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Chapter 3: Aberdeen Joint Alcohol and Drug Action Team Area

Action Team: The Action Team is known as the Joint Alcohol and Drug Action Team or JADAT. The team meets quarterly and the membership of 27 includes health (7), local authority officers (5), elected members (2), prison (1), police (2), voluntary sector (1) Alcohol/Drugs and HIV Forum (2) Procurator Fiscal (1) and JADAT staff (3). At the time of the inspection the team was chaired by the Director of Corporate Planning for NHS Grampian but plans were being progressed to appoint an independent chair to be employed on a part-time basis. There were 4 themed sub-groups, each chaired by a key stakeholder.

The JADAT was supported by a team leader, 3 development officers, a health improvement officer and an information officer.

3.1 Key Outcomes

In Aberdeen we found some evidence of attempts by the JADAT to promote and progress an outcomes-focused approach to the development and delivery of services. However, we considered that these attempts were under-developed against the backdrop of long-standing problems with capacity. Nonetheless, there was sufficient evidence of improvement in positive outcomes to merit an evaluation of ADEQUATE on this measure.

Prevalence profile

During 2005-06, Aberdeen reported to the Scottish Drug Misuse Database ( SDMD) there were 516 new people seeking care and treatment. This figure was a decrease on figures for the four previous years. We know that the City had seen a year-on-year increase in the number of people seeking specialist addiction intervention. The numbers of people accessing shared care methadone had increased by more than 10% a year for the previous three years and numbered approximately 1200 per year at the time of inspection. Aberdeen City had five Community Pharmacy Needle Exchanges, five outreach services and one fixed base enhanced needle exchange. Between them in 2005-06 they distributed 623,469 needles with a return rate of approximately 70%. A report in 2003 indicated that Aberdeen had a prevalence rate of opiate and benzodiazepine use of 2.03%, while the Scottish average was 1.84%. It also had the highest rate of injecting and a higher incidence of psychostimulant use than elsewhere in the country.

There were over 600 people on the waiting list for the Substance Misuse Service ( SMS). While approximately 40% of these were being prescribed methadone by their GPs, we were concerned that those in this group had not had an assessment of their needs made. In the most recent National Drug Treatment Waiting Times Information Framework Report, 23% of people referred were offered an assessment appointment within 21 days of being referred. Aberdeen used prioritisation criteria to fast-track those who were at particular risk, including pregnant women, and families with children were prioritised. Young adults with no dependents who were injecting drugs but not seen as high risk, could wait up to two years for assessment. The JADAT was aware that this was not acceptable.

It was harder to obtain reliable data on people accessing help for alcohol misuse than for drug misuse. Adults with alcohol problems were waiting for services from the statutory sector but we were told by voluntary alcohol counselling services that they could see people within 21 days of referral. Alcohol counselling services attracted self-referrals more than other addiction services.

The figures for under-age drinking exceeded the national average on a number of key measures. Between 2003 and 2005 the number of children referred to the Reporter on substance misuse grounds almost doubled, while national figures dropped. The JADAT informed us that one possible reason for this increase was the proactive referral to the Children's Reporter by the Grampian Police Youth Justice Management Unit ( YJMU) of any offences where alcohol or drugs are featured

Performance profile

Performance data on outcomes was being developed. The information which follows on performance relates to the priorities set by the Scottish Executive as well as emerging evidence of progress on planning and delivering services with a focus on measurable outcomes.

Each Action Team produced an annual Corporate Action Plan ( CAP) which set out how it had addressed the priorities set by the Scottish Executive and local initiatives and developments for the forthcoming year. Performance monitoring based on these priorities had contributed to slow progress in developing a focus on outcomes in the planning, development and delivery of substance misuse services.

Although it was not obligatory to develop a local strategy as well as a CAP, Aberdeen had such a plan for 2005-09 The strategic objectives of the local plan mirrored the national priorities and committed the Action Team to some local objectives. The strategy focused on activity and outputs rather than outcomes.

The CAP acknowledged that waiting times for assessment continued to be a problem, but reported that 82% of clients received treatment within 14 days once an assessment had been undertaken. The JADAT also reported it had exceeded its most recent target of 56 new clients, with 176 accessing substitute prescribing. This figure rose to 222 by the end of the reporting year (Scottish Drug Misuse Database p.11). The serious concern was about the unacceptably high number of people - over 600 - waiting for treatment, some of whom may have had to wait for up to two years to be assessed by SMS. At the time of the inspection an audit of waiting lists was in progress, as the Action Team wanted information about the make-up of the list, for example those who might be engaged with other services, including prescribing from their GP, whilst waiting for assessment by SMS. During the inspection we were advised that "names were dropping off already".

Culture, change and communities

The JADAT used a range of indicators to measure its performance against the national priority to reduce the percentage of adults exceeding weekly sensible drinking limits. The JADAT had a Binge Drinking Harm Reduction Task Group which was progressing a number of targeted awareness-raising initiatives, often linked to the community safety partnership. Despite the positive impact of individual initiatives, evidence presented on various measures did not point to an overall reduction in the incidence of harm-related binge drinking.

There was no percentage target relating to the national priority to reduce drug and alcohol related crime and the evidence on a range of offences between 2003 to 2006 did not suggest an overall reduction. Police activity in relation to stop and search had increased during the period but the impact on the volume of illicit drug seizures had been mixed.

Prevention, education and young people

The local target of developing a drug and alcohol strategy aimed at young people was being developed behind schedule as a result of staffing difficulties. The intention was to have outcome objectives consistent with the Integrated Children's Services Plan, which ranged from pre-birth support and protection measures through to youth justice. During a three year period Aberdeen had a number of strategic imperatives in relation to children and substance misuse relating to Getting Our Priorities Right, the results of Pregnancy and Midwifery research, and the rising number of children being referred to the Reporter on the grounds of substance misuse. The development of the strategy had been unduly protracted. Aberdeen should progress this strategy as a matter of some urgency.

The JADAT supported a number of inter-agency initiatives concerned with ante-natal and early years care when children were born to mothers who misuse substances. We were pleased to see that these brought together statutory services with the voluntary sector. The JADAT partners needed to clarify the respective roles of staff. Moreover, we found evidence from other stakeholders that social work capacity to offer support to pregnant substance misusing women and their babies was variable and sometimes insufficient. This service was undergoing a review at the time of the inspection.

The most recent figures showed that there had been an increase in the numbers of children on the child protection register as a result of parental substance misuse. We were also advised that the Families First service was running into difficulties in meeting demand and that this was also the case with the part-time maternity post attached to a voluntary sector agency.

