20 July 1993

THE NEEDS OF PEOPLE WITH ALCOHOL AND DRUG PROBLEMS WITHIN COMMUNITY CARE

Summary

This circular contains guidance to local authorities on the needs of people with alcohol and drug problems within community care services.

1. This Circular is intended to complement existing community care. It highlights particular issues which local authorities will require to consider in respect of people with alcohol and drug problems following the implementation of sections 51-58 of the National Health Service and /Community Care Act 1990 (NHSCC Act 1990) which came into force in April 1993.

2. This circular does not affect provision made within the NHS for treatment/rehabilitation. Health board responsibilities for funding health care from general allocations and other earmarked funding for alcohol, drug and HIV services remain unaltered by the new community care arrangements. It is important however for local authorities to recognise the distinct role that NHS services have to play in the treatment of individuals who have alcohol and/or drug problems and, in particular, the scope which exists for joint working with primary health care professionals and specialist staff within hospital or community settings. Local authorities will need to consider and draw up clear agreements with health boards under the community care arrangements framework covering arrangements for funding treatment and rehabilitation services for people with alcohol and/or drug problems from April 1993. Authorities may also wish to explore the possible benefits from liaison with local health education and health promotion departments.

3. The statutory basis for local authority assessment of need, provision of services and placement in residential care of children under 18 who have alcohol and/or drug problems is set out in the Social Work (Scotland) Act 1968 and Associated Guidance and Regulations and is not the subject of this circular. Likewise, this circular does not address itself directly to social work services in the criminal justice system, the main elements of which are subject to 100% funding and to National Objectives, Priorities and Standards. However, local authorities will be alert to the importance of a coordinated approach to planning and delivery of these different services so that appropriate resources are available to those who need them without unnecessary duplication.

Purpose

4. There has been concern in many quarters about the impact of the new community care arrangements on the provision of services for those who have alcohol and/or drug problems. This is due, in part, to the low priority which it is feared will attach in practice to this care group. Because it is considered important for local authorities to ensure the continued provision of services tailored to the needs of those with alcohol and drug problems after 1 April 1993, SWSG has decided to issue this supplementary circular of guidance. This is not to detract from the needs of other care groups but reflects the sensitivity of this particular area of community care need at this time.

Background

5. The Government's community care policy and the White Paper "Caring for People" commits the Government, local authorities, health boards, and others to the continuing development of a comprehensive range of services, including services to meet the needs of people with alcohol and/or drug problems. It is therefore necessary for authorities to ensure that:

a. Community care plans address the needs of those who have alcohol and/or drug problems as well as other user groups.

b. The circumstances of people who have alcohol and/or drug problems are recognised and reflected in appropriate procedures for assessment and care management, and the purchasing of care.

6. SWSG's letter of 2 October advised individual authorities of the size and distribution within Scotland of the transfer of resources from DSS under the community care reforms, and the additional resources in 1993-94 for implementation of these reforms. It was made clear that the sums transferred covered all adult client groups who have had recourse to the system of DSS board and lodging allowances for residential and nursing home care, including those with alcohol and/or drug problems. Available information also gives authorities an indication of existing patterns of spend on this care group, and should assist authorities to determine reasonable budgets for 1993/94.

7. The Government White Paper "Caring for People" states as one of its 6 key objectives for service delivery that the Government's intention is to promote the development of a flourishing voluntary and private sector alongside good quality public services. A flourishing voluntary and private sector is particularly important for this care group because many people with substance misuse problems are reluctant to approach local authorities for help. Local authorities are reminded that their key planning and purchasing role means they must seek the best quality and value for money in meeting assessed needs from a range of different suppliers and services. The precise terms of contracts with particular providers have to be addressed at local level taking account of the particular needs and circumstances in question. Advice on this is given in SWSG Circular No SW19/1991 on Commissioning and Purchasing.

