The Scottish Government

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Section 1 - Background discussion and evidence

1.1 Introduction and context

1. In 2007 the Scottish Executive published reports on the role of methadone in drug treatment (1,2,3). These concluded that replacement prescribing with methadone should remain a main plank of the Scottish approach to opiate dependency. The reports also highlighted challenges for services if medical treatments were to achieve optimal outcomes. There was a need for Scottish strategy to become more aspirational and for service providers to become more systematic in delivering integrated person-centred services that had the capacity to address a full range of substances as well as the range of psychological and social aspects of life impacted on by problem substance use. Care and treatment needed to become a partnership between service users and agencies with the aim of achieving recovery.

The methadone reports were welcomed at the SACDM meeting on 11 May 2007. SACDM requested that further work be undertaken to advise on the additional services required to improve outcomes. The SACDM Integrated Care Project Group was asked to take this forward and commissioned a time-limited multi-disciplinary working group to: consider the range of services required to maximise effectiveness of care, treatment and recovery; identify the potential challenges faced in delivering comprehensive services in Scotland; and make recommendations aimed at overcoming these challenges. The working group was to report in December 2007.

This paper is the result of this work. It has been prepared by a diverse group of professionals involved in the commissioning and delivery of care, treatment and rehabilitative services for those experiencing problems associated with the use of substances in Scotland. A list of contributors is included in Appendix 1.

The report was commissioned to inform the debate regarding how best to ensure that care and treatment is delivered to the highest quality and achieves the best possible outcomes. This must include the opportunity for all those suffering from problem substance use to access a full range of services that not only effectively reduces harm but also maximises recovery, facilitating a return to mainstream society. The paper aims to be pragmatic and realistic but is also aspirational. It forms a coherent consensus regarding the strengths and weaknesses in current care and treatment in Scotland, clarifying what services should be aiming to achieve and what additional service elements and processes may be required to maximise effectiveness. It concludes with recommendations to Ministers outlining key actions for the Scottish Government, local commissioners and services.

The Challenges

Services to address problem drug use have developed greatly in the last 20 years. In the 1980s developments were driven by concerns regarding blood borne virus ( BBV) infection - particularly HIV - in intravenous drug users, resulting in adoption of a national policy of 'harm reduction' (4). This brought concepts such as needle exchange and replacement prescribing with methadone into mainstream policy (5). The 1990s saw harm reduction extended to include social behaviours - in particular the relationship between treatment and reduced criminal activity. In this context Scotland has seen significant increases in funding of services over the last 10 years with the main aim of policy being to bring more people into treatment and engage them in approaches which reduce harm (6,7,8). The result has been a massive growth in the numbers of people - mainly opiate users - in contact with services (9).

This apparent success is tempered by the lack of detailed information currently available regarding how successful these programmes are at achieving reduction in drug-related harm or promoting recovery. Until now services have seen their main 'outcome' as attracting users into services and retaining them. Despite clear guidance on care planning and review processes, few services record information about outcomes achieved, progress against agreed treatment goals or successful rehabilitation (2). Services may not be emphasising recovery - instead engendering a culture of dependency on the services themselves. Some services may even resist service users' requests to explore other approaches to recovery such as detoxification or residential rehabilitation, reducing opportunities to progress. In some services staff can find themselves dispirited and may lower their expectations of service users (3). Service users may find themselves caught in an environment that is not able or willing to share with them the struggle and risk associated with breaking away from their problem substance use. In this context, our systems of care are not achieving a high degree of engagement. Scottish services saw 13,781 new attenders in 2005-06 but also classified some 8000 cases as 'unplanned discharges'.

Services should be enabling those with problem substance use to live as meaningful and satisfying lives as possible. There are many paths to well-being and recovery and a person's attempt to deal with their substance problem is a unique and personal process. It is important that a full range of high quality services is available for all at the point of need. We must create a continuum of care which balances the undisputed need to reduce the harm associated with problem substance use while maximising the opportunity to return to normal lifestyles and activities whenever this is realistic. Recovery may not mean abstinence. Scottish services must demonstrate that they achieve improved outcomes for people. The complexity of substance users' problems should not be accepted as an excuse not to pursue recovery.

In summary: The challenge

1. A range of services, additional to medical treatment services - essential services - are required in any area to promote recovery from problem substance use.

2. Local systems of care treatment and rehabilitation must meet the identified needs of individuals and recognise that harm reduction and recovery form two aspects on the same continuum. The continuum contains all those aspects of care that will support people who use substances to improve their well-being and minimise harm to others.