The JADAT had commissioned Robert Gordon University to map services for children to inform wider integrated children's services planning. The JADAT Children and Young People's sub-group had subsequently identified a gap in dedicated provision for children who misuse substances.

Initiatives in relation to Hidden Harm and Getting Our Priorities Right had resulted in a Grampian-wide "Framework for Reducing the Harm" guidance, inter-agency information-sharing protocols in the city, as well as "Children at the Centre" training for social work staff.

There is a national target concerned with reducing hazardous drinking by young people. The JADAT had used the Scottish Schools Adolescent Lifestyle and Substance Use Survey ( SALSUS) to set a baseline for levels of drinking by young people in Aberdeen City and these showed that Aberdeen was matching or exceeding national trends. There was no recent data to enable performance to be compared as the most recent survey was undertaken in 2004 and information was only available on a Scotland-wide basis. However, the JADAT undertook two local surveys in 2005-06, one in Torry and one in Kincorth which revealed very high levels of drinking among 14-15 year olds. These surveys provide a good baseline to measure the impact of a number of actions assigned to the Torry Neighbourhood Youth Team for 2006-07.

Provision of support and treatment services

The CAP figures for 2005-06 suggested that, in most of the services commissioned through the JADAT, the target of a year-on-year increase of 10% of drug misusers in contact with services had been met. The number reported to be accessing the primary care methadone shared care scheme had risen in the same period by 25% [ CAP]. The CAP also listed the main public sector and commissioned services and the numbers of 'active clients' for the last two years. This provided a much more accurate picture of actual numbers in contact with services and the JADAT had rightly taken the decision to include alcohol services even though these were not included in the national priority or target. The differences in the figures between the two years varied from service to service and it was too early to draw significant conclusions. However, this represented a step forward in systematic reporting from the various agencies delivering services and we consider this should be built on when developing outcome-related performance measures.

Aberdeen reported uncertain results regarding the national target to increase the numbers of drug misusers successfully completing treatment. Between 2004 and 2006 there was a significant reduction in the number of unplanned discharges from a high of 37% to 14%. Planned discharges had also decreased by 29%, however, which suggested longer-term engagement with services. Bearing in mind what we know of the journey of drug users through services and the improved outcomes where contact is longer, this seems to be a positive response

The Integrated Community Drug Rehabilitation Service ( ICDRS) had reported a 70% retention rate of people who use services for the last two years in succession. We noted that the ICDRS had identified a series of output measures such as health gain through core fitness measures, improving social networks of non-drug using associates, and people who use services reporting less anxiety. It was intended to build on this progress with the appointment of a well-being worker from the summer of 2006 to support people who use services into mainstream activity. This service reported that 60 service users had engaged in employability or training programmes in each of the last two years and that the retention rate of referrals it made to Progress 2 Work rose to 85% in 2005-06.

Good practice example - progress 2 work
Progress 2 Work is a scheme funded by Job Centre Plus which aims to help support people, including recovering drug users, into work and employment opportunities. The scheme is delivered in partnership with Aberdeen Foyer, Aberdeen Cyrenians and APEX, in conjunction with the Community Rehabilitation Service. The scheme supported well-stabilised drug users to take up training and employment as part of a rehabilitative programme. Of the 73 people who started the scheme in 2005-06, 96% had positive outcomes in relation to training, education and employment.

We found the ICDRS to be a good example of a service developed with very clear expectations with regard to outcomes, where different agencies or disciplines contributed to the overall package of treatment and support. The evaluation of the service in 2005 revealed issues around clarity of role between the different agencies, and a lack of focus on rehabilitation. The promotion of recovery and routes out of services had been re-asserted as goals of this service.

Performance summary

The CAP was very active during 2005-06 and had set out a challenging agenda of key actions for 2006-07. Most of these had timescales and leads identified, the latter being individuals, sub-groups or agencies. However the measurable outcomes still related largely to inputs and process measures, e.g. numbers and completions of plans, rather than being outcome based.

Aberdeen's self-evaluation questionnaire acknowledged that while the JADAT gathered a lot of information about performance on an ad hoc basis, there was no corporately agreed means of demonstrating outcomes across the spectrum of provision. It was an area "where all services had struggled". Senior management in the statutory sector acknowledged that they were still measuring inputs and processes. In contrast, the voluntary sector expressed concern that they had become too focused on outcomes and were being required to provide a lot of information for different commissioners and stakeholders which detracted from direct work with service users. However, there was no real consensus in the voluntary sector about re-defining outcomes to make them more meaningful.

Recommendation 1
A recommendation on outcome and performance measures applicable to all three Action Teams is made in Chapter 6.

In 2006 the JADAT appeared to have made efforts to progress measuring outcomes, but the over-riding impression was of too many impact measurement tools and initiatives and a lack of a clear strategic direction. The JADAT intended to address the failure on the part of service providers to use outcome measurement pro-formas through commissioning arrangements.

During the local authority and voluntary sector file reading we found evidence that the circumstances of people who used services had improved in 60% of cases in Aberdeen City. In 64% of these cases, the improvement in circumstances could mostly or to a greater extent be attributed to effective social work services. In 52% of the cases where the individual's circumstances had improved, this could be attributed mostly or to a greater extent to effective collaboration between services. In nearly half of cases where there was no perceived improvement, the lack of effective collaboration was at least partly attributable.

3.2 People Who Use Services, Staff and Other Stakeholders

Aberdeen had a number of plans to ascertain the experience of service users in order to inform service development. There was a considerable gap between these plans and practice at the time of the inspection. We found that staff expressed high levels of job satisfaction and key to this was the belief that their service made a positive difference. We were particularly concerned about the continued impact on the community of the scale of unmet need as measured by the numbers of people on waiting lists for assessments for treatment services.

We considered that Aberdeen performed to an ADEQUATE standard on this measure.

Experience of people who use services, their families and carers.

Peer research was the primary means by which we engaged with service users during the inspection and we interviewed 157 people across Grampian. The broad findings are reported in Chapter 7. We found it more difficult to identify carers and met with a very small number living in Aberdeen, or who had experience of services in Aberdeen.

This section includes some findings from the peer research specific to Aberdeen, as well as findings from observed practice and our meetings with service users and carers during field work.

Slightly more than half the service users we met with used services in Aberdeen. In addition to responding to multiple-choice questions, 57 made evaluative comments about their experience of substance misuse services in the area. These comments have been grouped in the following table.

Fieldwork meetings with service users

Service users we met with were very positive about the substance misuse services they were receiving.

There was a general consensus that drug users on a substitute prescription were treated with dignity at pharmacies. It was acknowledged by senior staff that more needed to be done to involve service users in decision making around their care. Aberdeen University was to undertake a user preference study.

