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Section 3 - Recommendations
The following recommendations aim to put in place obligations for national and local strategic bodies to ensure that local providers improve access to services promoting recovery from problem substance use. The response to these recommendations will be led at national or local level.
Clearly all national recommendations will also include local implications for action. These will be particularly relevant to local commissioning partnerships and service providers. It is hoped that the Scottish Government's response to these recommendations will take into account the need for robust governance and accountability processes highlighted in the 2007 ADAT review as well as the national quality standards and other key governance documentation relating to professional practice in this field.
Section 1 - Background discussion and evidence
National recommendations
1. In its strategic approach to problem substance use, the Scottish Government should develop and introduce governance and accountability processes which scrutinize local performance in terms of both reducing harm and promoting recovery. These processes must ensure that all elements of care which may be required to support recovery have in place agreed contractual levels of activity and performance monitoring - including relevant outcome measurement.
These governance and accountability processes could be delivered through a national quality improvement unit working in association with reconstituted ADATs.
2. In its strategic approach to problem substance use, the Scottish Government should require that all areas demonstrate the local availability of a full range of the essential interventions listed in this document and that service providers are engaging service users in approaches aimed at promoting recovery.
3. In its national strategy, the Scottish Government should bring forward options for establishing a Scottish Problem Substance Use recovery network.
Local recommendations
4. All service users have the right to a comprehensive assessment of need which will lead to an inclusive recovery plan that is measurable, achievable, realistic and timeous ( SMART) in design. The plan will place the service user - the owner of the plan - at its centre; be agreed and signed by both the assessor and service user; and include a timetable for ongoing formal review of changing needs. The plan will be coordinated by a named professional who will be responsible for assisting the person to achieve their goals; arranging, facilitating and recording reviews and updating the plan; and advocating for the service user when required to ensure that their needs are met.
5. Local strategic planning partnerships should regularly undertake a comprehensive needs assessment including service user views and review of:
- their current care, treatment and rehabilitation provision; and
- available funding and current spending - with a view to informing the future configuration of services.
This must address ring-fenced substance use funding, other ring-fenced resources of special relevance to substance use and 'generic' funding. Any resulting reconfiguration should integrate specialist care and treatment services and the range of essential interventions described in this report. This will require a plan to address workforce development. Best value principles should apply.
Section 2 - Essential services to maximise recovery
National recommendation
6. The Scottish Government should ensure that problem substance use is addressed explicitly in its national strategic plans addressing general health improvement, health inequalities and social exclusion/regeneration programmes. In response, local health improvement partnerships must have in place a coherent plan which clearly states the priority given locally to issues associated with problem substance use and lays out the local actions which will be taken to address these.
7. The Scottish Government should bring forward plans to improve primary care involvement in the full range of GMS interventions relevant to problem substance use. Scottish Government plans should include exploration of and the use of the GMS governance arrangements to improve performance and encouraging synergy between the elements of care addressing problem substance use and substance use/ BBV.
8. The Alcohol and Drugs Workforce Development Action Plan should take due cognisance of the need to develop staff in the full range of competencies to assist recovery. Attention should be given to more skill-based approaches dealing with values, attitudes and the delivery of psychological therapies at all levels of staff engagement with service users.
Psychological health - local recommendation
9. In all areas, comprehensive packages of care - including a range of recognised psychological treatments - should be available locally. Psychological approaches to address the commonly occurring issues of trauma, abuse, sleep disorders, anxiety, depression and anger in the promotion of recovery are seen as a minimum requirement in all areas.
10. It must be recognised that medical and social interventions may increase fertility. All women attending services must receive care to help them protect and control their fertility to ensure optimal timing of pregnancies.
Housing and homelessness - national recommendation
11. Mechanisms should be put in place to consolidate a Scottish strategy for integrating local housing, homelessness and problem substance use services. This must include approaches which assist settlement of individuals and the maintenance of tenancies.
Legal - national recommendation
12. National and local accountability arrangements should require ADATs to describe the mechanisms in place to ensure access to free independent specialist legal advice and representation which has expertise around the specific issues presented by those with substance use problems.
Education, training and employment - national recommendation
13. In its strategic approach to address problem substance use the Scottish Government should prioritise the development of a robust strategy to improve prospects for employment or meaningful activity. Employability/meaningful activity issues must be part of assessment. Agreeing and setting a national employability referral target with consideration given to incrementally increasing this target to reflect the developing understanding of client aspirations should be a priority. To increase the employment rate of people with problem substance use, all local areas should agree employability performance measures and outcomes, including:
- percentage of service users asked about employment, training, education or volunteering during assessment;
- number of clients referred to employability services; and
- measures of 'distance travelled'. Exploration of the potential for improving employment opportunities within public bodies should be considered.
Social Care - criminal justice - national recommendation
14. Community Justice Authorities ( CJAs) in association with ADATs must have in place a written strategy which describes clearly how targeted criminal justice resources will be used to increase access to treatment services as an option for the courts and for those sentenced to custody. Priority must be given for them to access services on return to the [non- CJS] community.
Social Care - children and families - national recommendation
15. The role and approach of all services in relation to children of substance misusing parents needs to be explicitly stated to ensure consistency of approach and support across Scotland. Each area will agree and publish the support it offers substance-using parents. This statement will be designed to ensure consistency of approach within the locality and ensure support is available at the earliest opportunity - even before pregnancy; services must publish their confidentiality policy and informed consent process. Information-sharing between professionals should be in line with good practice (as articulated in GIRFEC). There must be a recognition that the needs of children at risk are paramount.
In conclusion
The working group has acknowledged that, to date services offering care, treatment and rehabilitation for those experiencing problem substance use in Scotland have focussed their activities on achieving the key goals associated with reducing harm - increasing engagement with treatment services, offering replacement prescribing for those who are opiate dependent and retaining people in treatment. Services delivering these interventions are not available equitably, reflecting issues of funding, demand and strategic planning priorities nationally and locally.
Treatment options which have been associated with 'abstinence' outcomes - detoxification and residential rehabilitation facilities - have not been well integrated with these 'harm reduction' focussed approaches and availability of these is extremely limited. Furthermore, treatment options for those not involved with injecting opiate use are of limited availability across Scotland. This fails to recognise that many Scottish substance users are 'poly-drug users' and often use alcohol in association with drugs.
At the same time, services may be reducing options and aspirations. People with substance use problems are at high risk of poor health and social functioning - but have aspirations, like the rest of society, involving happy, healthy families, a nurturing home environment and opportunity to progress through training or employment. Currently, some services dealing with problem substance use may struggle to share these aspirations with service users.
There is a need to change this situation
In other conditions which are characterised by a chronic relapsing course, services must become more person-centred and focus their activity on the needs of their population. In such a system the person is helped to identify their priorities and services are organised around them in an integrated way to assist them to achieve their goals. This 'recovery' approach does not see harm reduction and abstinence as opposing philosophies - but as aspects on the same continuum. There is no reason to believe that a recovery focus will increase harm.
To make this change we require a national philosophy of care which acknowledges the possibility of recovery and a nationally supported, thriving recovery network with the service user at the centre. Local commissioning practice must change and become a systematic process of identifying local need and targeting resources to achieve the best outcomes. Staff should be trained to carry out their functions professionally and effectively and should be working within well-structured safe systems of care. Local and national governance and accountability processes must be robust to ensure delivery.
The working group has listed those elements of care which are seen as 'essential services'. These should be available in all areas. The group has also made clear recommendations which, if actioned, will increase the likelihood that those suffering substance use problems will be able to access the services, support and guidance they need to recover, at whatever stage of their continuum they find themselves.
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