Planning and Provision of Drug Misuse Services

Planning and Provision of Drug Misuse Services

APPENDIX B

Core Principles and Areas for Service Improvement

1. Effective practice is underpinned by a number of key principles, regardless of whether services are to be commissioned by agencies acting solely on their own behalf, or are working jointly with planning partners. Wherever possible, agencies should ensure that sufficient emphasis is given to efforts to reduce the demand for drugs by assisting people to become and remain drug free as part of harm reduction measures. When considering the provision of services, those responsible should take account of how best to:-

assess and improve service effectiveness based on needs;
improve speed of access to services;
improve efficiency;
take account of the views of service users and carers; and
ensure equality of access to services.

2. Once these considerations are complete, they need to:-

identify needs;
assess current services against these and identify service gaps;
identify services required to meet unmet needs taking account of effectiveness considerations;
prioritise service need in the light of available resources;
clarify aims and objectives of required services;
set out quality standards to be met by providers with whom they contract;
determine level of funding to be made available for each service;
identify and select providers against these criteria;
clarify contractual arrangements;
identify appropriate staff training needs;
monitor and evaluate services against objectives, targets and outcome/cost effectiveness; and
review service provision regularly, in the light of emerging needs, service outcomes, effectiveness etc.

3. It will be for Health Boards, local authorities and others to determine in detail the standards they require those delivering services to meet. Areas in respect of which standards might apply include:-

quality of service/service level agreements (the Scottish Drugs Forum may be able to assist here);
policies (e.g. in relation to services for children under 16 years, rights of service users, etc.);
procedures (e.g. maximum waiting times, referral mechanisms etc.);
staffing (e.g. qualifications or training required, including consideration of need for joint training strategy);
management structures and arrangements;
involvement of service users (eg. taking account of views of service users/carers in service department);
quality assurance systems;
monitoring and evaluation arrangements (including identification of key indicators)
value for money issues; and
clear policies in place in respect of users rights, complaints, health and safety issues and confidentiality.

4. When entering into contract or agreement with those delivering services, those responsible should always:-

clarify the aims and objectives of that particular service;
set targets for each service (outputs or units of service to be delivered, timescales etc.);
identify desired outcomes (which may include interim objectives such as reduction in drugs use or in associated harmful behaviours);
ensure that monitoring and evaluation systems are in place (including clear performance indicators); and
review current provision and projected needs regularly.

5. Proven effectiveness is a key criterion against which to judge services for drugs misusers. The Scottish Office Department of Health will provide Drug Action Teams (DATs) with National Treatment Outcome Research Study (NTORS) findings, as they are published. Statistical data from those delivering services (eg in relation to service retention rates, user completion rates etc), the views of service users and existing research studies, will also guide the planning of future services.

6. What is clear, is that a range of different types of service are necessary, offering different approaches in order to meet the varying needs of misusers. Required services are likely to encompass shared care, residential treatment, counselling services, education, information and advice and outreach. These different services need to be well-targeted (which requires good assessment of users' needs), well advertised and delivered efficiently.

7. Consideration should also be given as to how social care services can address the financial, legal, housing, child care and other problems that are frequently encountered and to assist clients in exploring opportunities for further education, training, employment and leisure activities.

SERVICE USERS' RIGHTS

8. Polkinghorne outlined what service users should be able to expect in terms of quality standards. These are outlined below:-

the right to assessment of individual needs within a specified number of working days;
the right of access to specialised services within a specified time;
the right to respect for privacy, dignity and confidentiality, and an explanation of circumstances in which information will be divulged to others;
the right to access to a complaints procedure;
the right to full information about treatment options and informed involvement in making decisions on treatment;
the right, in appropriate circumstances, to be referred for a second consultant opinion; and
the right to an individual care and treatment plan.

AREAS FOR SERVICE IMPROVEMENT

9. Some specific areas for service improvement are discussed below. These are based on the findings of the Polkinghorne Task Force and reflect action recommended under the Ministerial Task Force agenda and the more recent views of the Scottish Advisory Committee on Drug Misuse (SACDM). Consultations with planners and providers of drug misuse services in Scotland have also been taken into account.A summary of the Polkinghorne findings is in Appendix G.