Most people we spoke to were also positive about other health services, although access to dental treatment, substitute prescribing and perceived increased risk associated with injecting because of decision by NHS Grampian not to include citric acid in needle exchange packs, were all raised as concerns.

Service users spoke particularly highly of the main service they were involved with, whether or not they identified this as part of a wider inter-agency package of treatment and support. The importance of good working relationships with a 'constant' was clearly very important, whether a GP or a key worker in a statutory or voluntary agency.

An integrated Drug and Alcohol Service Assessment and Review form being rolled out across Grampian had the potential to quality assure services from a user's perspective It contained a number of review/exit questions which attempted to elicit their satisfaction with the service received. However, there were no mechanisms in place at the time of the inspection for routinely collating and reporting on answers.

The Action Team had made plans to improve the collating of service user's views and their place in informing planning and development strategies. On the whole, voluntary sector agencies seemed to be exceeding the rather modest commissioning expectation that they have "Service Suggestions and Complaints" in place. We saw service user groups influencing service delivery and had evidence that Aberdeen had undertaken surveys of service user's views.

The file reading results also showed good practice across statutory and voluntary organisations with regard to the sharing of information from worker to service user. Similarly, in over 90% of cases it was clear from the file that the views of service users were taken into account in care planning processes.

Experience of carers

All of the carers we met with in Aberdeen who used carer support services had found out about them as a result of a family member seeking help, and the carer having played a role in this. One in particular was clear that when his adult child had approached a service for help, the agency had invited him to be part of the help provided. Others spoke of their frustration at being perceived in this light, in what they felt was the absence of consideration of their needs. They all derived support from their involvement in carer support groups. Agencies in the voluntary sector, both drugs and alcohol, facilitated or hosted such groups.

We met with a carer who felt that she had had to fight for services for her son for many years. Problems resulting from his substance misuse were exacerbated by a medical condition, but she considered that there had been a very poor assessment of how these would impact on each other. She was supported throughout by her GP but felt frustrated that specialist health and social work services could not join up to properly support her son.

Recommendation 2
There is a recommendation for all three Action Teams about the involvement of users and carers in developing services in Chapter 6.

Experience of staff

We received seven responses from nine staff employed by Aberdeen City council substance misuse services. This number of responses was too small to provide statistically robust results, and the results were indicative only.

Of those who responded, the survey results for local authority staff in Aberdeen City were very positive but the picture was something of a mixed one in that both written comments in the survey and complaints and concerns expressed during the fieldwork sometimes contradicted these results.

Most respondents agreed that they enjoyed their work and felt that the work they did made a positive difference to reducing the harm associated with substance use and made a positive difference to the lives of people who used services and their families and carers. The survey results pointed to key motivators being in place - working in partnership with people who use services, their families and carers to achieve agreed goals; being clear about what they were expected to achieve in their job; and having regular training and development opportunities, often being involved in training and sharing good practice with staff from other services. The majority of staff agreed morale had been good in their team for the previous six months.

Partnership working

The results from questions relating to partnership working were positive.

In circumstances where adult service users had parenting responsibilities, all seven respondents agreed their team or service was proactive in the sharing of information for assessment purposes. Nearly all agreed that teams worked effectively with social work child care services where there were parenting/child protection concerns. This indicated that staff were aware of their obligations in this regard. However, in our local authority file reading for Aberdeen City (12 files) we found no initial assessments of the impact of parental substance misuse on the children where there were children in the household.

We were concerned about this and consider that managers should make sure that staff are familiar with Getting Our Priorities Right and the local guidance published in 2006 on the inter-agency sharing of information on children affected by substance misuse in Aberdeen.

Some respondents expressed concerns about how accessible their particular service was, with only three of the seven respondents agreeing it was easy for people to get access to the services their team provided, and about gaps in the range of services available. However, it was clear that staff felt that those who did manage to access the service achieved positive changes as a result. All seven respondents agreed that their team promoted recovery and routes out for people who use services.

All 7 staff who responded agreed they understood the role of the JADAT and most agreed the JADAT had effectively communicated its plans for substance misuse services in the Aberdeen area. However around half of the staff who responded disagreed that there was top-level commitment in health, social work and the voluntary/independent sector to work together to improve substance misuse services.

Around half of staff who responded disagreed substance misuse services were highly valued by elected members and by the NHS board.

Impact on community well-being

The self-evaluation questionnaire characterised this area as one "where there were a number of tensions", mostly resulting from communities - either geographic or of common interest - being frustrated by or attempting to circumvent resource constraints in substance misuse services, particularly drug treatment services. These could be communities of interest making a case for fast tracking to certain services, or by-passing the Action Team to apply for funding for an initiative or project. The self-evaluation questionnaire made reference to heightened tensions when development funding was available. We found evidence that such tensions did exist. While we found some evidence of steps being taken to proactively engage with communities on these issues, for instance in relation to the planning of new accommodation, these were not systematic.

We found widely acknowledged gaps in relation to engaging with the public on substance misuse services, on capacity building within communities, and the development of services to ameliorate adverse consequences for those communities. Local authority services had been in a protracted process of radically re-structuring their service delivery model into three neighbourhoods. A key objective was to put the information and the services in place to offer maximum responsiveness to local needs. It was acknowledged that substance misuse could lose out to those issues which seem to preoccupy the public more, particularly environmental factors. The 2004 household survey included data on reported neighbourhood disturbances involving drug or alcohol use. The rate for Aberdeen was marginally higher than the national average. The Action Team should re-engage with communities to ascertain the scale of the perceived problem and where best to deploy resources.

Aberdeen was using much of the same material - DVDs, board games - as elsewhere for awareness raising with young people on substance misuse issues. All school nurses were trained to use these materials, to complement the role of youth project and youth justice staff attached to schools. Schools routinely received drugs awareness input from the police and from a local voluntary sector agency. The management of alcohol-related incidents was to be made explicit in substance incident policy currently dominated by drugs.

Strategically, the Action Team was linked to the regeneration and community safety strategies. We were told that bringing the strategies together to develop more effective approaches required further work. While we found that there had been an over-emphasis to date on developing individual projects rather than sustainable capacity building, we were impressed by the reported impact of some of these initiatives. These included the work being done with young people, particularly in schools, and also those identified by police as being engaged in offending or anti-social behaviour which was substance misuse related.

