The Scottish Government

« Previous | Contents | Next »

Listen

Chapter 3: Accessibility

This Chapter examines and discusses the various factors that influence accessibility to drug or alcohol treatment, care and support services, both in Scotland and elsewhere. These factors will affect (and even determine) the extent to which integrated care can be delivered in any area.

What is Accessibility?

A service is accessible when it is available to all potential users at a time and place suitable to meet their assessed needs and delivered in a user-friendly way. To make services accessible, it is essential to remove the barriers (real or perceived) that individuals experience. These barriers can lead to a lack of engagement and non-attendance. Key issues to be addressed include:

• equity of access for all potential users
• the location and opening hours of services
• the length of time to wait to be seen by a service or to get into treatment
• ensuring an initial (and subsequent) positive experience, as perceived by the user

Above all, a service is accessible when it is designed to meet the needs and aspirations of the individual. In other words, the organisational arrangements should be flexible enough to offer a service that is as person-centred as possible.

The Rationale: Why is Accessibility Important?

Guaranteeing the accessibility of services to users will help ensure that individual users:

• reduce harm to themselves and others
• reduce their drug or alcohol use
• address other health and social problems
• have an opportunity to rebuild their lives

There is a growing evidence base regarding the range and combination of interventions that can work with drug or alcohol users. Research shows that a range of treatment interventions (with a range of philosophies) may work; however, the outcome depends on the individual getting the right treatment at the right time. Ensuring access to a range of interventions and matching interventions to client needs can help promote the effectiveness of treatment. This relies upon systematic and effective assessment procedures.

As outlined in Chapter 2, it is widely recognised that people who have a drug or alcohol problem will have a range of other needs. These must be resolved before the individual can make a full recovery. Interventions which help people to deal with wider problems in their lives and to move on after stabilisation or recovery also show promise and should also be accessible to all users. This highlights the importance of an integrated approach to the treatment, care and support of users.

The assessment process may identify a need for better and more stable housing; help with addressing difficult family relationships; help with addressing debt problems; and a need to improve employment prospects. Conversely, a referral may be made to a drug or alcohol service because there has been a problem in another area of the individual's life, for example, because a tenancy is under threat and a drug or alcohol problem has been identified.

Overall, the available evidence suggests that (ideally) a broad range of user-friendly interventions that tackle the plethora of health and social needs of drug or alcohol users should be accessible to those who need them at appropriate junctures. This includes being sensitive to the needs of individuals based on their socio-demographic characteristics. However, service users in Scotland and across the UK appear to have difficulties accessing co-ordinated drug or alcohol treatment for a number of reasons including the unbalanced availability of health and social care services and interventions, poor assessment procedures and lengthy waiting lists.

Factors that Affect Accessibility

Integrated Care identified a number of service and individual client characteristics that potentially impact on accessibility. These include the needs of specific groups of drug or alcohol users whose circumstances require additional consideration to make services accessible to them:

Recent Updates

Since the 2002 document there have been a number of publications in a variety of health and social care fields which highlight some of these accessibility issues. The key messages from these publications are outlined in this chapter.

Homelessness and Alcohol Problems

The Health Technology Assessment Report 3: Prevention of Relapse in Alcohol Dependence highlighted the extent of alcohol addiction among the more than 5000 homeless people in Scotland stating that 50% of 'rough sleepers' are alcohol dependent. One of the major problems identified in dealing with this group was their limited access to services and lack of facilities specifically targeting homeless people. Therefore, there is a need to address this problem and ensure that this marginalised group is offered adequate services.

The HTA report states that, 'in Greater Glasgow, a multi-disciplinary Homelessness Addiction Team with representation from Greater Glasgow Primary Care Trust ( PCT), social work and housing (Glasgow Problem Drug Service and the Alcohol and Drug Directorate) has been formed. Particular problems that they have identified in dealing with homeless people include:

• a proportion of people who do not wish any help
• limited access to services and a lack of facilities specifically for the homeless
• ensuring referrals are appropriate
• considerable co-morbidity'

Changing Habits: Multiple Referral Routes, Unco-ordinated Assessment

Changing Habits: The Commissioning and Management of Community Drug Treatment Services for Adults (Audit Commission, 2002) highlighted that clients make contact and enter treatment through many different routes and several different professionals are involved in making onward referrals to specialist treatment services. People may go to street agencies, community drug services and social services departments or their GP and, in turn, these agencies may either provide or arrange direct treatment interventions or make an onward referral to another service. This system is referred to as the 'multiple entry system' and it is argued that it enables rapid access to services and increased choice regarding the kind of agency approached. However, in order for this system to operate effectively, systematic screening and assessment systems must be used to ensure clients are put in contact with the most suitable provider regardless of their route of entry.