Individual Needs of People with Alcohol and Drug Problems

8. People who have alcohol and/or drug problems will have certain characteristics which create problems in care management and assessment. For example, they may have health needs which require management by trained health professionals; they may move between areas frequently; and they may behave unpredictably. While these characteristics will also be found in other care groups people with substance misuse problems are likely to experience them more frequently. In addition, many will have problems particularly related to this care group. For example, some may have been involved in criminal activity or have been the subject of criminal proceedings as a consequence of their substance use and be reluctant to contact statutory agencies. Women drug users in particular are often reluctant to contact statutory services for help with their substance misuse because they fear their parenting will be scrutinised and their children received into care. Other people with alcohol or drug problems may require to be counselled and some will need to be made aware of testing for viruses such as Hepatitis B and HIV. People who have alcohol and drug problems are also particularly prone to relapse. It will often be necessary to provide services several times before they succeed in controlling their alcohol and/or drug problem.

9. Assessment procedures and arrangements should recognise the immediacy of the needs of many people with alcohol and/or drug problems and should facilitate a quick and effective response within the parameters of available resources. A rapid response may help to reduce the risk of further deterioration in any health, social, legal or care difficulties which the individual may be experiencing. Attention should also be given to the needs of carers where people with alcohol and/or drug problems approach or are referred to an agency for assistance. Extensive guidance is contained in Circular SW11/1991 on Assessment and Care Management, notably paragraphs 5, 8 and 9.

The Role of Local Authorities

10. Following the introduction of the community care reforms, local authorities' responsibilities for arranging and funding the care of people with alcohol and/or drug problems will be:

a. Assessing the social care needs of the local population for alcohol and drug services.

b. Including a range of services for people with alcohol and/or drug problems in their community care plans.

c. Assessing the social care needs of those with alcohol and/or drug problems, including those whose habits make them more susceptible to health problems, for example drug users who share needles.

d. Arranging appropriate packages of care which may include a range of options.

11. People with alcohol and/or drug problems who were in voluntary and private residential care or nursing homes on 31 March 1993 will generally have preserved rights to higher levels of income support. Local authorities are responsible from April 1993 for assessing needs, in consultation where appropriate with health professionals and the voluntary and private sector, and making appropriate provision in accordance with the community care arrangements.

12. People who enter voluntary and private sector homes from 1 April 1993 are eligible to claim ordinary income support, including premiums, and a residential allowance. The local authority will take account of these payments when assessing the person's ability to contribute to the cost of their care. Local authorities are responsible for arranging and funding the social care costs of alcohol and drug services from resources provided.

Community Care Plans

13. Community care plans should address the needs of local populations for alcohol and drug services and show the local arrangements for the delivery of community care services. Local authorities should, in co-operation with other agencies involved in the field, establish machinery to measure the prevalence of alcohol and drug use within their areas and identify and cost the services currently provided and resultant gaps or deficiencies. In addition, they should demonstrate that appropriate arrangements are in place to consult, and maximise the use of, the voluntary and private sector. A strategy for service provision needs to take account of the patterns of prevalence of alcohol and drug use within an area and the fact that some people who have alcohol and/or drug problems for whom authorities are responsible may require services outside that authority's area. Community Care Plans should also describe the arrangements and criteria which are in place for assessment and joint action.

14. Letters from SWSG have now gone out to local authorities giving them general comments on the first round of community care plans. Generally, local authority services in the alcohol and drug field are uneven. Some are poorly developed and unsupported by a strategic or operational planning framework. Future community care plans will need to address these issues. The next stage of monitoring community care plans will closely examine the progress achieved by local authorities and health boards in agreeing policy objectives for meeting specific targets and outputs for all the care groups, including people who misuse drugs and alcohol. Correlating local prevalence and need with a purchasing plan for services is an important future task for local authorities.

15. It will also be necessary to ensure that the drugs element within community care plans complements and informs the strategic plans to be drawn up by the Drugs Action Teams (DAT). DATs are to be established in all Health Board areas by 1 April 1995, at the recommendation of the report of the Drugs Task Force which was led by Lord Fraser, Minister of State at The Scottish Office.

16. The National Objectives and Standards for Social Work Services in the Criminal Justice System, Part 1, paragraph 53.1.3, emphasises that local authority plans for criminal justice services should contain a statement as to how these services are organised, managed

and delivered with particular reference to arrangements for linking policies and services in this area with those which span several client groups, for example, alcohol and drug services. Plans for young offenders should also reflect the link with alcohol and drug services.