3. Recovery may not mean abstinence.

4. People must have access to a full range of support and care options to meet their assessed needs - whatever the substance they use or the severity and nature of the problem they experience.

5. Any problems faced by the individual substance user cannot be seen in isolation from their family, local community and society.

1.2 Philosophy of care - a recovery focus

Exclusion, risk and personal aspirations

People who have problems with substance use are some of the most socially excluded and high-risk members of our society. When compared to mainstream society:

• They are more likely to experience significant mental illness
• They are more likely to suffer a premature death
• They are more likely to be homeless
• They are more likely to be unemployed, often having failed to complete their education
• They are more likely to have criminal justice involvement
• Women are more likely to die in childbirth, to have low birth weight babies and to experience family planning problems
• They are more likely to be the subject of concerns regarding the welfare of their children

It is important to recognise, however, that problem substance users share their general life aspirations with other members of society. In response, local commissioners must ensure that everyone has access to essential care, treatment and rehabilitation services which recognise this. Holistic assessment needs to take cognisance of the person's family, children, education and employment, housing and legal position and their aspirations around these areas. Health care interventions may be an integral part of the care package and access should follow a full clinical assessment covering physical, mental, sexual and reproductive health, diet and dental health. Parental substance use does not always preclude the possibility of effective parenting. However, in order to minimise the potential harm to both the unborn and any children, services and professionals involved with people with problem substance use should pro-actively encourage the discussion of contraceptive needs and plans for children. Medical and social treatments of substance use will increase fertility. All of these aspects of an individual's life must be regarded as essential areas to be addressed in all care packages.

Reducing harm - but limiting recovery? The case for change

In response to the perceived nature of problem substance users, many services have developed approaches which fail to maximise potential. These services can make service users into passive recipients of interventions which are organised, not around their hopes, wishes and aspirations, but around the needs of services to develop systems which meet high levels of demand and manage risk. This approach is rarely person-centred. Services should have higher expectations of the users' ability to overcome problem substance use, rather than settling for a process which engages them in contact with treatment services for long periods. This approach is not wrong in itself. Problem substance use is a long-term chronic relapsing condition and many struggle to ever overcome it. Evidence shows that 'retention' is associated with positive harm reduction outcomes and attempts to remove oneself from problem substance use within existing treatment approaches can be unsuccessful or hazardous (10). However, focusing only on the user's attendance and ability to work with professionals may limit expectations and could prevent recovery and re-integration into the community. It may serve to prolong people's drug using careers, so that being a problem substance user becomes akin to a lifelong identity. This may limit problem substance users from reaching their full potential.

It is inevitable that some professionals in the field will see a move towards recovery as a move away from harm reduction. This is not the case. Introducing recovery into the care of problem substance users does not in any way dilute the need to support efforts to reduce harm. Instead, such an approach could increase the effectiveness of activities focussing on harm reduction. Staff and service users would plan their work together and would alter their focus over time as a partnership based on the user's changing circumstances. Plans would be the product of an active process between service and user that is likely to increase engagement with the process and commitment to the agreed outcome. Recovery and harm reduction are not mutually exclusive but part of the same continuum.

A fresh approach? What is recovery?

Problem substance use is a chronic condition characterised by relapses which users must learn to manage or minimise to maintain their recovery. Evidence for the effectiveness of relapse-prevention approaches can be found in the alcohol literature (11). This reflects the fact that, in the absence of an easily delivered medical [methadone-like] solution, the approach to alcohol problems has remained a pragmatic attempt to balance medical, psychological and social influences on problem behaviours, with reliance on the development of a person's own abilities at the forefront of their care.

Recently, lessons have been learned in the fields of mental health and learning disability, shifting care from a passive model to one regarding those being helped as active participants with services facilitating their recovery. By using this approach it is possible to change the providers' and service users' beliefs in their ability for self direction. This approach implies that people can develop strengths and skills in the face of the challenges they encounter when dealing with the chronic relapsing nature of their problem. Part of believing in their own recovery is 'believing it can happen for you' - being optimistic that they can recover. It may also help to be in contact with others who believe recovery is possible. Recovery represents a significant paradigm shift in thinking towards different groups throughout Health and Social Care. Why shouldn't individuals with drug problems become part of that change?

