« Previous | Contents | Next »
Listen
FINAL REPORT
Background
1. In January 2007, the Scottish Advisory Committee on Drug Misuse ( SACDM) established a Project Group tasked with examining ways to improve the integration and co-ordination of drug services in Scotland. Its main aims were to review and build on the work already done, make recommendations for the speedy and co-ordinated implementation of good practice, identify any obstacles to change and provide practical advice on improving outcomes.
2. The Integrated Care Project Group ( ICPG) recognised that much valuable work has already been done and that a series of existing documents and policies have been published all with the aim of promoting the integration of services and best practice. However, implementation of meaningful systems to build on these policies and identified good practice has been both slow and inconsistent.
3. The Group concludes that without mechanisms to support and ensure implementation, integration will continue to be slow and patchy.
4. The final recommendations of the ICPG are made with this in mind.
Tasks completed
5. To fulfil the aim of reviewing and building on work already done, the Group commissioned an update and strengthening of Integrated Care for Drug Users: Principles and Practice (Effective Interventions Unit, 2002) linking practice to more recent developments such as Joint Futures and the National Quality Standards for Substance Misuse Services.
6. The result of this project - Integrated Care for Drug or Alcohol Users: Principles and Practice Update 2007 is an update of the 2002 EIU document and was presented to SACDM in January 2008, SACDM Paper (07)(24) where it was accepted after amendment.
7. The ICPG recommends that this document is redated to 2008 and published in support of the new national drug strategy. While the document should be principally in electronic form we further recommend that a small number of hard copies be printed to facilitate ease of use and the clear understanding that this is a principle operating manual. We judge this a priority action and recommend the production of the document be completed by October 2008.
8. Following the publication in July 2007 of Reducing Harm and Promoting Recovery, a report on methadone treatment for substance misuse in Scotland, the ICPG was charged by SACDM to consider the 'wrap around' elements of care needed by substance misusers which were beyond the scope of that report. An additional sub-group was therefore established and produced Essential Care: a report on the approach required to maximise opportunity for recovery from problem substance use in Scotland. This document, SACDM Paper (07)(23) was presented to and accepted by SACDM in January 2008.
9. The ICPG considers that Essential Care is a significant document signposting the way to a wholly improved and effective service model for problem substance use. Its central pillar - 'Recovery' - should be embraced and we recommend that the principles of Essential Care be embedded in the national drug strategy and together with Integrated Care: Principles and Practice be considered the 'engine' of a new approach to treatment and recovery for substance misusers.
Barriers to integrated working
10. As part of its remit ICPG was tasked with "identifying the main barriers which prevent partnership working in provision of support for substance misusers, with particular emphasis on information sharing."
11. The Group considers that there are distinct elements to this issue.
The new landscape
12. The Group recognised that in the last ten years the landscape i.e. the number of agencies with partial involvement in substance use in Scotland has grown. Community Health Partnerships, Community Safety Partnerships, Community Justice Authorities and the Community Planning framework, all established in the last ten years and along with Alcohol and Drug Action Teams ( ADATs), all with an interest in substance use, all with different priorities, separate funding and for the most part separate leadership.
13. The Group believes that a degree of confusion exists regarding the roles and responsibilities of these agencies and that it is essential that these are clarified beyond doubt so that integrated working is promoted in an efficient and cost effective way.
Partnership and information sharing
14. The group believes it self-evident that effective partnership working throughout the problem substance misuse field is essential to effective service delivery. Despite this, we observe that throughout Scotland there is a lack of consistency regarding the structure and functioning of these partnerships. The best appear thoroughly integrated, sharing common objectives, funding and performance management systems. The worst can only be described as 'talking shops' with important decisions being taken in isolation and with a reluctance to share information or funding.
15. The Group believes it essential that the nature and essential components of partnership be more clearly defined in line with business models. In particular we identify essential components to be:
- A common single shared assessment ( SSA) tool accessible to all relevant services, statutory and voluntary.
- A 'Care Pathway' that ensures a continuity of care towards recovery for service users.
- A common business model in which service level and outcome agreements are common across both the statutory and voluntary sectors.
16. The Group recognised that these are not new thoughts or concepts but that despite common acceptance of these components as essential there is no evidence of widespread or consistent application.
Funding streams and accountability
17. The new landscape and the number of bodies and groups with an interest in problem substance use in Scotland has already been discussed however this diversity has increased the number and nature of funding streams. This also creates a barrier to integration.
18. The Group accepts that to some extent this problem will be resolved by the streamlining of funding streams via the single outcome agreement but notwithstanding we believe there are threats remaining in this area.
19. In particular the Group foresees potential difficulties for the many well established services in the voluntary sector when in times of financial restraint, all monies are channelled through the major statutory services (Health and Local Authority) who may naturally favour their own services.
20. The Group believes that the voluntary sector has a valuable role to play in an integrated service. It therefore recommends that steps be taken to preserve, or in some areas create, the mix and balance of statutory and voluntary services, bound together with common operating processes and performance management. To achieve this the Group believes that all services should be attached to local accountability structures via ADATs and Community Planning with a firm outcome focus. The Group believes that a substantial training need exists in both ADATs and alcohol/drug services in order to deliver this.
Prisons
21. The ICPG spent considerable time considering the issues of our rising prison population and the complex management of substance misuse amongst this highly vulnerable group. The good work done by the Scottish Prison Service ( SPS) must be recognised and in some areas there is evidence of effective throughcare, yet overall the Group agreed that integrating the chain of health and addiction services with wider wraparound support is essential to ensure continuity of care on admission, on transfer to other prisons during a sentence and on release into the community. The Integrated Case Management ( ICM) process of delivering individualised care and forging vital case links with throughcare networks could be further enhanced by developing information sharing protocols between prisons and community service providers to ensure a smoother return to community post-release, lessen the risk of overdose soon after release and reduce the risk of re-offending in the future.
