatives. It was interesting to note that the majority of these joint initiatives focused on problems related to alcohol misuse as the dominant source of adverse impact on communities, although educative initiatives covered drugs, alcohol and a range of other life choice issues.

Service delivery

Grampian Police were involved in considerable joint activity with support staff from the Aberdeen Action Team to examine the feasibility of developing an assertive drug treatment programme aimed at addressing the area's most problematic high-tariff drug-using offenders. This was to be based on a service model in England, and a smaller-scale version of the same model was being considered for Aberdeenshire. This showed that initiatives were being considered across Action Team areas, although in this instance the project seemed to have stalled.

The 11 School Liaison Officers supported teachers in the delivery of personal, social, health and citizenship education. They had anti-social behaviour operations where they could identify young people who had an incipient or fully fledged substance misuse problem and refer them to an appropriate youth support service. Educational input, awareness-raising about services, and alternative activities were crucial preventative investments in which all the Action Team partners had a stake, given what we know of typical onset of problematic substance use in mid teens.

The police have a multi-faceted contribution to promoting early intervention for children and young people. As well as their direct work in schools and with youth in organised activities or on the streets, they automatically referred to child protection enquiries for domestic disputes, which commonly involved substance misuse. The re-structuring which took place in 2005 re-designated the CID lead officer post for drug misuse to the strategic Force Substance Misuse Co-ordinator, Community Partnerships, and was re-aligned to include alcohol issues. This should be helpful in adopting an overview of where and how to best deploy resources, provide greater community focus and should enable the school liaison role to be developed further.

There was a force-wide needle exchange scheme operating in all major custody suites. There were established arrest referral schemes in North Aberdeenshire and Moray, and funding had recently been granted for one in Aberdeen.

Police were represented on the Drug Treatment and Testing Order Advisory Group and staff had found that the police had been good in the passing on of information about changes in drug market conditions/added risks. Similarly, workers from a voluntary sector agency in the city working with women in the sex industry found that most police they dealt with handled issues sensitively if and when the women were the victims of crime.

There had been an increase in police activity in all areas of substance misuse in recent years, with mixed results. They had had operations specifically targeting the disruption of crack cocaine coming into the Aberdeen area. It had been known for some time that the North-east of Scotland had a disproportionate share of this particular drug problem and seizures of this drug continued to exceed the target. This was consistent with the finding that, although opiate dependency was still the dominant drug for new presentations at specialist addiction services, a third of this number presented with crack cocaine problems.

7.4 Social Work Criminal Justice Substance Misuse Services

The Social Work Inspection Agency produced a report in September of 2006 on the Northern Partnership Criminal Justice Social Work Services. The Northern Partnership consisted of the three local authorities in the Grampian area plus Highland Council. The inspection found that "there is a lack of effective joint working between the Partnership's criminal justice addictions team and case managers in the four authorities", and recommended that the Partnership should "review the function and operation of the criminal justice social work addictions service and the co-ordination of externally provided addictions services". We do not intend to cover the same ground in this report, though we do comment on aspects of criminal justice addiction work in the chapters on Action Team areas. The report, however, did not cover Drug Testing and Treatment Orders, and we comment on this here.

Drug Treatment and Testing Orders ( DTTO) were available in Aberdeen , Aberdeenshire and Moray. The service was staffed by an integrated team of nurses, social work and addictions staff. The service provided an intensive programme of treatment, support and rehabilitation to offenders on a court order. During the course of the fieldwork we heard very positive reports from both staff and service users about the efficacy of the service and the advantages of a multi-disciplinary approach. It was encouraging to note that the completion rate for orders was running at 50%, given that programme completion was recognised to be a critical success factor in reduced risk of re-conviction.

Our concern was centred on those who were not given the opportunity to access the service and why this was the case. The DTTO service was available to Sheriff Courts across city and shire but very few referrals for consideration of an order came from outside Aberdeen. Moreover, there had been persistent difficulties in sustaining a viable level of referrals from criminal justice colleagues in the city, despite the issue having been raised repeatedly with criminal justice management. The relationship between criminal justice social workers and addiction services was noted to be ineffective in the SWIA inspection report of criminal justice social work services in the Northern partnership, especially in Aberdeen. We understood that the partnership had therefore decided to review the city addictions service to give it a clearer remit.

Recommendation 23
Criminal Justice Social Work Services should review the current position of the Drug Treatment and Testing Orders in order to ensure that offenders and the courts have credible community-based intervention options. Any such review must include strategic partners and other key stakeholders.

7.5 The Role of Voluntary and Independent Sector Providers

The findings in this section are based on the written survey returns and file reading. Where we met with focus groups or individual staff during our fieldwork these are reported in the chapters for the relevant Action Team area.

Job satisfaction was as high for voluntary sector staff as for other sectors, while the experience of partnership working was decidedly more mixed. In the analysis of the particular issues highlighted in the survey returns, this was very much related to how they experienced being perceived by their statutory colleagues.

Almost all staff agreed that they enjoyed their job and believed that their team was successful in reducing the harm caused by substance misuse. They generally felt that they worked within a framework of clear expectations, had manageable workloads and had access to relevant training opportunities.