In practice, current means of assessments do not always ensure rapid access or appropriate treatment. One of the main problems is that multiple assessments are often carried out as many areas do not have a common screening and assessment framework or arrangements for sharing information between providers. The other problem is that assessments are often carried out by a single member of staff and are narrowly focused on the client's suitability for one specific intervention. Consequently, options may be limited according to the personal preference or treatment philosophy of the assessor and/or the eligibility criteria for a particular type of service. It is also argued that the current system fails to minimise risk to both individuals and the wider community as those with high level needs often do not receive the more intensive support they require.

In order to avoid inappropriate referrals and ensure that people's needs are dealt with effectively, systems must ensure that there is no disparity between clients' needs and the service provided. Services need validated tools that are able to diagnose the degree and severity of drug dependence, and eligibility criteria that clearly stipulate the type of person they are most likely to help.

In 2004, the Audit Commission published an update report titled Drug Misuse 2004: Reducing the Local Impact. The report looks beyond community treatment to determine how well the national drug strategy is being delivered locally. To improve local performance, some recommendations are aimed at government and national agencies in England and Wales. It provides a number of useful updates and recommendations that are applicable to Scotland. This document can be downloaded at http://www.audit-commission.gov.uk/reports/NATIONAL-REPORT.asp?CategoryID=&ProdID=BCD29C60-2C98-11d9-A85E-0010B5E78136&SectionID=sect2#

Young People - A Guide to Assessment

The Guide to Assessment report (EIU, 2004) on young people with, or at risk of developing, problematic substance misuse highlights the need to consider young people as those up to the age of 25 due to the fact that young people mature at different rates. This is important in order not to isolate any particular group and ensure that those providing support are able to engage and relate to the person in question. This document also draws attention to the risk of labelling young people as 'substance misusers' when they should be treated as young people above all else. In addition, the authors also stress the need to ensure that young people are at the centre of the assessment process, making them feel fully involved at every stage. They also highlight the importance of not simply focusing on young people's substance misuse alone but on this problem within the wider context of their lives.

This document also highlights the importance of the employee's approach when dealing with young people. The authors suggest certain factors that will help to ensure that workers are able to effectively engage with young people and conduct a meaningful assessment. These include:

• An open, welcome and 'young person friendly' manner
• Language that young people can easily understand
• An approach that is neither condescending nor patronising
• An upfront and honest style
• An ability to express empathy with the young person's viewpoint/situation
• An approach that enables young people to identify where they see themselves

The Step it Up: Charting Young People's Progress report (Scottish Executive, 2003) provides further information about the youth work approach to engaging with young people. It is available via the following link: http://www.youthlink.co.uk/docs/Training%20docs/stepitupreport.pdf

It also suggests that projects, which are set up as part of the culture of the community, provide a unique opportunity to engage successfully with young people and be influential within community life.

Needs Assessment: A Practical Guide to Assessing Local Needs for Services for Drug Users

The EIU's Needs Assessment Guide ( EIU, 2004) highlights the importance of conducting local needs assessments in order to determine the extent and nature of the drug problem in an area, the socio-demographic profile of users and the most common referral routes. This guide describes needs assessment as a strategic process, the benefits of which include greater capacity within services, better access to services for users and improvements in the quality and range of service provision. In addition, it highlights that needs assessment is an integral part of other strategic initiatives, such as reducing waiting times, which also improve accessibility.

Rural and Remote Areas

The Rural and Remote Area: Effective approaches to delivering integrated care for drug users report ( EIU, 2004) highlighted the belief that drug misuse in rural areas in Scotland is on the increase and, therefore, more needs to be done to ensure that people living in these areas have access to care and support services. It identified the use of the internet and other information technology as a means of improving accessibility for service users and communication between service providers. However, it stresses the importance of combining electronic communication with face-to-face contact instead of simply replacing direct contact.

National Treatment Agency for Substance Misuse

The NTA published a research briefing on Engaging and retaining clients in drug treatment in May 2004. This suggests that practitioners and services have a wide range of responses available to minimise poor engagement and retention. The research suggests that low retention figures should appropriately lead to a review of the attitudes and characteristics of the service among other factors. The simple assumption that such problems are only due to poorly motivated drug users is difficult to sustain.

http://www.nta.nhs.uk/publications/documents/nta_engaging_and_retaining_clients_2004_rip5.pdf

Key Principles and Elements of Effective Practice: Accessibility

Integrated Care identified the following key principles and elements of practice to help improve accessibility to integrated drug or alcohol services. These are rarely one-off exercises, but rather they are cyclical or become an integral part of service development and review.

