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Chapter 6: Recommendations Which Apply to all Three Action Teams
Recommendations about several issues of some importance applied to all three Action Team areas. These were outcome and performance measures, the involvement of users and carers, children affected by substance misuse, the use of integrated assessments and risk assessments, strategic links, financial arrangements and management information. These recommendations did not necessarily apply to all three teams equally, but we considered them important enough and general enough to recommend that all three teams take action on them. Benefit might be gained from Action Teams working together on these issues. They are listed below.
Outcome and performance measures
The Scottish Executive has set a number of national priorities for Action Teams, some of which have specific targets, not all of which are outcome based, for example reduction in waiting times and numbers of drug misusers in contact with services. Each Action Team has a performance contract with the Scottish Executive, and we have commented on their performance in relation to this in previous chapters, most of the information for which was drawn from the self-reporting in the CAPs and the Drug Misuse Scotland database. We found it difficult to provide an independent evaluation of performance in relation to key outcomes across all three areas as the quality of performance information was not good, a position recognised by the Action Teams themselves. Many performance indicators were process or output rather than outcome based, and gaps in information hampered the making of meaningful comparisons over a number of years. The replacement of SMR 24 with SMR 25 in April 2006, which improved collection of information on clients attending drug services, and in time for follow up information on clients' drug use and other circumstances, further complicates matters in the short term.
All three Action Teams were aware of the need to define and agree a set of outcome measures. We invite them to consider developing a set of shared outcomes and performance measures across NHS Grampian and Grampian Police as well as a set of local outcomes and performance measures to reflect local priorities.
Recommendation 1
All three Action Teams should continue the work they are doing to develop and agree local outcome and performance measures and develop systems for collecting and analysing information to monitor performance against them. They should do so jointly rather than independently. The Scottish Executive should work with Action Teams to develop appropriate local outcome and performance measures.
Involvement of users and carers in developing services
While involvement of service users varied in the three areas, generally they did not feel engaged in developing services which would help them. The Forums are one way in which their role might be strengthened. Carers were noticeable by their absence in most planning processes, perhaps in part because of their reluctance to be identified, but their involvement should be encouraged.
Recommendation 2
NHS Grampian and the three Action Teams should review the role of users and cares in developing services, and create ways in which they can become more involved. The Action Teams should review the role of users and carers in the Action Teams and Forums.
Integrated assessments including risk assessments
We found that while the integrated assessment and review form was in use by many health and social work staff, this was not true of all, and not true of most voluntary organisations staff across the three Action Team areas. There was some concern about the length of the document and its relevance to alcohol services, and indeed to voluntary sector services, some of whom said they would not use it. It would undoubtedly benefit service users for an integrated assessment framework to be in use across substance misuse services, and consistent and universal use of the assessment form would provide a useful tool to inform performance and future service planning. We have expressed concerns about risk assessment in previous chapters, and it is important that the form includes a section on risk assessment, that staff in all agencies are trained in its use, and its use is monitored.
Recommendation 4
All three Action Teams and NHS Grampian should ensure that the integrated assessment and review form for substance issue is rolled out across Grampian, that it is used by both health and social work staff, and that voluntary organisation providers are also brought on board. This tool should include a risk assessment section, and use of this should be monitored carefully.
Children affected by substance misuse problems
The three Action Teams, and the NESCPC had developed a useful document, 'A Framework for Reducing the Harm to children affected by parental drug or alcohol problems', and staff we spoke to in all agencies seemed to be aware of the importance of this issue. However, in our file reading we had concerns that staff were not always assessing the impact of parental misuse on children and appropriate action was not always taken when problems were identified.
Recommendation 5
All three Action Teams should ensure that staff who work with families where there are children are trained in screening for the impact of parental misuse on children, and in collaborative assessment procedures where this is necessary. This should be monitored by senior staff managers to ensure any risk to children is identified and appropriate action taken.
Strategic relationships
We recognise the difficulties partners have in connecting strategic developments in the field of substance misuse through the agencies and the plans these agencies develop individually and in partnership. DAATs have particular problems in relation to the accountability of constituent members. One senior staff member told us that "the Action Team works by persuasion". Another spoke of "the myriad of circles and interactions". Other senior DAAT members spoke of the lack of clear guidance from the Scottish Executive on the role of DAATs and of how they were often reacting to directives from the Scottish Executive, with a variety of funding streams, sometimes short term, to contend with. At the time of our inspection the Scottish Executive stocktaking exercise was still in progress. The DAATs were also in an environment where CHPs had recently been introduced, influencing the health component of substance misuse policy and services. Some local authorities, such as Aberdeen, were restructuring services such as social work education and housing, which have a significant part to play in responding to the needs of people with substance misuse problems.
NHS Grampian, the three CHPs, the three local authorities and the three Action Teams have to work together closely to deliver improvements in substance misuse services through the implementation of the various plans, such as CAPs, Community Plans, Community Safety Plans and Health Improvement Plans. While all three Action Teams were working to develop integrated planning and service delivery, we found that the three Action Teams had some way to go to be able to deliver on these. Consideration should be given to formal and agreed reporting mechanisms from the Action Teams to NHS Grampian, the CHPs and the local authorities.
Recommendation 6
All three Action Teams should continue to work to develop and improve strategic links through relationships between strategic planning groups and the integration of substance misuse issues into appropriate plans. Reporting mechanisms from the Action Teams to the partner authorities should be agreed.
Management information
The three Action Team areas identified the difficulties in gathering and sharing information which could be used to improve joint performance. Different IT systems and reporting mechanisms contributed to this. All three Action Teams had recognised the importance of developing better management information systems, but had some way to go to providing effective systems.
Recommendation 8
All three Action Teams should continue to develop management information systems to enable the appropriate sharing of information and the joint identification of performance information and unmet need. This information should be used to inform key planning and decision-making processes in the Action Teams.
Financial management
The three Action Teams differed in their approach to the collection and presentation of financial information, and there were inconsistencies, even in their submissions in their CAPs. These differences made it difficult to monitor effectively the use of funds by each Action Team. We did not have the capacity to examine this complex issue in detail, but all three Action Teams recognised the need to improve joint financial governance, including the need to clarify contractual arrangements with the voluntary sector, which provides many of the services, particularly in Aberdeen. They had already begun to take steps to do this.
Recommendation 11
The three Action Teams should continue to review their financial governance and put in place processes to enable them to improve their capacity to monitor and review spending on substance misuse in their areas.
Conclusion - The three Action Teams operated separately, and for many issues this was entirely appropriate. However, they should take the opportunity to use the above recommendations to work together in areas where we have expressed concern about the need for improvement in all three Action Team areas. One way to improve joint working would be for Action Team chairs and co-ordinators to meet regularly to discuss areas of common concern and learn from each other's problems and successes.
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