Planning and Provision of Drug Misuse Services
Planning
and Delivering Effective Treatment
and Care for Drug Misusers
1. This guidance sets out key principles that Health Boards, local authority social work departments and others should take into account in the planning and commissioning of effective treatment and care services for people with drug related problems. It builds on the initial work of the Drug Action Teams (DATs) and provides advice on the commissioning implications for Scotland arising from the Polkinghorne report - the Department of Health Task Force Report of an Independent Review of Drug Treatment Services in England. The main thrust is that commissioning of drug misuse services should be based on principles of joint planning, joint commissioning, an evidence base and clinical effectiveness. The guidance is aimed at:
- General Managers of Health Boards and Directors of Social Work - for action;
- Chief Executives of NHS Trusts - for action;
- Local Authority Chief Executives - for action;
- Chief Social Work Officers - for action;
- Members of DATs, including local authority Chief Executives and police force and prison service representatives - for action;
- GPs, including GP fundholders - for action ;
- Statutory, voluntary and independent providers of drug misuse and allied services, including providers of training, housing, employment, education, community and leisure services - for information.
2. The guidance does not cover:
- the primary prevention of drug misuse except where this overlaps with care and treatment for drug misusers;
- detailed commissioning techniques such as prevalence data analysis and needs assessment - information on these is available from the material listed at AppendixI.
3. This document does not cover alcohol misuse services, although they are often commissioned alongside services for drug misusers. Commissioners may therefore wish to consider the scope for combining action as many of the principles, concerns and opportunities outlined here are also relevant to the commissioning of alcohol services. AppendixD outlines some of the key points to be considered by commissioners in relation to these services.
4. Health Boards, local authorities and other agencies should use this guidance to inform the 1998/99 service planning process.
PRIORITIES AND PLANNING GUIDANCE
5. Improving the health of the people of Scotland by assessing need, promoting health, preventing illness and improving the clinical effectiveness and cost effectiveness of health care interventions is one of the 5 strategic objectives for the NHS.
6. DATs have a critical role as the focal point for local action on drug misuse. They should lead and co-ordinate local action, drawing as necessary on the advice received from local drugs fora, and ensure delivery of good treatment services in line with their strategic plans and effective development of drug prevention measures. In the delivery of drugs services, DATs have a particularly important role in :
- ensuring that relevant information is collected and shared;
- assessing whether the quality and range of services meets identified need, across all categories, and initiating and planning improvements where they do not;
- initiating regular evaluation and reviews of the services and activities of all the agencies working in the field with a view to improving efficiency and effectiveness;
- ensuring effective joint working between the key agencies and leading joint commissioners, including in relation to spending decisions;
- influencing the resource decisions of the agencies represented on the DATs;
- ensuring that the wider interests represented on drugs fora, such as family support groups and users, are taken into account.; and
- taking account of the interests of the wider community.
The references to those responsible for the planning and delivery of services in this guidance are therefore made on the assumption that DATs are fully involved in the decision making processes, even though the statutory responsibility for the care and treatment of drug misusers rests with Health Boards, local authorities and others.
7. The Scottish Office Home and Health Department's letter of 16 March 1995 gave guidance on the implementation of some of the recommendations in "Drugs in Scotland: Meeting the Challenge", the report of the Ministerial Drugs Task Force report on drug misuse in Scotland. That guidance is still extant and theTask Force report continues to provide the broad framework for action on drug misuse in Scotland, including the development of services. However this guidance also reflects consideration of the Polkinghorne report - the Department of Health Task Force report of an Independent Review of Drug Misuse Services in England - which provides guidance on the development of services for drug misusers. This document is referred to as the Polkinghorne report in this guidance to avoid confusion with the Scottish Task Force work. The DATs set up as a part of the implementation of the Scottish Task Force report are taking forward the resulting strategy at local level. All have drawn up strategies and action plans which include service provision, some already addressing issues raised here.