1. Establish the need for services in the area

This is usually achieved by conducting a local needs assessment. The key principles and elements of needs assessment are set out in a separate EIU publication Needs Assessment: A practical guide to assessing local needs for services for drug users (2004). This can be downloaded at http://www.scotland.gov.uk/Resource/Doc/26487/0013530.pdf

Conducting a local needs assessment will help establish the extent and nature of the drug or alcohol problem in the area; describe the socio-demographic profile of users; and examine common referral routes. This will help build a picture of area population need.

The Audit Commission report Drug Misuse 2004: Reducing the Local Impact (2004) suggests that 'agencies need the combined evidence to plan and build the capacity to respond effectively. The extent to which partnerships have gathered sufficient information varies. Some are collaborating with neighbours to derive the benefit of access to a larger information 'pool'.' In Scotland, this may be especially relevant in situations where ADATs are not co-terminus with other planning bodies such as Health Boards or police services. In these situations linking up with neighbouring ADATs may provide a more accurate information pool across the area.

The results of the needs assessment should be written up and distributed to all key stakeholders.

2. Review the appropriateness, accessibility and capacity of the existing range of services

This involves taking a systematic look at the current service profile including both specialist and generic services, and statutory and voluntary agencies. To conduct this review ADATs will need to complete a number of activities including a mapping exercise of current provision (in particular the characteristics and capacity of services) and identifying the relative roles and relationships between service providers.

3. Establish whether the existing range of services meets the need identified in the assessment exercise

It is important to examine whether the capacity of both specialist and generic services is sufficient. Furthermore, it is important to assess whether the interventions and services delivered do indeed meet the needs of the local drug or alcohol using population, and that they are accessible. This is sometimes called a 'gap' analysis.

4. Ensure that the range and capacity of services and joint working is adequate

If gaps in service provision are highlighted, ADATs need to consider how these gaps can be best addressed. This may be achieved by developing more effective multi-agency working, making adjustments to service characteristics and developing new approaches (such as outreach) to meet the needs of the local drug or alcohol using population, including harder to reach groups.

5. Establish clear arrangements for joint working between agencies to facilitate an integrated approach to providing health and social care services

This includes working with other specialist services and generic services, such as mental health, housing services, employment services and youth services. In rural areas, partnerships with generic services may be particularly important. This will be aided by:

• Developing shared screening and assessment tools and procedures across partner agencies.
• Developing referral protocols and procedures for use by all staff.
• Developing joint training for workers across partnership agencies, both at strategic and operational level.
• Using other training approaches, such as work-shadowing and mini-presentations about the services offered.

6. Develop more effective assessment processes

Existing knowledge about the client should be used to avoid duplication of effort by agencies and service providers and frustration for the client. Key tasks are:

• Development of single, core assessment information to be shared by relevant agencies to reduce the number of reassessments.
• Use of a consent statement that allows agencies to share information about the client across their partner agencies.
• Investment in multi-agency training and awareness of the roles of different agencies and their assessment processes.

7. Produce clear and concise information about services and make it widely available

It is important for clients to know about the range of services in their area and how to access them. It is equally important that other service providers also know about the range of services available in order to ensure appropriate referrals.

• Draw together information about services in your area for potential service users, families of drug or alcohol users and other service providers.
• Identify the most appropriate techniques for making information available to both clients and service providers. The material should be designed and adapted for each of its target audiences and clearly state:
  • who the service is most suitable for (and who it is not suitable for)
  • what the service offers (and what it does not offer)
  • what clients can expect on arrival at the service
  • whether clients can bring someone with them
• Service users and service providers should be consulted on the design and content.

8. Provide a variety of access points and times

It should be possible for service providers to take into account the previous progress of clients who have dropped out or relapsed and for clients to enter or re-enter treatment at an appropriate stage. Going back to the beginning of a care process can be demoralising and counter-productive for both staff and clients.

• Arrangements should be in place to ensure that individuals do not go back to the beginning of the care process.
• Assessment should build on existing information held on the client, rather than start from the beginning again.
• More flexible discharge arrangements should be developed.

9. Employ staff with appropriate skills, attitudes, training and qualifications

It is clear that, in most cases, staff need to have well-developed skills and competencies in their own areas of knowledge and expertise, but also knowledge of the range of provision available and how it can be accessed. Therefore, staff members:

• Should be encouraged to build on existing training and qualifications (e.g. through Scottish Training on Drugs and Alcohol ( STRADA) training modules).
• Need to be trained in the assessment processes, referral mechanisms and joint working arrangements that characterise integrated care.