We found that community safety planning and activity yielded positive evidence of strategic co-ordination and performance. The JADAT had set up a Criminal Justice and Community Safety sub-group, which worked at the interface of the Corporate Action Plan and Community Safety Plan. There had been a number of different strands of an overarching strategy to promote community well-being through the management of the night-time economy in the city centre. These strands included information and education, encouraging public houses to act responsibly to discourage irresponsible drinking, and practical public order measures such as marshals to help with ensuring that people had safe transport means to get home. Targets in respect of these had been met and these initiatives were to be extended. However, Aberdeen city centre had the highest number of public order offences in Scotland. We were told that senior police officers were concerned that too many licensed premises were partly to blame for this situation.

3.3 Key Processes

Aberdeen was in the process of a major redesign of services for people with substance misuse problems to improve their journey through the services. Steps were being taken to integrate services, and the ICDRS was having some success in providing a joint service, but other initiatives for integration were largely still at the planning stage. The integrated assessment and review tool was being used by some of the agencies, but not by all.

We consider Aberdeen's performance in this area to be ADEQUATE.

The journey of the service user and family through services

There was a useful "Guide to Services" for alcohol, drugs and sexual health in Aberdeen and Aberdeenshire. Aberdeen had a range of leaflets about the JADAT and about individual services. Information was also available on a JADAT website and websites run by Drugs Action and AACS. There was also a Helpline.

We found access to substance misuse services in Aberdeen to be varied. People seeking substitute prescribing services through their GPs were referred to nurses from the Fulton Clinic. Some GPs were content to prescribe methadone once the service user had been stabilised while others would not take back service users until CPN support had been identified. Some GP practices had CPNs attached to them while others did not. We were told that re-design plans had been developed to address this.

Waiting lists for CPN support from the Fulton Clinic were long. The Integrated Community Drug Rehabilitation Service ( ICDRS), a partnership of four voluntary sector services, Aberdeen City Council Social Work Services and the NHS, as commissioned, only took referrals from SMS and had regular referral meetings. However, this represented only a part of substance misuse services. The other main commissioned voluntary sector services took a mixture of self-referrals and referrals from other agencies, including GPs and social work care managers Those working solely with people with alcohol problems tended to have predominantly self-referrals. Referrals to some individual voluntary sector services also came from the Helpline, especially from sex workers and oil industry workers.

The percentage of people seen in under 21 days from referral to initial appointment dropped between 2004-05 and 2005-06, with particular problems in Drugs Action, with a 69% drop, and SMSGP services with a 57% drop. The CAP noted that "overall Aberdeen City is still faced with a bottleneck of people waiting to access services, particularly primary substitute prescribing". Waiting lists varied from service to service. We were told in a GP focus group that there was a wide variation in waiting times between practices depending on whether they were linked or not to SMS through the shared care scheme. Patients were known to de-register with non-linked practices and become "homeless" to jump the queue.

Waiting lists for the various services were currently being reviewed to exclude any 'double counting' of people who may have referred themselves or been referred to another service in the meantime and were now in receipt of a service We were also told that revenue funding was available for the appointment of three additional nurses to SMS as part of the plans for an Integrated Care Planning and Stabilisation Service. Their appointment had been delayed due to lack of identified interim accommodation.

Aberdeen was looking to the proposed Integrated Care Planning and Stabilisation Service, as part of an overall redesign of drug treatment services, to solve their capacity problems but we did not see clear enough evidence that this would suffice. The appointment of additional staff should take a significant number from the waiting list but the throughput of substance misuse services was small and demand was therefore likely to grow each year.

The plan to tackle capacity issues on an ongoing basis appeared to centre on the expectation that the ICDRS would extend, prescribing would expand, and that the role of the new service would be to stabilise clients who would then be passed to GPs for continued prescribing and ICDRS for other services. We saw no evidence of plans to extend ICDRS nor to expand prescribing and could not see how either would impact on initial referral rates to the Integrated Care Planning and Stabilisation Service.

Recommendation 3
Concerted action should continue to be taken to reduce waiting times and lists. As well as addressing capacity, Aberdeen should further consider redesign of services and set short-, medium- and long-term targets to reduce waiting lists.

Frontline staff told us that efforts would always be made to see people at least once as soon as they were referred. There was a standard protocol for prioritising referrals, but it was used with some flexibility to ensure that young single men were seen and were not always at the bottom of any list. Workers tried to keep in touch with clients by phone when they were on a waiting list. After two appointment letters with no response, people might be removed from the list (but not if they were under 18), though there seemed to be some flexibility about this.

All of the agencies delivering substance misuse services in Aberdeen City had their own files. We read 55 social work and 54 voluntary sector files. NHS Grampian conducted an internal audit of 88 of its Substance Misuse Service files, but this sample size was not sufficient to allow analysis at Action Team level. The results from the health file reading are discussed in Chapter 7.

We found that all of the social work files and three-quarters of the voluntary sector files contained an assessment. Seventy seven percent of social work files contained an integrated assessment while this fell to 12% for voluntary sector files. Forty six percent of the assessments in the voluntary sector files were rated as weak or unsatisfactory, while 75% of the social work assessments were rated as good, very good or excellent. Seventy nine percent of the social work and voluntary sector files had a care and treatment plan or equivalent and in 60% of cases this was being reviewed at regular intervals which reflected the level of need and risk. However, in cases where risk to the service user or others in the household was identified, only four of the 24 relevant files contained an up to date risk assessment and risk management plan.

Multi-agency and multi-disciplinary working and integrated, person-centred care

There was a Joint Future management structure in place for substance misuse services, with a single manager, co-location of social work care managers and SMS staff, and the development of specialist GPs. ICDRS was co-terminus with GP practices.Aberdeen City JADAT had received additional funding from the Scottish Executive to set up an integrated drugs services. However, at the time of our visit only the ICDRS could be described as operating in an integrated way. SMS staff, the specialist substance misuse social workers and ICDRS were using the latest draft of the integrated assessment and review form and it was a requirement to access Phoenix Day Care. The other commissioned voluntary sector providers had their own systems and expressed some misgivings about the integrated assessment and review form. Although there had been extensive consultation on, and revision of the form, they felt it was unwieldy and of much less relevance to alcohol than drugs. The JADAT planned for the integrated assessment and review form to be rolled out to all agencies, and commissioned services will be expected to use it as a condition of their service level agreements.

Recommendation 4
A Recommendation on assessments and risk assessments applicable to all three Action Teams is made in Chapter 6.

There was no shared IT system across the agencies. This hindered information sharing. Consent to share information was evident in significantly more social work files (67%) than voluntary sector files (42%).