OPPORTUNITIES FOR IMPROVED SERVICE CONTACT

Outreach

Outreach services and street-based agencies are effective in reaching drug misusers not in contact with services and providing advice on harm minimisation.
They can be a useful method of establishing contact with young people who are experimenting with drugs and must be sensitive to local needs.
They also have a role in encouraging drug misusers into treatment, although early intervention by street-based services may reduce the need for later contact with more specialist services.

Generic Service Contacts

Generic services include all those forms of social and health care available to the entire population but will also be used by drug misusers.
Contacts handled appropriately can bring drug misusers into early contact with specialist treatment services.
All Accident & Emergency, maternity staff and a wide group of non specialists should receive basic drug awareness training. (See Appendix E for examples of innovative practice in Glasgow and Edinburgh.) This should include handling aggression and de-escalation techniques.
It may be useful to train some members of the nursing staff to act as drug liaison workers, to help to reduce tensions where someone is seeking drug services and perhaps using the departments inappropriately.
Those planning services may wish to explore with staff the scope for developing needle exchanges in Accident & Emergency departments on an ad hoc basis, if there are no adequate local needle exchange facilities.
Care should be taken with the in-patient with a drug misuse problem where efforts should be made to assess their motivation to address their drug use and, if possible, to use the opportunity as a route into treatment. The Glasgow Drug Problem Service have prepared Notes on Prescribing for Drug Misusers in Hospital. A contact name and telephone number can be found in AppendixE.

Primary Care

GPs should be sensitive to the signs of drug misuse and the needs of people affected by it, acting as a gateway to other services, as well as providing relevant care directly.
GPs are required to provide General Medical Services to all their registered patients, including drug misusers. Where GPs receive additional payments to reflect their participation in shared care arrangements, these payments should not be seen as being specifically for substitute prescribing, but for participation in shared care programmes involving education and training; specific reporting and recording arrangements; working to agreed clinical protocols; and participation in clinical audit.
The provision of care through shared care schemes is recommended, where training, support, guidelines and evaluation should be present. The Glasgow Drug Clinic Scheme is a good example of a shared care arrangement (see Appendix E), where a major factor in the success of the scheme has been the payment of an extra fee for services in addition to General Medical Services. Another is the shared care arrangement in Lothian and the GP Facilitator Team (HIV/AIDS and Drugs) (also outlined in Appendix E). In order to assist GPs and other relevant health care professionals in the treatment of drug misusers, Guidelines on Good Practice in Substitute Prescribing was issued by The Scottish Office in summer 1997 (see Appendix I).
Pharmacists may also be able successfully to offer drug misuse services such as needle exchanges and methadone dispensing and the use of pharmacies for such purposes should be included in DAT strategies. This might include supervised consumption to reduce the possibility of diversion of methadone onto the illicit market (see Appendix E for an example of supervised methadone consumption by community pharmacists in Glasgow).
Pilot projects involving pharmacists prepared to offer extended hours of pharmacy care for people with drug misuse related problems, including over the weekend, provide a valuable way of encouraging innovative practice.
Services for the dispensing of methadone for drug misusers and needle exchange schemes are provided by pharmacy contractors by local negotiation. (Advice contained in the Scottish Health Service Management Executive letter dated 27February 1997 - see Appendix I)

Criminal Justice System

The threat or risk of prosecution can be a strong motivator for dependent drug misusers to enter treatment.
Arrangements for the provision of these services are set out in the annual Criminal Justice Social Work service plans produced by each local authority.
Local authorities need to ensure better co-ordination between these plans and community care plans developed in tandem with Health Boards and other planning partners.
DATs, including commissioners of drug misuse services, should enter into detailed discussion with those involved in the criminal justice system to see how alternatives to custody programmes can be developed.
Discussions should also include the identification of opportunities to make drug misuse services available to people who are arrested for suspected drug misuse offences - whether or not they are subsequently prosecuted. The effectiveness of any referral scheme is reliant on the wholehearted commitment of all the organisations and agencies involved, with an adequate support structure.