Almost all staff believed that skills were deployed effectively within their team. In contrast to the statutory sector, nearly half agreed that their organisation had a policy of encouraging employment applications from people with a previous history of substance misuse problems.

Eighty nine percent of staff reported that their service was easy to access, and there was 100% agreement that their team promoted routes out of substance misuse. Ninety percent of staff agreed that all service users had care plans, but in one Action Team area the figure was as low as 50%. However, this area had the highest incidence of regular reviews. Although 89% asserted that they worked with other agencies to 'wrap around' service users with complex needs, this was not borne out by the file reading results, where significantly more social work files showed evidence of partnership working than voluntary sector files.

Voluntary sector engagement in partnership working was mixed. It was a matter of concern that there was almost an even split on agreement concerning good relationships with colleagues from other agencies, notably social work and housing. Nearly half said that they did not regularly attend multi-agency meetings and more than half did not agree that there were clear guidelines in place about the sharing of information where more than one service was involved with a service user.

More than half did not agree that effective systems were in place for two-way communication between the Action Team and front-line services. Staff in the voluntary sector were significantly less likely to agree that good partnership working by all agencies on the Action Team had resulted in improved outcomes for service users.

The following were examples of written comments about what would improve services in the area:

"Better relationships with social work - more clarity about the aims of the project";

"More accessible treatment, more GP involvement".

These results suggest disaffection of staff in the voluntary sector. The Action Teams should take active steps to explore and to address these.

Concerns were also expressed in the written comments about disparities, including those of pay and conditions, between alcohol and drug services, with the latter resourced to pay more. The differences in the make-up of the services was quite marked, with alcohol services usually employing more unpaid volunteers than would typically be found in a drug service. This seemed to be partly evolution and partly pragmatism, the latter in the context of the national market-place.

Eighty six percent of staff agreed that 'Hidden Harm' and 'Getting Our Priorities Right' had impacted positively on the practice within their team, but this was not reflected in the file reading results. The numbers surveyed were too small to be of statistical significance but there was a lack of evidence to demonstrate that the impact of parental substance misuse was being assessed as a matter of course.

The Action Team areas had included the voluntary sector in in-house training made available through the local authority, but to different degrees and in different ways.

Risk assessment was an area which required further development and more focus in the voluntary sector. There were 21 files where it was identified that the person was vulnerable to abuse or that a person in the house posed a risk to other adults in the household, but an up-to-date risk assessment and risk management plan was present in only 19% of cases. Case files showed very little evidence of first-line manager scrutiny.

Recommendation 24
Voluntary organisations in Grampian should conduct an internal audit of all files, focusing on critical areas of parenting assessment, risk assessment and care planning processes. The Action Teams should put measures in place through contract compliance processes to monitor progress on this.

7.6 Feedback from Service Users and Carers

Service Users

To obtain the views of users of services in the three Action Team Areas, we commissioned a peer review, conducted by Scottish Drugs Forum. One hundred and fifty seven service users were interviewed and we also had a number of opportunities to observe practice and meet users in a number of different settings across the Action Team areas. The views of service users throughout Grampian are presented here.

National Quality Standards were introduced in Scotland in the autumn of 2006. On the basis of the evidence set out below, service users in Grampian perceived that services were largely being delivered in accordance with these standards. Access to services could be a problem, but once in services, service users reported that they felt safe, consulted and that the service improved their lives.

Most service users were very positive about the changes that services had helped them to make:

• Twenty eight percent reported that they had stopped using illicit drugs or misusing alcohol as a result of engaging with services and a further 59% had significantly reduced misuse. More than half attributed this outcome to effective inter-agency working.
• Self-reported outcomes for the 81 interviewees who had been involved in offending prior to attending a service were particularly positive. Sixty reported that they had stopped offending and 14 that their offending had reduced.
• One hundred and eleven of the 136 service users we spoke to who had suffered physical health problems as a result of their substance misuse felt that they had recovered or were recovering, as did all of the 109 people who reported having suffered mental health problems. In around 35% in both health categories, people felt that inter-agency working had played a significant part.
• Ninety five of the 122 who told us that they had experienced family relationship problems related to their substance misuse felt that engagement with services had benefits in repairing or improving these relationships.

It was encouraging that those who took part in the peer review spoke positively about the services they received. However, we were not able to interview people on waiting lists, of whom there were many, nor those who had dropped out of services.

Observed practice and meetings with service users yielded powerful personal testimony about the difference services had made, but by their nature what we heard was from people part-way through planned care and support and it was not possible to ascertain sustained positive change. Typical reports from service users related how services had "turned my life around", "saved my life" or "provided much-needed respite from the chaos that had gone before".

In 58% of the local authority and voluntary sector files read, there was evidence that the individuals' circumstances had generally improved while the figure was higher for health files.

Eighty nine of the 157 interviewees in the peer research were parents. Of these, 30 lived with their children. Of the 89, 64% reported the service they attended for their problem also offered support in their parenting role. Forty eight percent provided direct support, 12% linked to another child-care agency and 40% felt that they did not need this kind of help. Eleven percent experienced problems in accessing substance misuse services because of child care issues.