22. The Group felt that nowhere in the problem substance use spectrum is there more risk or more to gain, both for the individual and society than in effective intervention with prisoners.
23. In considering this issue the ICPG concluded that the needs of prisoners, though more concentrated, mirror exactly the needs of problem substance users in the community. The Group believes that prisoners should not be considered discreetly or the sole responsibility of the prison service, rather they should be seen as members of the community, temporarily in the custody of SPS, and due to return to society. The Group believes that great care should be taken to ensure a seamless delivery of service to prisoners and that this should include short term prisoners. Furthermore it would wish further consideration of the introduction of Addiction Support Areas within prisons to encourage prisoners to distance themselves from illegal drug use whilst recognising the reality that lapse and relapse are part of the treatment cycle and recovery from problematic drug use.
24. In essence, the Group saw prisoners as an important group of problem substance users who deserved concentrated efforts. Accordingly we believe it especially important that alcohol and drug services are fully integrated before, during and after prison, and that this be identified as a high priority for services. Ministerial consideration will be given over the coming year as to whether it would be appropriate for health services for this high need group to be provided directly by the NHS. In the meantime, SPS and NHS are working together to achieve closer integration of services.
Read across and the need for integration with other service areas
25. While the remit of the Group was to consider and report on integration of care for substance misusers across Scotland the ICPG concerned itself principally with integration issues as they affected agencies already providing substance misuse services either from the statutory or voluntary sector.
26. While such integration is essential as a first step the Group is aware that just as important is the relationship of alcohol and drug services with other services which at first sight seem remote. It concluded that the relationship of substance misuse services with mental health, social work, housing, employment services and family support are as important to recovery as are traditional health or psychosocial interventions.
27. The Group concluded that no matter the strength of individual substance misuse services, if standing alone or discreet they will fail. Likewise it seems unlikely that alcohol and drug issues will get the priority attention they require until the connections and relationships are recognised.
28. ICPG recommends that care be taken to ensure that the product of SACDM working groups and the new drugs strategy be harmonised with mental health, social work, housing and employment strategies in order to achieve effective integration and synergy overall.
Governance, scrutiny and delivery
29. From the beginning the ICPG recognised that there was little new or revolutionary about its findings and observed that most of the recommendations had been made before, sometimes on several occasions. This was significant because despite general acceptance of their merits, few had been implemented comprehensively.
30. In consideration of this problem it became apparent that a significant reason for failure to implement was that on most occasions no implementation plan had been put in place, no incremental timetable had been established and no system of governance or scrutiny put in place to ensure compliance or the measurement of outcomes.
31. In addition it was observed that no specialist assistance had been given to implement sometimes significant change. It appeared that on occasions new strategies were simply published and then left in the mistaken belief that their merits alone would ensure compliance.
32. As highlighted in paragraph 26, many substance misuse services sit outside local accountability structures, and Corporate Action Plans were generally seen as unsatisfactory as a system of accountability.
33. ICPG concludes that in order to ensure delivery of the drugs strategy and associated SACDM recommendations, in an integrated and consistent way, a phased implementation plan should be put in place. This is a priority action which the Group believes should be in place by December 2008.
34. In recognition of the difficulties some service areas will have in making such changes, especially in a time of financial constraint, the Group further recommends that a support system or group be established by the Scottish Government in order to develop the implementation plan and then assist and support by using best practice examples to help in delivering the strategy. The Group believes this is a priority action to be undertaken urgently by January 2009.
35. Lastly, the Group emphasises the importance of including substance misuse services within local and national performance frameworks via the Community Planning structure, with clear outcomes being identified and monitored.
Leadership
36. In consideration of the remit of the Group, ICPG identified leadership as a key component of success. The Group recognised the important role already played by Government Ministers by their personal leadership and wished to emphasise the continued importance of their role.
37. Significant change is both challenging and threatening. Continued strong personal leadership of the kind already seen in the development of the drugs strategy will be essential to the delivery of a high quality Integrated Care System for substance misusers.
In summary the ICPG recommends
1. That the roles and responsibilities of the new bodies Community Safety Partnerships, Community Justice Authorities, Community Health Partnerships and Community Planning, as well as ADATs be clarified beyond doubt and that these roles be linked to clear accountability and performance management frameworks, locally and nationally. We believe that clear information and advice should be made available by December 2008.
2. That all services involved in provision of care for problem substance use be actively encouraged to implement:
- Single Shared Assessment systems
- A Care Pathway for service users
- Common performance management structures for statutory and voluntary sector providers
The Group recognises that there are several good models to achieve these objectives so does not recommend one model - it does, however, see this as an area of priority and believe that given adequate support, such systems should be in place by May 2009.
3. That care be taken to preserve the mix and balance of services between the statutory and the voluntary sector and that all substance misuse services be included in local frameworks of accountability with firm outcome focus;
and
That ADAT and other service staff receive training to enable them to implement the above. Training of staff in adopting a recovery approach will be a priority in this respect.
4. That prisons and the prison population be recognised as a priority area and that, as a matter of urgency, an improved integrated care pathway between prisons and the community is developed which allows prisoners to access the required specialist addiction services and social skills, to meet their individualised needs, to assist them in their recovery from substance misuse and lead crime-free lives on return to the community. In some geographical areas across Scotland, where gaps in community services are evident, the Group believes that ADAT support and assistance may be required but overall the Group expects that such arrangements should be able to be put in place by December 2008.
Chair
SACDM: Integrated Care Project Group
May 2008
« Previous | Contents | Next »