Prison Throughcare Services

The Scottish Prison Service aims to provide a range of services within prisons, reflecting, so far as possible within the constraints of the prison setting, good practice within the community.
The period following release from prison can be especially problematical for drug misusers. Health Boards, local authorities and others, within the context of the DAT framework, should work with prisons to ensure that the needs of prisoners returning to their area are addressed before release and then adequately provided for once they have returned to the community.

Note

The Scottish Office has provided funding to the Scottish Drugs Forum to investigate and make recommendations for improvements in practice in relation to the needs of drug misusers who are released from prison. The outcome of this work is likely to be available in 1998, and should inform national and local policies in relation to this group.

EFFECTIVE INTERVENTIONS

Methadone Treatment Programmes

There is firm evidence of the benefits of prescribing methadone to opiate misusers through well managed and structured maintenance and/or reduction programmes.
The benefits available from the development of shared care arrangements which bring together primary health care, pharmacy and secondary care providers in structured and fully maintained schemes for the prevention, care and treatment of drug misuse should be recognised.
There needs to be sensitivity to the possibilities of 'leakage' of legally prescribed and dispensed methadone onto the illegal market and the prescribing regime should be structured accordingly with due regard to the benefits of daily and supervised consumption.
Those delivering services should receive regular training, updating of knowledge and support and should follow the advice contained in the Guidelines on Good Practice in Substitute Prescribing (see Appendix I) and within the clinical guidelines on drug misuse and dependence issued to all doctors (see Appendix I); this includes the provision of adequate counselling and other support to clients who wish to become or have become drug-free. The importance of appropriate counselling both before and during treatment should be recognised.
Methadone treatment programmes must involve regular reviews of service user requirements, including their readiness to contemplate reduction leading to abstinence, and be constructed and monitored in such a way as to ensure cost-effectiveness and the protection of the community and clarity about objectives for both the individual and the wider community.

Hospital/Community Detoxification and Drugs Crisis Intervention Services

Sufficient detoxification services should be available. Whilst in detoxification clients should be able to receive appropriate counselling and social support and that support should continue once the initial detoxification has been completed.
Those responsible for services should develop criteria for the monitoring and outcome of those who enter detoxification programmes. Measurements should relate to the numbers completing treatment, further contact with services, success with harm reduction and progress towards abstinence.

In-patient Treatment

Specialist inpatient detoxification programmes can have significant impact on certain types of drug misusers who may not benefit from outpatient detoxification.
Services should be based on a comprehensive assessment of need by Health Boards and Social Work Departments reporting through the DATs.
Relative cost effectiveness of in-patient and out patient detoxification programmes require consideration because of the costing implications of residential services.
The need for consistent referral criteria for residential treatment should be considered.
The outcome of both in-patient and out-patient detoxification should be monitored.
Intercurrent mental disorder may contribute to chaotic behaviour on the part of a drug misuser. There should be a close working relationship between drug misuse services and the mainstream mental health service, which will allow adequate assessment and treatment of any mental disorder, where appropriate. This may well have a beneficial effect on the prognosis for the misuser.

Residential Care

Those responsible for drug misuse services need to be aware of the different types of treatments available and should have strategies in place which are flexible enough to ensure that the full range of provision can be accessed, according to individuals' needs.
This means that policies will need to continue to be a mix of block contracts and spot purchase.
Social work departments should monitor the impact of residential services on individual service users and try to follow-up people who drop out of services. This information should inform subsequent planning of services. In the absence of detailed objective information about effectiveness, retention rates and service user feedback are likely to be important indicators.