Currently, there is little objective evidence to support this approach in the field of problem substance use. In light of the mental health experience, it is, however, reasonable to conclude that similar approaches to recovery may be useful in this area. In some areas of Scotland, specialist nursing teams in problem substance use are being trained and developed in the recovery approach as part of the national recovery programme.

Approaches to Recovery in Mental Health - United Kingdom

In the report A Common Purpose: Recovery in Future Mental Health Services written jointly by the Social Care Institute for Excellence, The Royal College of Psychiatrists and The Care Services Improvement Partnership (12), the concept of recovery is described as:

'having very broad applicability to many domains of life where people struggle with long-term conditions that may not be particularly responsive to treatment measures. This shifts from an exclusive focus on the problem, to the person struggling with and learning to cope with and manage the problem. Recovery is significantly about recovering an emphasis on the relationship people have with their problem as a counterweight to the endemic tendency to see people defined as and by their problems'.

The report describes common themes in recovery, including:

• the pursuit of health and wellness; a shift of emphasis from pathology and morbidity to health and strengths;
• hope and belief in positive change; service supports reconceived as mentoring not supervisory;
• social inclusion (housing, work, education, leisure);
• empowerment through information; role change; and
• awareness of positive language-use in framing the experience of illness

Approaches to Recovery in Mental Health - United States of America

The report Transforming Mental Health Care in America, Federal Action Agenda, identifies the 10 'Components of Recovery' as being: self-direction; individualised and person centred; empowerment; holistic; non-linear; strengths-based; peer support; respect; responsibility; and hope. It states that, crucially, 'at times and places where doctors are more optimistic about the possibility of recovery, recovery rates appear to be higher' (13).

Approaches to Recovery in Mental Health - Scotland

In Scotland the fourth key aim of the Scottish Government's National Programme for Improving Mental Health and Well-being is 'to promote and support recovery' ( www.wellscotland.info). The Scottish Recovery Network ( SRN) is funded to work towards this aim by the National Programme ( www.scottishrecovery.net). The Network is working to raise awareness of the fact that people can and do recover from even the most serious and long-term mental health problems. To support this it is working to learn more about the factors which help and hinder recovery directly from people's lived experience and to consider the implications for people who experience mental health problems and those who support them.

New Scottish research on the recovery experience suggests that 're-finding and re-defining a sense of identity and self-confidence that has potentially been eroded by institutionalisation or ill health was often the first step on a recovery journey' (14). The importance of narrative inquiry as a method of research and support for recovery has been described. People can learn what may help them to recover from a person telling their own story (15).

How can we apply recovery to the field of substance use?

A Common Purpose: Recovery in Future Mental Health Services states that 'new ways of thinking and working will only flourish in a sympathetic policy and funding context. This supports innovators and gives a rationale and resources to others to take up these new ideas and practices. In fact recovery is wholly congruent with the current direction of government Health and Social Care policy'. The Scottish Government supports many policy areas where the ideas inherent in recovery are becoming apparent. The National Quality Standards for Substance Misuse (16) describes the importance of service user involvement. To demonstrate compliance with the Quality Standards, service providers and commissioners must demonstrate that any service provided meets the needs of the intended target group. This is further clarified in the recently published Service User Involvement Manual (17) which defines user involvement as 'The active participation of people who, because they have used services, can bring their knowledge and experience to contribute to the design, planning, delivery and evaluation of services at a local, regional and national level'.

Where could we start? First steps

In Scotland, we have tried to incorporate service user participation and involvement in service design and in giving feedback on policy initiatives. This has only provided isolated pockets of success. Substance users often remain on the margin, at worst passive and increasingly involuntary recipients of treatment, with limited hope of achieving the real change in their situation many are seeking. We need to explore any opportunities there are for changing this picture. We can use lessons learnt from the recovery movement in other fields to refresh our strategy towards working with substance users. Adopting an approach which emphasises the strengths and abilities of people with substance use problems, while harnessing and learning from their lived experience, could go a long way to challenging expectations and promoting better outcomes.

What would this mean for care, treatment and rehabilitation services?

The recovery movement has adopted a set of indicators by which people can assess whether services are moving towards a recovery orientation. These indicators include a leaning towards: less coercive services; increased self management of treatment; and greater participation in their own treatment on the part of individuals (18). Partnership and respect are key features and this should be reflected in the treatment environments and services provided. Services should be coordinated to meet the wide range of issues affecting people with problem substance use. These should be available in a range of settings as required. There should whenever possible be a choice in terms of what services are available and who provides them. Systems should be in place to facilitate coordination and evaluate effectiveness. Further information on what can help and hinder recovery from the mental health recovery field is included in Appendices 5 and 6.