"Sometimes I couldn't get to service if my kid's off school. The workers were alright but I don't want my kid mixing with other addicts."

"Social work helped with after-school care when I was attending service."

Most respondents reported positive effects on their parenting abilities as a result of the help they were receiving, whether or not they had additional help with child care.

" DTTO has helped get my drug problem under control therefore I had more time to spend with my children instead of committing crime and being in prison."

"I lost my child and was not far off finishing my life. Down to losing script. They made sure I was stable and it has made me a better parent."

7.6.1 Access to services

Despite what we know of waiting list problems for some services, the service users we interviewed had not generally had to wait long for the main service they were receiving. The problem which was identified from the majority of comments on the subject of access, was that most did not believe the range of services was adequate for their area, and limited or delayed access to prescribing services was highlighted as a particular problem. Many commented about a lack of residential rehabilitation in the area.

The other issue which came up repeatedly in the research and the fieldwork related to information about services and concern about lack of awareness of the help available. The main source of information was reported to be GPs, which illustrated the vital role they had in referring to other services as well as providing them.

Those who told us that their involvement with substance misuse services came about through criminal justice generally felt that this resulted in speedy access to treatment services, although some expressed reservations about this.

"It was a court order so it was easy."

"It took me to get on a DTTO to get a script and get stabilised."

7.6.2 Involvement in assessment, care planning and reviews

The majority of service users agreed that an assessment of their needs was started within a week of their accessing the service. Almost all service users believed that the assessment reflected their needs completely or partly. A slightly lower number were positive about their own involvement in the assessment process and felt that their views were taken into account. While almost half the assessments were thought to include the views of their GP, less than one in six involved families or spouses.

Sixty four per cent of the 157 people interviewed reported that they had a care plan, while the other third did not believe they had or did not know. Three out of four who believed they did have a care plan said they attended regular meetings in this regard.

Almost all service users in the peer review reported that they were happy with the service they received and this was also true of the service users we met with during the fieldwork. In alcohol services there was a high agreement that staff had the ability to understand the problem, but only half of users of drug services rated staff as excellent in this regard. Across all services, service users were virtually unanimous that their service was sensitive to issues of ethnicity, gender, disability and sexuality. Many spoke in the warmest terms about the regard and affirmation they felt they receive from their key worker.

We heard examples of service users and carers being involved in staff selection or staff training (both of and with staff) but these tended to be exceptions, and should be examined carefully in relation to further development. These can be extremely positive experiences for all concerned if properly planned.

7.6.3 Carers

We were only able to meet with a small number of carers and therefore cannot be clear how representative their views were. We did not meet with any carers who felt that they had only good outcomes to report. In contrast to an improving health picture for service users, carers told us that their own health and sense of emotional well-being had worsened as a result of their caring role. They were unanimously of the view that their support needs were not recognised or responded to in sufficient measure to avoid these adverse outcomes.

Carers were clear that it had taken them a considerable period after problems developed for them to even think about their own need for support, rather than supporting services to care for their family member. They reported that they did not know where to go, some worried about whether their own difficulties in coping would somehow back-fire (especially if they had assumed partial or complete responsibility for the care of dependent children), and they also reported a deeply felt sense of the stigma of drug use, particularly within the family. We were given access to a recent research paper which looked at issues affecting access to support for carers in one of the Action Team areas. The findings from this small-scale study supported our own - that people had a mixed experience of attempting to access support but felt it was extremely worthwhile once they received support.

Example of Good Practice
Family support group facilitators with whom we met had opened up training opportunities to family members. We heard from one carer of his experience of attending a conference funded by the group and finding that he was the only non-professional there. This particular carer also accessed training in therapy, funded through the group, which he was then able to use to therapeutic effect with the person he cared for.

We heard very mixed accounts from carers as to how accessible and how helpful they had found carer support services. They had also experienced different degrees of inclusion in assessment and care planning processes in respect of the person they cared for.

They spoke about the stigma felt by all members of a family when the drug problem of one member becomes known about by others. This can result in them trying to manage the problem without external support until a crisis point is reached.

Carers also reported different experiences of contributing to assessment and care planning in respect of their family member. We heard an example of a carer who supported his adult child to access a service in the city and was not only involved in the assessment process but was provided with information and encouragement regarding family support. Another carer told us of how she had had to fight for services for her son for several years. Problems resulting from his substance misuse were exacerbated by another condition, but she believed there was very poor assessment of how these would impact on each other. She felt excluded from assessment and care planning and experienced great frustration that health and social work services did not join up to support her son.

Each Action Team was supporting some form of support for carers, sometimes in-house and sometimes through commissioned services.

We were concerned that while all of the Action Teams gave us evidence of how they were improving the means by which they captured and collated service user experience, none made any such claim in respect of carers' experiences.

Recommendation 2

There is a recommendation for all three Action Teams about the involvement of users and carers in developing services in Chapter 6.

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