We analysed the care and treatment plans in the social work and voluntary sector files to determine to what extent they evidenced integrated care around the individual's needs. We found that in approximately one third of plans this was completely or mostly the case, in a further third it was partially the case, while the remaining third offered no evidence of this. In significantly more social work files (91%) it was clear which agencies and professionals were involved, compared with voluntary sector files (67%). In only a third of all social work and voluntary sector files was there evidence of multi-agency working with clearly stated roles and responsibilities.

We found that none of 12 relevant social work files and one of the four relevant voluntary sector files, where there were children in the household, contained an initial assessment of the impact of parental substance misuse on the children. Furthermore only one of the nine relevant social work files contained a parenting assessment, while one of the four relevant voluntary/independent sector files did, an average across the city of 15%.

Recommendation 5
A recommendation applicable to all three Action Teams on working with families where there are substance misuse problems is made in Chapter 6.

Good Practice Example
The Integrated Community Drug Rehabilitation Service ( ICDRS), a partnership of four voluntary sector services, Aberdeen City Council Social Work Services and the NHS was a successful model of multi-agency working, with very clear expectations with regard to outcomes. Partner agencies worked together effectively to establish who should best deliver different parts of care plans and also positively influenced prescribing practice by SMS.

There were cross-referrals within the voluntary sector, but limited partnership working with GPs. GPs felt that there was a good working relationship between SMS and maternity services in the care of pregnant drug users.

There were multi-agency posts, such as those at ICDRS, and also a maternity post and a joint Families First service with Aberlour, focusing on early intervention. We observed a fortnightly case meeting where four cases showed evidence of good multi-agency working with all parties - SMS, ICDRS, CPNs, Foyer, etc. - communicating well with each other. There was a focus on forward planning with movement towards education or employment.

There was some confusion about how packages of care were co-ordinated - the role of care management. One view held by some staff was that there were barriers to holistic care because of difficulties of referrals within the service. There were only two social work care managers in the city. They did not attend clinical meetings at the Fulton Clinic, and we were told that nurses did not act as care managers. However, we were told that in practice there may not be any real difference between care management and co-ordination. One nurse whose practice we observed clearly saw his role as co-ordinating care packages.

Historically, services in the city seem to have developed separately, with the NHS being a provider and the local authority largely a purchaser of services. There appeared to be a consequent underinvestment in social work services. In addition the statutory bodies had independently commissioned services from the voluntary sector, with little reference to the JADAT. There was now the beginning of an integration agenda and an attempt to commission services jointly and strategically.

The involvement of, and partnership with, people who use services, their families and carers

Aberdeen City staff and managers stated that they felt they were "adequately effective in relation to work in partnership with people who use services". Staff were required to assess and consider the views of significant others in the integrated assessment tool and "there were no reasons why staff across all services should not be applying this". Although this aspect was not routinely or consistently performance managed, almost all of the social work and voluntary sector files we read contained evidence that the views of service users were taken into account. Eighty five percent contained evidence that service users were invited to attend decision making meetings and reviews.

Commissioned services were required to provide user feedback as part of their service level agreement, and quality assurance measures to monitor this were in the pipeline. Service users had had some involvement in the development of ICDRS, the proposed new drug treatment centre, and needle exchanges through a service user preference study. There had also been a recent survey of women in the sex industry to inform service delivery. Some of the services provided showed a good level of service user involvement.

Inclusion, equality and fairness in service access and delivery

The two aspects of access to service delivery which particularly disadvantaged individuals were different practices in how waiting lists were managed and the variation of experiences in individual GP practices. We were told this was being addressed through the GP Enhanced Service Contract, the Commissioning Strategy and through the service redesign to establish an Integrated Care Planning and Stabilisation Service. Current contracts specified an equal opportunities approach to services. The needs of some groups, such as offenders and pregnant women, had been targeted through commissioned services.

3.4 Strategic Management and Leadership

We found that the Aberdeen Action Team faced significant and complex challenges in responding to the comparatively high levels of substance misuse problems in the city. The scale and nature of the challenges required concerted strategic leadership from the Team, but we found that capacity at the most senior membership level was limited by a combination of wide-ranging individual responsibilities, change within organisations and change within the Action Team support structure. There was a lack of knowledge and understanding of the vision for substance misuse services among staff. The planning and deployment of resources did not match the spectrum of needs linked to substance misuse. We found that the Action Team did not yet model robust performance management to service providers. We found performance in this area to be WEAK.

Vision

The chair of the JADAT saw Action Teams as having four purposes - direction of strategy, allocation of resources, monitoring and management of performance and governance.

Aberdeen JADAT had aims and objectives for the treatment and rehabilitation of people with substance misuse problems. The overall aim was for services to move from being delivered on a 'functional' basis to being constructed around a central multi-disciplinary care process with three key objectives: stabilisation, moving on and moving out. Specific aims included the stabilisation or detoxification of individuals. The ultimate goal was to help them stabilise or become drug/ alcohol free. Other aims included reducing the risk of the spread of blood-borne viruses, improving the holistic health of individuals (mental health was specified), reducing involvement in criminal activity, improving people's personal, social and family functioning and helping people to move on through education, employment and housing opportunities.

We found a lack of consensus in Aberdeen about the vision for substance misuse services. Many staff we spoke to were either unaware of the vision, felt there was no shared vision, or that they had not been involved in shaping it. Some said that different agencies held different views about the way forward. The voluntary sector expressed concern about the lack of transparency of decision-making in the JADAT, particularly with regard to the allocation of resources. This had led to a lack of trust, and confusion about the role of the JADAT and its members. Some continued to see the JADAT as a forum for bidding for money rather than a forum for joint strategic planning and development of services. We considered that this limited its effectiveness, and the JADAT and its members should clarify their respective roles and responsibilities.

Staff we spoke to in focus groups from across the agencies felt that there was poor communication between the JADAT and front line staff and that their knowledge and experience was not taken into account in service planning and development. They were unaware of major developments, e.g. the new Community Alcohol Team. The Action Team chair recognised this.

Aberdeen City JADAT had two elected members and they were well informed about substance misuse services. However, other elected members were less aware of the JADAT or of the overall strategy for substance misuse in the city. The council had set up an elected members group called the Alcohol and Drug Task Group. It had a small budget of £50k per annum which it distributed to small local groups based on reports from officials. However, the councillors were not aware of where this fitted with the JADAT's strategic overview.

Aberdeen City Council had recently undergone an extensive re-organisation with the aim of delivering services on a multi-agency neighbourhood model. As a result of the re-organisation, responsibility for delivering on substance misuse objectives rested with several senior strategic posts in the council. The Head of Planning and Policy for Services to Adults had overall responsibility for planning and the Chief Social Work Officer ( CSWO) had specific statutory duties but no operational responsibilities. The re-organisation had led to a gap in key council representation on the JADAT, which required to be filled. The Chief Executive saw substance misuse as one of the eight priority areas for the Council. We think that if the Council is to be effective in delivering on this priority, they will need to make sure that they have relevant senior management representation on the JADAT.