In summary: Philosophy of care - a recovery focus

1. Problem substance users are people with considerable needs and risks.

2. Services have developed a service-led culture to manage demand and risk which promotes a passive response from service users - not a person-centred culture which puts the users' aspirations and recovery at the centre of care.

3. Services for substance users must be designed to engage users in their own process of recovery. This means actively involving them in all aspects of service design, delivery, planning and evaluation.

4. Lessons from mental health/learning disability may facilitate this culture change.

5. Harm reduction is part of the continuum of care. It is not an end goal. Recovery is part of the same continuum.

1.3 Maximising the delivery of essential services

1.3.1 Principles - A consensus - the principles of service delivery

The delivery of comprehensive services that meet the range of needs experienced by problem substance users must be underpinned by the following principles.

1. People with substance use problems, in common with society, have aspirations to have healthy and happy families and to experience fulfilling lives. Disadvantage, poverty and social exclusion are closely aligned with problem substance use. Services to improve health and well-being must reflect this.

2. Services must acknowledge the stigma associated with substance use. It is their duty to challenge it.

3. Recovery must become the focus of the care available for problem substance use rather than an ideology which advocates any particular type of treatment. Recovery encompasses harm reduction and abstinence.

4. All services and commissioning partners must put service users at the heart of their activities. Person-centred approaches must underpin all services.

5. All services provided to people with an alcohol or drug problem should be accessible to individuals regardless of their race, religion, gender, gender identity, sexual orientation, disability or age. Local governance and accountability processes must ensure this national drive is translated into local, effective service design and delivery.

6. Assessment must address the totality of peoples' lives. Recovery plans must therefore address a full range of social issues including housing, education and working aspirations, legal difficulties and health improvement. There should be regular formal review of progress.

7. All people with problem substance use must have access to the same services as everyone else - this includes the right to be registered with a GP and to access primary health and social care services. Services must take cognisance of the full range of substance users' needs.

1.3.2 Commissioning of services

We have described the change of emphasis that would be required to develop a more recovery focused approach to problem substance use in Scotland. Such a paradigm shift would require a systematic approach to the commissioning of services.

'Commissioning' is 'the strategic activity of assessing needs resources and current services and developing a strategy to make best use of available resources to meet identified needs'. Recent guidance to Drug Action Teams ( DATs) lists responsibilities which may help define the terms of reference around joint commissioning. This comprehensive list includes: working in partnership; developing and gaining commitment to strategies; achieving local change; needs assessment; strategic planning; contract setting; contract monitoring; quality assurance; and leadership (19). In the current document, commissioning reflects this broad definition.

Core components of the commissioning process

Commissioning must be underpinned by the core components of needs assessment; governance and accountability; data exchange; and outcome measurement and be inkeeping with European Union Procurement Law.

Needs Assessment - How do we know what is needed?

Each area (Alcohol and Drug Action Team ( ADAT) or otherwise defined) should undertake a regular needs assessment based on a recognised format. Guidance regarding process is available nationally (19). Support, advice and information will also be available from local partners and Information Services Division ( ISD). The needs assessment must explore prevalence and nature of substance problems in each area. Ideally this would include surveys of relevant populations. It should look at what arrangements are in place to address local issues and the level of unmet need. The process of identifying need has to include all those who are affected by substance use - including families and communities. This process goes beyond simply seeking endorsement for decisions already made to deliver particular service provision.

Provision of specific interventions in the area should be based on the identified need. The range of possible interventions delivered locally and supported by public funding must be based on the evidence available. Areas will choose from appropriate evidence-based interventions. Exceptions could be made for short-term pilots that are subject to a process of objective evaluation. The needs assessment for each area should also include information on local workforce recruitment, retention and development needs and proposed solutions. The effective provision of any of the interventions detailed below is wholly dependent on having a competent, supported workforce able to deliver all relevant interventions. When appropriate, this should include those who have had substance problems in the past.

Governance and Accountability - How do we know if we are making a difference?

All services in receipt of public funds should have a written, published service specification and explicit contract monitoring process. There is a need to demonstrate effectiveness. The responsibility of service providers, commissioners and national bodies and the nature of decisions regarding how services are established, who manages services and how they are monitored must be transparent and explicit. Services must demonstrate the active, on-going involvement of people with substance problems, including involvement in the management, regulation, inspection and audit of services.