8. In planning service provision account should be taken of the national strategic objectives for tackling drug misuse explained in Part 1 of this guidance and listed at AppendixA. One of these objectives is the development of responsive and effective services for drug misuse and others such as those relating to drug deaths, injecting and communicable diseases have a direct bearing on the provision of services. However it is for Health Boards, local authorities and others to undertake needs assessment to determine the extent to which the national concerns behind strategic objectives are reflected in their own local circumstances, and take account of local variations.
9. Together with the DATs, Health Boards, local authorities and others need to assess the extent of all forms of misuse in their populations and commission services which reflect the full service options, the resources available, service users needs and the localities highest priority service requirements. The views of others with an interest, including local drugs fora, whose representation should include family support groups, should also be taken into account. In this way those responsible for services can address the harm caused to the individual and others around them. Well targeted, efficiently delivered and properly monitored care and treatment can significantly reduce such harm.
10. Information contributed to the Scottish Drug Misuse Database (SDMD) is an important local and national source of drug misuse information, supplied by specialist drug services, general practitioners and others which can be used to monitor activity to help plan service provision. DATs, Health Boards, local authorities and others should encourage relevant services within their areas to make returns to the SDMD in order to ensure a consistent and reliable source of information across Scotland from which routine comparative data may be obtained. It should be noted that with the closure of the Addicts Index the SDMD is now the only source of routinely collected national data concerning patients seen by doctors.
11. The Scottish Advisory Committee on Drug Misuse (SACDM) has recently approved a drugs information strategy for Scotland, which will support the planning and provision of drug misuse services. It establishes a coherent structure for the long term availability of appropriate information on drug misuse. The information strategy provides for the co-ordination of the activities of the main players; will improve access to key information; and will provide central support for DATs and other agencies involved in the delivery of drug misuse services. Guidance on the operation of the information strategy will be issued in due course.
12. SACDM has expressed concern that, in general, agencies represented on DATs are often unable or unwilling to surrender resources in support of the corporate decisions required of DATs. The Committee concluded that joint commissioning of services for drug misusers, following identification of need, would be one way of addressing this difficulty and was the key to effective service provision. SACDM looked to the DATs to initiate and lead the joint commissioning of services, and The Scottish Office supports this view.
13. The following priorities in service provision are commended from the Ministerial Drugs Task Force and the Polkinghorne report:
- Practical co-operation and, wherever possible, long term partnership between all the agencies involved in the commissioning and delivery of drug misuse services.
- Systematic and comprehensive assessment of the nature, extent and distribution of need.
- An evidence based approach to commissioning underpinned by monitoring of costs and outcomes towards the achievement of cost-effective services.
- The need for information on the clinical and relative cost effectiveness of various types of service provision, including advice on what type of service, or combination of services, suits which type of user.
- Monitoring by DATs to ensure that arrangements are in place to evaluate the extent to which services are meeting the needs of drug misusers.
14. A number of key points on commissioning arise from the Polkinghorne report and SACDM's consideration of issues arising from it which have a bearing on Scotland:
- Co-ordination A range of interventions by various agencies may be involved in tackling drug misuse by people at different stages of their drug misusing careers. If the agencies concerned are not properly co-ordinated, resources will be wasted. To maximise efficiency and effectiveness, commissioners need to ensure that a comprehensive well co-ordinated set of services is available covering a wide variety of health and social interventions, and including practitioner groups. It is important to take into account value for money, not only for the commissioner but also for others ( eg the police) and the locality ( eg the neighbouring Health Board area).
- Commissioning Expertise Effective commissioning requires development of commissioning expertise as well as investment in direct services. There is a need to ensure that staff have a minimum level of training or service provision experience, clearly defined objectives, and adequate capacities and resources. Training should cover specialists and non-specialists. The Scottish Drugs Forum is a resource which commissioning bodies can draw upon for advice.