Joint planning and development of services

Aberdeen's Community Plan (2001) prioritised "reduction of drug and alcohol use and the associated acquisitive crime" and stated it was a key goal. The plan made no specific reference to alcohol, but drugs were mentioned under Health and Social Care and under Safety. There were no specific targets under Health and Social Care, but actions included the DAT (now the JADAT) taking forward the drugs strategy, providing a spectrum of services from education and prevention to treatment and rehabilitation and raising public awareness of the risks of transmission of infection among drug injectors. Under 'Safety' there was a specific target to increase drug seizures by 25% by 2005 and to establish a DTTO scheme in 2001.

The most recent update on the Community Plan (2003-05) set out a number of key priorities for 2005-06 including the further development of Joint Future to include joint drugs and alcohol services. The update stated that detailed targets in relation to drugs and alcohol were contained in the Joint Health Improvement Plan ( JHIP) which was set to become the Health and Social Care Action Plan. Targets for 2005-06 included reducing drugs/substance misuse/dealing, along with a reduction in underage drinking. There were links to alcohol misuse in the plans for safer streets with recognition of the role of alcohol fuelled violence. The JHIP (2006-08) made a number of strong statements about the need to reduce the impact of substance misuse on communities. The CAP was set out around the Scottish Executive's national priorities. The Children and Young People's sub-group of the JADAT acted as a sub-group of the Integrated Children's Services Planning structure.

Although there were links between the high level strategic plans, there was room for greater alignment of strategies, especially in the light of the stated move towards neighbourhood service delivery.

Recommendation 6
There is a recommendation on strategic links applicable to all three Action Team areas in Chapter 6.

User and carer involvement in the strategic planning process was piecemeal. The chair of the Alcohol and BBV Forum attended JADAT meetings, and AVCO, which represented voluntary sector carer forums, also had a seat on the JADAT. The JADAT had supported initiatives at a service level to consult people using services on 'what works/worked' when developing services. Drugs Action had a forum for people using services, called Unite. They told us they had the opportunity to meet with the JADAT and had advised them that counselling services were urgently needed alongside methadone maintenance.

Commissioning arrangements

The JADAT had recently undergone restructuring and had put commissioning and performance management high on its agenda. Traditionally Aberdeen City Council had been a purchaser of substance misuse services rather than a provider. In order to make sure that future services for substance misuse were commissioned in line with the overall strategic direction, the JADAT was in the process of introducing a new joint commissioning strategy. It had plans for a pooled budget and a single point for service commissioning for drug and alcohol treatment and rehabilitation services (both statutory and non-statutory) in the city.

The new joint commissioning strategy was aimed at improving commissioning from the voluntary and independent sectors but NHS Grampian and the council were expected to adhere to the same principles of best value, standards and performance management. The strategy proposed putting in place an annual commissioning cycle led by an assessment of needs. Commissioned services would have a single contract and all commissioning of substance misuse services would take place through this structure. The JADAT would establish broad strategic objectives, and its Treatment and Support Services Sub Group would identify commissioning intentions based on these. The Joint Future Commissioning Team would then be responsible for selecting providers.

Council and health commissioning staff would undertake contracts, monitor compliance and feed performance information back to the JADAT. The JADAT would not support short term or pilot projects although they were exploring an Innovation Fund to enable projects which were part of a wider development and which generated learning to be supported. Currently services were commissioned in different ways and outcomes were not specified. The JADAT planned to review all its existing service level agreements in line with the new strategy.

We were encouraged by the plans which the JADAT had set out for the new commissioning strategy but we had concerns. Firstly, we were told that the council had just advertised for a Commissioning Strategist with a commissioning team to sit under the CSWO and it was not clear whether this would be a joint post with health.

In addition, there was a need for the JADAT to review the existing balance of services as well as commissioning arrangements. We found no clear rationale for the current balance of services or evidence that it was based on identified need. It was therefore not possible to say if this presented an appropriate range of service diversity or opportunistically developed services with duplication and gaps.

Recommendation 7
The JADAT should review the balance of services in Aberdeen to make sure they meet the current identified need in the city.

Range and quality of services

Aberdeen's substance misuse service was based at the Fulton Clinic and consisted of one consultant psychiatrist, two staff grade doctors, and 24 nurses, with two social work care managers attached. The health staff prescribed and detoxified, while the social work staff assessed and care managed and referred to residential rehabilitation. The CPNs held sessions in the majority of GP practices, including the Homeless Practice, as well as a number of specialist drug misuse clinics for target groups such as criminal justice, ante and post-natal services. A variety of voluntary organisations provided counselling, support and help in moving on. A Community Alcohol Team was planned.

A service to respond to the needs of psycho-stimulant drug users, INCITE, was set up in Aberdeen in 2003 as a pilot, with Scottish Executive funding. This funding came to an end in 2005, and the JADAT continued to support the project until 2006. Drugs Action, where the project was based, were to continue to support the project until May 2007. At the time of the inspection an evaluation of the service had been carried out, though not published. The JADAT was to put together a psycho-stimulant strategy to develop services to psycho-stimulant users.

The recently developed commissioning strategy was aimed at helping to address the opportunistic development of services. Some of the gaps in services identified by service users, staff and elected members, in our questionnaires and during the fieldwork, included residential rehabilitation, information about available services, the need for more preventative and throughcare services and counselling in localities. No alcohol detoxification was available in the community.

The JADAT's self-evaluation questionnaire identified a need for the dedicated social work resource to be increased and this was confirmed by senior staff on our visit. We considered there might be some tension about the strategic direction for the council into neighbourhood structures. The Council and the JADAT would have to work together to develop an appropriate balance of centralised and neighbourhood services

Aberdeen had faced difficulties over the years, due to the pressure of demand for drug treatment services. In order to address the current waiting list and capacity problems, the partner agencies had invested capital of £2.7 million for the construction of a new building to house the integrated drugs service in the city. Plans for a site had been agreed but planning permission had yet to be obtained and senior staff informed us it was unlikely to be open in less than three years. In the meantime they were setting up temporary accommodation and had identified premises. The aim was for every referral to pass through the same initial point for assessment. Stabilisation was the goal for health and social work services, while the voluntary sector (through the ICDRS) provided rehabilitation and routes out.