10. Clear information sharing protocols

Clear information sharing protocols should be developed and explained to clients approaching service providers for help. This may be especially important for particular groups, such as female drug or alcohol users with children who may have concerns regarding child protection issues.

11. Involve family members

It is good practice to involve family members and close friends in the care of the user. The research evidence points to the benefits of including significant others in treatment and care. Family members can also be pivotal in securing access to service for drug or alcohol users.

• As part of the assessment process, it is important to assess the level of potential support the individual is likely to receive from family members.
• It is also important to assess the extent to which family members should be involved in delivering treatment, care and support to the individual.
• It is important to be clear about where family members can get help and advice if they require it. There are a growing number of family support groups developing across Scotland.

12. Address negative community attitudes

ADATs and partner agencies should find ways to engage with communities and improve understanding of the nature of drug or alcohol problems and their impact. This may ease the stigma associated with drug or alcohol use, particularly in rural areas and help the development of services in the area. For further information see the EIUGuide to Community Engagement at http://www.drugoralcoholmisuse.isdscotland.org/goodpractice/EIU-commeng.pdf.

• ADATs should develop a community engagement strategy for their area. This involves being clear about the definition of 'community', the level of engagement they are aiming for and the techniques they may use to achieve this.
• The strategy should include plans to support user groups and family support groups in the area to help empower these individuals and help reduce community stigma.
• As with all strategies, this should be revisited and reviewed periodically.

13. Regularly undertake needs assessments and review the integrated care process and its effect on accessibility

Needs assessment needs to be a cyclical process linked to action planning and review. Regular reviews of these arrangements and procedures will help to identify if improvements can be made and to build on success. This will include:

• Revisiting and updating the needs assessment exercise described earlier in this section.
• Revisiting the analysis of current need compared to the profile and capacity of service provision.
• Reviewing the effectiveness of joint working arrangements, assessment processes and referral procedures.
• Exploring the attitudes of staff regarding appropriateness of involvement and perceptions of role suitability.
• Reviewing the skill set of staff working in agencies, including identification of training needs.

Good Practice in Care Planning

An example of good practice cited in the Good Practice in Care Planning (National Treatment Agency for Substance Misuse, 2007) is that of Kensington and Chelsea, an inner London borough, which offers a broad range of drug treatment services with close collaboration between them. The services offered are as follows:

• Two large NHS community drug treatment services:

A community assessment service that operates on a relatively short six- to eight-week intervention period with a multi-disciplinary team that provides daily drop-in treatment.

A drug treatment centre that offers medium- to long-term methadone maintenance, detoxification, long-term methadone and buprenorphine maintenance and injectable prescribing.

• A social services substance misuse care management team that performs community care assessments and purchases care packages based on individual need.
• A shared care scheme in which clients are managed by the GP but supported by the keyworker and substance misuse nurses based at the assessment service.
• Several voluntary sector agencies, including a service that specialises in working with crack users, a young people's service and an alcohol service.
• Criminal justice services, including a rapid opiate prescribing service co-located with the community assessment service, a probation-based Drugs Rehabilitation Requirement team and a Drug Interventions Programme team.

Although there is no formal structure for joint working, the services have a history of collaboration with many well-established links between them and good working relationships. This is aided by low staff turnover, which means that many staff members have been working in the different treatment services in this area for a long time. In addition, as a result of the relatively small geographic area covered, many of the service users, in particular the longer term ones, are known across the services. Furthermore, joint working is encouraged by regular borough-wide meetings and forums, and shared staff training events. The DAT partnership holds various events, including conferences to give further opportunity for shared learning and collaboration.

In terms of care pathways and care plans, the services in the borough have a range of care pathways developed to support interagency working and to ensure that no single treatment model is given preference. Although each service does its own care planning, the DAT partnership has an agreed common assessment and care planning framework and tools used by all the treatment services.

As regards information sharing, Kensington and Chelsea has a borough-wide protocol agreed by all treatment services. When a client is transferred, his/her paperwork is provided to the other service so that it can build on the work already done. Furthermore, clients are assigned a keyworker and a GP or specialist doctor and have a care plan showing the different interventions that they are receiving at each service, including their service contracts. Clients often have referral documents containing a summary of their care plans so that all services are aware of the interventions they are receiving and who their keyworkers and doctors are.

Actions Points: Accessibility

« Previous | Contents | Next »