Counselling Services

Counselling should be recognised as a core component of drug treatment, not an optional extra.
The benefits of progress towards abstinence as well as harm reduction alone, should be reflected in the design and delivery of counselling.
Commissioners of counselling services must be clear about their expectations of the service to be provided, and must distinguish between structured counselling and the provision of information/advice.
Before commissioning counselling services, social work departments should clarify both the type of counselling offered by an agency and the nature of accreditation gained by agency staff.
Social work departments and other commissioners should require those delivering services to increase their numbers of accredited counsellors, in order to improve the quality of counselling services available.

Alternative Therapies

Alternative therapies may be beneficial when undertaken in conjunction with other treatment therapies.
Their use must be carefully assessed and results published.

BLOOD BORNE VIRUSES

Injecting drug misusers are at high risk of acquiring blood borne virus infections such as hepatitis B, hepatitis C and HIV by sharing blood contaminated needles and injecting equipment. These infections have long term implications for the health service in terms of prevention and health promotion and in the clinical care of those who become infected.
For those already injecting, the advice about not sharing any injecting equipment needs to be frequently reinforced and those found to be HIV infected should have sufficient information on how to avoid infecting others. Needle and syringe exchange schemes have an important part to play.
Those who have been at risk of exposure to these infections through injecting drugs and who seek testing for these infections should have access to well-informed advice, so that they are fully aware of the implications of having a positive test.
A preventative vaccine is available against hepatitis B only. Commissioners should ensure that the vaccine is available to injecting drug misusers, and all those at current or possible future risk, including close household contacts and sexual partners of any injecting drug misuser who is infected.
A model service specification/agreement for syringe exchange schemes has been prepared by The Scottish Office. Consideration should be given to adopting this or adapting it to suit individual needs. The specification includes the provision of information and advice on general health and referral to GP or accident and emergency department if indicated, rather than basic health checks.

MEETING INDIVIDUAL NEEDS

Drug misusers have the same rights as any other people requiring help from health or social services and it is important that drug misusers are not stigmatised because of their addiction. Respect for these rights and concern for misusers' needs does not, however, imply tolerating their causing avoidable harm to others or that people living in a chaotic state do not sometimes require directive treatments.
Services should be open at times convenient to users and in agreeing service specifications, it should be considered how this can best be achieved within the resources available.
Providers should publicise their opening times widely.

SPECIFIC CLIENT GROUPS

Services may also need to be structured to meet the requirements of particular groups of users, and to be sensitive to particular needs.

Rural Drug Misusers

There are some characteristics of rural communities which need to be taken into account when developing services:

Poor compliance with centrally based, distant services is common because of long and inconvenient travelling times and the relative scarcity of reliable child care.
There are very real concerns about confidentiality and stigma given the difficulties in maintaining rural anonymity and the frequent blurring of professional and social boundaries among generic and specialist workers.
Inter-town rivalries can often produce situations where there is a reluctance to accept services in nearby towns.

These problems need to be addressed to the point of providing an accessible, acceptable drug service. The following are worth considering:

Strong coherent and consensual policy making and service provision, with effective and efficient networking procedures. In addition to involving significant specialist and generic service providers there needs to be a genuine involvement of the various local communities, including drug users and their families.
Communities need to be helped to understand that there is a problem and support and education needs to be readily available to help them begin to provide solutions. This has the added benefit of helping to reduce stigma and thus increasing the service acceptability.
In widely dispersed communities generic workers will inevitably bear the brunt of the problem and require readily accessible support and training.
Given the more "hidden" nature of drug usage outreach work needs to be domiciliary rather than street based and often provides the basic information for further elaboration of services.
While 'shared care' will always be the preferred option, in rural communities this will not always be possible. Specialist services need to be readily accessible.
Flexibility and imagination are required when determining the specifics of service. The provision of satellite needle exchanges, the provision of satellite substitute prescribing clinics based in local drug agencies and the utilisation of a wide variety of community resources such as community centres make services as accessible and unobvious as possible.