There were also plans for a Community Alcohol Team with a doctor, three nurses, two social work care managers and two voluntary sector support workers The Joint Future Management Structure for Drug Services was being adapted for the implementation of Alcohol Services. Two voluntary sector service providers, with support from JADAT, NHS Grampian and Aberdeen City Council, were undertaking a merger to form a new organisation, Alcohol Support Ltd. Staff and other stakeholders we spoke to during our visit seemed less aware of the plans for the Community Alcohol Team than for the Integrated Care Planning and Stabilisation Service.

We remained concerned that senior SMS staff were unable to articulate a clear long-term plan to address capacity issues, particularly of initial drug stabilisation services.

Residential detoxification and rehabilitation

Aberdeen did not have a residential resource for drug users but did have a dedicated homeless resource. The one residential service for people with alcohol problems also accommodated four designated places as an alternative to police custody.

The 2006 Care Commission inspection report on this service noted that a number of recommendations from the previous report had yet to be fully addressed. These were areas of critical importance to the safe running of the service, including accident recording and medication handling. A former recommendation had been strengthened to a requirement in the more recent report.

There was an unresolved issue about the up-grade of the accommodation to offer the choice of single rooms and en-suite facilities. The service had recently been re-structured to amalgamate with the advisory and counselling service. Discussions were on-going about the future configuration of the residential service, stalling progress on the up-grade.

This service was subject to joint commissioning. Contract compliance monitoring should include an obligation on the service provider to feed back any recommendations and requirements arising from an inspection report. It then becomes a shared responsibility to ensure that necessary steps are taken to address these with the timescales committed to in the action plan. These obligations required to be tightened up in Aberdeen.

Quality assurance and continuous improvement

Aberdeen City Council accepted that their performance management needed to improve. JADAT staff agreed that this was also so for the JADAT, and told us there was no performance management framework. However, they were setting local implementation targets in relation to the integrated service and shared care programme. Information collected through the use of the integrated assessment and review form could be used to help measure performance outcomes. In addition, performance against Corporate Action Plan objectives was reported at JADAT meetings through a traffic light system.

Management information

Aberdeen's SEQ stated "we have inadequate information systems in place in relation to IT and having systematic reporting from a practice, operational management and strategic level". It also noted that the NHSSMS had no systems in place other than paper records, making management information such as missed appointments, outcomes and other performance information un-reportable. Information from GP activity and Community Pharmacy was collected but not used systematically in the management of care. Individual providers had their own range of systems. They were developing a system for monitoring outcomes at a service level. Outcomes from the assessment tool were monitored monthly, and the ICDRS routinely collected quantitative information on numbers attending.

Recommendation 8
There is a recommendation for all three Action Teams on management information in Chapter 6.

3.5 Partnership Working

We found that joint working varied. Partners were not able to commit the time necessary to chair the JADAT. We recognised the difficulties involved for agencies in taking on this responsibility, but it raised questions about the priority given to the commitment to partnership working in Aberdeen at a strategic level. The recent re-organisation in the Council had also created a hiatus in representation. Voluntary organisations often felt excluded from decision-making processes. There had been only slow progress in moving to pooled budgets and the deficiencies in the contracting system were just beginning to be addressed. We therefore considered performance in this area to be WEAK.

Partnership arrangements

Senior officers in Aberdeen City Council were positive about the good well-established working relationships with other agencies, the strength to resolve problems and the energy and enthusiasm devoted to developing joint strategies for better services. In particular we heard about how the police had adjusted their command structure to reflect the new service delivery neighbourhoods.

However there were mixed views among stakeholders about partnership arrangements in the city. For instance, some felt that partnership working had been affected by the major organisational change in the Council as senior experienced staff had left, some of whom chaired the JADAT sub-groups. Some voluntary sector organisations were frustrated at not being equal partners and felt excluded from key decisions. Initiatives tended to be single agency based with the exception of the ICDRS and the proposed Integrated Care Planning and Stabilisation Service.

Although JADAT meetings were well attended, some spoke of a lack of continuity of membership and existing members did not feel able to take on the role of chair. The lay chairperson, once appointed, would be accountable to the chair of the CHP committee and the Chief Executive of the local authority. It would be the lay chairperson's job to manage the partnership working.

ICDRS had a well developed service structure and positive working relationships among its four partner organisations. There was a Management Protocol for partner agencies and the service coordinator met regularly with the chief executives of the partner agencies.

GPs generally felt partnership working arrangements with them were not adequately supported at a strategic level although they sometimes existed for individuals. Some felt strongly about the fact that they had not received the support from the Fulton Clinic that they believed they had been promised in the enhanced care contract.

The proposed Integrated Care Planning and Stabilisation Service was to be overseen by the Joint Futures Service Management Team. This included providing direct operational management on behalf of NHS Grampian and Aberdeen City Council to the service. A joint paper/case file system, joint policies, procedures, programmes and activities for working with service users, joint performance measures, quality assurance, evaluation and reporting systems, joint staff training and appraisal systems, jointly agreed financial reporting mechanisms, managed service level agreements and implementation of the move towards single shared accommodation as well as ICT solutions for integrated working were all part of this package.

Development and review of joint policies, procedures and protocols

The JADAT chair believed there had been a real partnership approach to the implementation of GOPR through the Children's sub-group. Working with Children and Families Affected by Substance Misuse in Aberdeen City: Interagency Guidelines, July 2006 was available in draft. Voluntary sector front line workers thought that 'Getting Our Priorities Right' had been responded to positively across the city. It had increased good practice between the people who used services, drug agencies and child care social work.

The Fulton Clinic had a practice of no home visits by nurses to drug users, as this was not seen as a good use of resources, given the demand for treatment. One member of staff told us that that this practice was based on a view that it was dangerous for staff. However, evidence could not be provided for this, and this was not a practice followed by health staff in other parts of Grampian. We were told that if deemed clinically appropriate, a home visit would be organised by the team. Risk should be assessed on an individual basis, following clear protocols.

Recommendation 9
The Fulton clinic should review its practice on home visiting by nursing staff to ensure that risk is assessed on an individual basis, and that resources are deployed effectively, based on clear agreed criteria. The assessment tool in use may be helpful.

Recruitment, deployment and development of staff

We were informed by nursing managers in the Fulton Clinic that all nursing staff in the SMS had responsibilities for both drug and alcohol services. A senior manager in the SMS said that all posts were advertised on a 75% drugs/25% alcohol basis. Staff were recruited to work in either drugs or alcohol, and the 75/25 split was notional, to ensure that if there was a requirement to cover clinics at short notice, staff would have a working knowledge of each other's remits. Managers suggested some staff still worked with historical remits. In our view staff should be supported to develop their remits and skills in line with the requirements of the service. We consider the fact that staff were allowed to continue working unchallenged with outdated remits and that managers seemed unaware of what their staff were doing indicated weaknesses in line management. Voluntary organisations tended to have separate drug and alcohol remits for historical reasons.