- Assessing Needs Commissioners must be fully aware of the full range of service options available to meet drug misuser's needs. The full range of services covered by the Polkinghorne report is at AppendixG. SACDM's comments on Polkinghorne recommendations of relevance to Scotland have been incorporated in AppendixB.
- Audit As a minimum, a basic audit of service demand should be undertaken to justify current levels of provision. DATs are in the best position to know which providers of services and service agencies should be consulted. Providers of services consulted should, however, include community based drug services, needle exchanges, prescribing services, GPs, social workers, the police and accident & emergency departments. Adjoining Boards and DATs should be consulted to identify if demand is being met elsewhere. In some localities more sophisticated needs assessment exercises may be necessary.
- Identification of Resources The financial resources available to deliver identified service requirements should be identified. AppendixC provides information on the sources of funding available in Scotland. The Scottish Drugs Challenge Fund demonstrated the private sector interest in anti-drugs work and Health Boards and Social Work Departments should be alert to the possibilities of funding from the private sector.
- Strategic Frameworks Strategic frameworks, based on joint assessments of need, should be considered. Such frameworks should be agreed by the Health Boards, local authorities, the DATs and other relevant agencies. Although agreed strategic frameworks don't guarantee complementary investment programmes, they promote good co-operation, help identify barriers to success, and can avoid wasteful duplication of provision.
- Joint Commissioning Health Boards, Social Work Departments and DATs should consult partner agencies about their spending on drug misuse services and their service plans before decisions are finalised. Wherever possible joint commissioning between agencies, and in particular those represented on the DATs, should be considered. Consultations between Health Boards and Social Work Departments should result in agreement on who funds what element of the care and treatment of individual clients. DATs should consider appointing a sub-committee to consider the appropriateness of joint commissioning arrangements, including performance monitoring, and provide a focus for action.
- Commissioning Consortia Consortium based and allied approaches can have benefits for Health Boards, local authorities and those agencies delivering services. They offer a means of sharing information about needs, costs and quality and of pooling specialist skills relating to such issues as working with the prison service. In London for example a consortium of 29 social service authorities has recently published a directory of agreed service standards and recommended prices covering almost 50 providers of drug misuse services .
- Supporting Joint Commissioning Satisfactory joint Health Board and Social Work Department action must mainly rest on the establishment of unified strategic plans, developed through the DAT structure, which are fully supported at all levels of both organisations, and implemented fairly by both partners. This can be facilitated by informing Councillors and non-executive Board members of priorities and challenges in a timely way, obtaining their explicit endorsement and ensuring that appropriate operational working arrangements ( e.g. co-location of staff) are in place. The DAT should be the central point for joint commissioning.
- Length of Contracts Longer term agreements or contracts should be considered consistent with local strategies and plans for provider development. A balance has to be struck between the strategic development of services and the need for flexibility, responsiveness and an adequate choice of treatment options for service users.
- Performance Monitoring Considerably more work is needed on developing agreed and validated indicators of service structure, process and outcome. Agencies responsible for planning and ensuring the provision of drug misuse services should promote the systematic use of indicators of service cost and outcomes. They should agree a set of performance indicators with those delivering services which are designed to meet the need both for external monitoring and internal process improvement. The Polkinghorne report proposed an outline set of indicators - at Appendix H - which have been endorsed by SACDM. These can be used as a basis for the development of local indicators ( see Part 1 of this guidance ).
- Data Collection Standards and Consistency Health Boards, local authorities and others should promote the development of standards and consistency in recording key information to ensure appropriate information can be compiled for comparative purposes within and across DAT areas. This will encourage benchmarking and dialogue on ways of improving practices in local areas.
15. Appendix B sets out core principles relating to drug misuse services, and identifies areas for service improvements. This material is based on the findings in the Polkinghorne report and takes account of the Scottish Ministerial Drugs Task Force report, the more recent views of SACDM, and consultations with planners and providers of services in Scotland.