Data Exchange - How we measure what we do?

There should be a commitment to collection of standardized data for analysis based on a nationally agreed, ideally web-based, core minimum dataset. Reports could be provided to local commissioners and service providers on a regular basis to inform needs assessment and on-going outcome reporting.

Reporting on Outcomes - What is the result?

High level national outcomes for care, treatment and rehabilitation services are being developed by the Scottish Government. These should be supported by locally relevant detailed outcomes. Reporting should be standardized and available to all stakeholders including service user and carer groups.

Operational delivery - primary requisites of effective care

The core components described above are linked to elements of the care process - primary requisites of effective care.

Where an individual seeks help regarding their substance use the service should undertake to ensure the following elements of care are in place. In order to be effective these elements require active participation and involvement of both the individual service user and those employed by the services. This process is one of facilitation. These elements include: initial assessment of need, with timetable for ongoing review of the individual and family needs; allocation of a named person to coordinate the response - key worker/care manager/care coordinator; agreement of a written plan; agreement of a recorded review process; clear documented care pathways for all essential services; and published information sharing protocols among all essential services.

Essential services - key aspects of service provision

Underpinning both the core components and the primary requisites of effective care are the key aspects of service provision. These key aspects form a description of what should be accessible to those individuals and families who have a problem with substance use problems in each commissioning area of Scotland. In each area it is essential that ADATs and their partners have in place arrangements to access a full range of interventions. In developing this range of services it is also important to reiterate that the process of needs assessment and commissioning must ensure that services are available for the full range of substance use problems encountered locally (not just opiate dependency) and are capable of offering tailored care to those whose problem is at different stages of severity and risk. In such circumstances it is clear that the range of services required or prioritized may vary from area to area. It will be important for ADATs to demonstrate that their service priorities reflect the issues identified in their local needs assessment. The list is not prescriptive regarding delivery. Some key aspects may be delivered by one agency or from shared premises as appropriate. However, it is essential that equity of access to services across Scotland is assured. This list reflects the minimum range of service options expected in any ADAT area.

Substance focused services - available locally

Some services should be available in all areas and efforts should be made to make them easily accessible for service users. These will include: direct access service/street level agency; needle exchange; specialist harm reduction services; structured 1:1 work/counseling and structured group work - to address commonly-occurring issues such as sleep problems, anxiety disorders, understanding relapse and relapse prevention, improving confidence and self-esteem; psychological therapies - including behavioral and cognitive behavior therapy ( CBT) approaches; solution focused therapy; specialist psychological and psychiatric care; substitute prescribing; supported self-detoxification; medicated detoxification; community rehabilitation programmes; specialised employability programmes; specialist services for young people with substance problems; and signposting or facilitated pathways to other services.

Substance focused services - available regionally

Some specialist services may be more appropriately commissioned on a regional, national or partnership basis. These would include in-patient detoxification programmes and residential rehabilitation.

Essential Services not specifically substance focused

As well as specifically commissioned services which have their focus on the substance use problem, all areas must be able to facilitate access to a range of 'generic' services. These may be provided within specialist substance misuse services or by generic mainstream services depending on local circumstances. ADATs/partners should monitor these services in terms of their quality, attitudes and accessibility when dealing with those people experiencing problem substance use. These include: primary health care - access to a GP and a dentist; child care support; housing support and advice; employment and training support; financial advice and support; reproductive health information, advice and treatment; family planning; BBV prevention, testing and access to treatment; clinical psychology and mental health services; social work services; and legal services.

In summary: Maximising the delivery of essential services

1. Areas must consider the principles of service delivery when planning services.

2. Commissioning of services involves the assessment of needs resources and current services, and the development of a strategy to make best use of available resources to meet identified needs. The involvement of service users is essential to effective commissioning. Service users can be involved in different ways at different stages.

3. The core components of this activity are needs assessment; governance and accountability; agreed data exchange systems; and outcome measurement.

4. The primary requisites of effective care include needs assessment; review processes; a named person to coordinate care; a written plan; clear documented care pathways; and published information-sharing protocols among all essential services.

5. The key aspects of service provision lists the types of service provision required in each local area.

6. ADAT areas must ensure a full range of services are available - either locally or through regional/national arrangements.

7. 'Generic' service elements should be monitored regarding availability, quality and attitudes.

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