The lead nurse and other senior nursing staff received their supervision through fortnightly senior nurse meetings and G grade staff had appraisals once or twice per year. Junior nursing staff were managed by the senior nurses. There was a psychotherapist to whom all staff could go to discuss clinical or personal matters in confidence. This was not mandatory but it was encouraged The clinical nurse managers met occasionally with the psychotherapist to discuss themes which had emerged.

Social work care managers did not attend the team meeting at the Fulton Clinic, and were managed separately from health staff by the Team Manager, Joint Future Mental Health and Substance Misuse. Much of the role of the specialist social work staff seemed to be to undertake assessment for residential rehabilitation, including running preparation groups. We were told that the original rationale for having only two specialist substance misuse social workers was that other care managers would undertake less specialised substance misuse work. Senior council staff acknowledged that this decision needed to be reviewed and that direct provision needed to be increased. We thought it important that this decision was undertaken in the context of a review of the balance of services. Recruitment generally was difficult as salaries were higher in Aberdeenshire.

Recommendation 10
Aberdeen City Council should review the level and role of its specialist substance misuse social work service in the context of a review of the balance of substance misuse services across the city.

Although staff told us that training opportunities were available we found that access to training in the city for staff was uneven. Some had minimal training while others were undertaking accredited courses costing several hundred pounds. Some staff said there were courses available but it was difficult to access them when the service was short-staffed. Drugs Action staff felt they were encouraged to go on courses but other city staff did not share this view. Many staff said they would benefit from accredited cognitive behavioural therapy and motivational interviewing courses.

SMS offered a 12-week programme for hospital and social care staff, GPs and, midwives where they could spend one day a week at the Fulton Clinic. This was now accredited through the university. We were told that this had helped recruitment difficulties to substance misuse services but it had the drawback of creating vacancies elsewhere in the health service, notably in mental health.

Some staff raised safety issues with the inspection team, e.g. an alcohol voluntary organisation where female staff sometimes undertook counselling alone with inadequate safety precautions, such as no panic buttons.

Joint budgeting and use of financial resources

The JADAT had recognised that current financial governance was hampered by inadequate Service Level Agreements ( SLAs) and contractual arrangements. The council chief executive said there had been little progress on moving to pooled budgets as this required maintenance of two ledger systems. Progress had however been made in respect of alignment of budgets across the three new neighbourhood management areas.

However, substance misuse was being used as a 'pathfinder' for the Joint Future partnership with the aim of establishing a pooled budget. This will include Scottish Executive Action Team monies, a core amount from the JADAT, and BBV funds, plus the potential to include shared care funds, e.g. the sum allocated to pharmacists for the provision of supervised methadone which was currently held within the medical budget. The budgets to be pooled from the Council included the two social work care management posts, the purchase commissioning budget and lottery funding for substance misuse, but not the resources currently in Children's Services or Criminal Justice where governance for these will remain. NHS resources to be pooled included the SMS funding, GP and pharmacy contract funding and current commissioned services from the voluntary sector. However we saw no reports which contained agreed figures for the pooled budget and we were aware that pooling budgets was a financially complex exercise.

Aberdeen had received funding from the Scottish Executive to set up an integrated community drugs rehabilitation service, and had an underspend to 31 March 2006 in their CAP of £772,000. We were told much of this had been identified as the revenue budget for the new drug treatment and rehabilitation service and that it was underspent due to problems recruiting staff of the right calibre and a lack of accommodation for these staff. We were told that lack of accommodation was a serious issue. According to senior SMS staff, it would be at least three years before any new-build was complete, and at the time of the inspection, planning consent had not been granted. We were concerned that there seemed no sense of urgency about tackling this problem and that, as we identified in the previous section, there seemed to be no long-term plan to address capacity.

The Aberdeen Joint Alcohol and Drug Action Team ( JADAT) submitted its Corporate Action Plan ( CAP) for 2006-07 to the Scottish Executive in May 2006 and received feedback on the CAP in October 2006. Our review of Section F of the CAP, which gives details of drug and alcohol direct spend by partner organisations, noted the following:

• Drug Specific Spend - £2,176,000 of Scottish Executive funding had been made available to the JADAT during the period 1998-99 to 2005-06. The 2005-06 funding and actual spend had not been identified separately by the JADAT. In addition, a further £2,781,000 of funding was available from partner organisations of the JADAT for 2005-06. Some financial information in relation to this category was outstanding.
• Alcohol Specific Spend - £392,000 of Scottish Executive funding had been made available to the JADAT during the period 2004-05 to 2005-06. The 2005-06 funding and actual spend had not been identified separately by the JADAT. In addition, a further £480,000 of funding was available from partner organisations of the JADAT for 2005-06. Some financial information in relation to this category was outstanding.
• Combined Drug and Alcohol Specific Spend - there was £105,000 of Scottish Executive funding made available to the JADAT for use in 2005-06. In addition, a further £257,000 of funding was available from partner organisations of the JADAT for 2005-06.

Recommendation 11
There is a recommendation on financial issues for all three Action Teams in Chapter 6.

3.6 Capacity for Improvement

The evaluation of capacity for improvement is based on three key factors: demonstrable improvements in outcomes for people who use services, quality assurance and performance management, and the effectiveness of leadership at all levels in health and social work services.

Aberdeen had a serious problem in relation to the large waiting list for people to gain access to prescribing services, and waiting lists for some other services. Plans to resolve this were at an early stage and we did not have confidence that the JADAT and its constituent members had strategies in place to address this quickly. Services for the treatment and rehabilitation of people who misuse substances were in the process of a major redesign. We recognised improvements in developing some aspects of an integrated service, but there was still some way to go for there to be an integrated service for the city. Changes in the structure of the Council services, particularly the place of social work in planning and service delivery, and proposed changes in the leadership of the JADAT, as well as uncertainty about the timescale for important new developments such as the Integrated Care Planning and Stabilisation Service, added to uncertainty about the future of substance misuse services in the city. Attempts to develop performance management of services were also at an early stage.

Factors which would underpin and support positive change were identified. It was clear that senior staff in the Aberdeen area were aware of much that needed to be done to improve services, and had begun to initiate a major redesign of services. There was evidence of improving outcomes for those in treatment. The appointment of a team leader for the JADAT team, the beginnings of joint commissioning, the good start made at integrated working by ICDRS, and the recognition by social work that more specialist social work staff were needed, were all promising. The capacity for improvement was therefore ADEQUATE.

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