Young People

Services specifically aimed at young people, for example, at a different venue or at different times to adults, may be more successful than mainstream services in gaining access to young drug misusers, and may also have some success in modifying attitudes to drugs, with improvements in health and reductions in criminal behaviour.
DATs and others planning services should review services provided to under 16s.
Close collaboration between specialist agencies and Social Work Departments, particularly around legal issues and child protection responsibilities, is particularly important, taking into account the implications of The Children's Act (Scotland) 1995.
Multi-disciplinary training programmes should be undertaken to facilitate closer collaboration between the various agencies.
Some young people being looked after by the local authority may be particularly vulnerable to drug-related problems - drugs prevention work with this group should be a priority for all local authorities, and needs to be co-ordinated with similar services provided by health, education and other agencies.
An appropriate local definition of young people should be agreed to ensure that services are properly co-ordinated.
Social work departments should also be aware of the likely emotional, psychological and practical needs of children of drug misusers, and ensure that services are available to address these.

Further guidance, based on the key findings of a review and evaluation of substance misuse services for children and young people in England, is contained in Appendix F

Drug Misusers with Mental Health Problems

Many drug misusers have mental health problems and some clients of mental health services misuse drugs and/or alcohol.

Effective liaison between services for individuals in both groups is essential.
Good practice within the community care programme approach may include joint assessments of individual needs by mental health care and drug misuse service providers and collaborative service delivery between drug, mental health and other agencies.

Overlapping Drug and Alcohol Problems

The need to respond to the needs of drug misusers with overlapping drug and alcohol problems needs to be recognised when planning services (see Appendix D).

Services for Women

The particular needs of women drug misusers need to be taken into account.
The provision of child care facilities may be an important factor in determining whether some women with dependent children make use of available services - fears that their children may be taken into care will be a relevant factor, to which service workers should be alert.
Some research evidence suggests that women drug misusers are more deterred than male users by the stigma attached to specialist drugs services - there may therefore be a need for more outreach approaches in "neutral" settings, such as community centres etc.
DATs should explore these issues further with those responsible for services and should actively seek the views of women service users to assist the process.
The special needs of pregnant drug misusers need to be addressed, and consideration should be given to the adequacy of liaison between maternity services and drug misuse services.

Ethnic Minorities

Services should be responsive to any particular service needs identified by minority ethnic groups.
Representatives of minority ethnic groupings should be consulted to identify such needs and ensure that they are then specified in subsequent contractual arrangements with those delivering services.

Self-help and Family Support Groups

The scope for encouraging the development of local self-help or family help groups who have the capacity to motivate and empower individuals to tackle their own or others' misuse needs to be considered.
Where possible, these groups should be encouraged to evaluate their work, with assistance from appropriate statutory or voluntary bodies.
People who look after relatives or friends who misuse drugs have the right to expect support as carers. This includes the right to an assessment of their own needs under the Carers (Recognition and Services) Act 1995. Local authorities must take the results of this assessment into account when deciding what services to provide to the person being cared for.

MANAGEMENT SKILLS AND THE PROVISION OF TRAINING

The delivery of high quality care demands good management skills, including:-
- being able to assess service user requirements accurately;
- enabling staff with different qualifications and priorities to work together well;
- being able to analyse and measure the impact of processes of care and treatment; and
- financial and strategic planning abilities.
Many small organisations such as voluntary sector community-based drug agencies may, because of their limited resources, find it difficult to recruit people with such management expertise. In these circumstances those responsible for services should ensure that appropriate arrangements are in place to overcome this difficulty. They can:-
- share in-house skills and training facilities through provider/ commissioner partnership schemes;
- include appropriately funded management training and audit requirements in contracts;
- support the development of training facilities and resources for specialised and non-specialised staff through DATs and other agencies; and
- support, through DATs and other agencies, service development initiatives.
It is essential for staff working in the drug misuse field to receive appropriate training to equip them with the necessary skills and expertise to deal with the myriad of problems with which they are confronted. Training in a number of forms is currently available to meet these needs, including specialist training for drug and alcohol workers by dedicated units at the Universities of Paisley (the Centre for Alcohol and Drug Studies) and Stirling (the Drugs Training Project) which receive Scottish Office funding. In light of a Drugs Task Force recommendation, SACDM is to consider the development of a strategy framework for substance misuse training