Eligibility for Assessment

17. Local authorities will need to address issues of assessment and care management for people with alcohol and/or drug problems. Local procedures will need to include criteria which are sensitive to the circumstances of people with alcohol and drug problems. Local authorities should ensure, in particular, that:

a. Individuals who have no settled residence are not excluded from assessment because of eligibility criteria which require a duration of residence.

b. Arrangements are in place to enable the assessment of people with alcohol and drug problems ordinarily resident in one authority, by another authority. Local authorities might wish to consider the benefits of agreement on the type of information to be recorded on assessment forms or of developing standard and agreed assessment procedures and forms. A network of named responsible officers within local authorities should help this.

c. Protocols specifying referral routes and systems are established with all the relevant agencies to which those with an alcohol or drug problem are likely to go for help, so that those agencies can initiate assessment procedures. Agencies should note Circular No.SW11/1991, paragraph 13, where it is stated that appropriate medical and nursing advice should always be sought in an assessment which is considering whether an individual's needs call for residential or nursing home care. A decision to provide nursing care may be made only after consultation with a medical practitioner. (Section 12A(2) of the Social Work (Scotland) Act 1968 inserted by section 55 of the NHS Community Care Act 1990). Close co-operation and good joint working between health boards and local authorities will assist this.

Adapting Assessment to the Needs of People with Alcohol and Drug Problems

18. Local authorities need to ensure that their assessment systems take full account of the different ways in which those with alcohol and drug problems may present. Few people are referred to social work departments explicitly or solely for help with such problems, although the difficulties they are experiencing may be exacerbated or caused by substance misuse. It is therefore important that:

a. All standard local authority assessment procedures and documentation include consideration of a possible alcohol or drug problem. All personal information should be regarded as confidential. Issues relating to confidentiality are dealt with extensively in the SWSG Code on Confidentiality of Social Work Records, January 1989, in particular paragraph 10. This includes the need for clear local guidelines on the circumstances in which relevant personal information may be shared, both within social work departments and with other agencies.

b. All relevant local authority staff have a basic understanding of alcohol and drugs and the ability to identify specifically related alcohol and drug problems. Practice guidance issued by Social Work Services Group in 1987 emphasised the importance of training to equip staff within local authorities to be able to identify where substance misuse is an issue. Some local authorities may wish to develop local education and training strategies jointly with the non-statutory sector and other relevant professional groups.

c. All relevant local authority staff are able to apply brief intervention techniques and know where to seek specialist help, either from another worker or another agency. Particular attention should be given to the training of unqualified staff including home helps and care workers, both residential and non-residential.

d. The needs of carers and/or families are addressed as part of the assessment.

19. There are a range of organisations and professionals who deal frequently with those who have alcohol and drug problems. Many services are provided by the voluntary and private sector, particularly by voluntary organisations. Local authorities should consult voluntary and private sector and health service providers in drawing up and agreeing assessment procedures with a view to involving them, where appropriate, in the assessment process. This might include, for example, involving independent sector agencies in the assessment process and utilising that experience to undertake assessment. Joint agency agreement will also be required on the establishment of referral protocols (see paragraph 17(c)) and rapid assessment procedures (see paragraph 22). If assessment is contracted to a voluntary and private sector agency to undertake, it is vital that ultimate responsibility for assessment and decisions to commit resources is recognised to remain with the local authority.

20. As with other community care provision assessment procedures will require to be needs led and not service led. They should examine the needs of the individual for any form of care or support, not for particular services. However, in drawing up the care plan for meeting identified need arising from this assessment, authorities will require to take account of, and consider realistically available resources and services. Circular SW11/1991, paragraph 6, explores this further.

Rapid Assessment Procedures ("Fast Track" Assessment) and Emergency Action

21. People who have alcohol and drug problems may sometimes be in such urgent need because of workplace or family crises, difficulties with child care or fluctuating motivation that either the process of assessment will require to be speedy, or assistance may need to be provided immediately. Advice on urgent admissions to residential or nursing home care and hostels is given in paragraph 14 of Circular SW11/1991 on Assessment and Care Management. SWSG have consulted ADSW/COSLA and the voluntary and private sectors to discuss whether further guidance is needed and a working group has now been established to take this forward.

22. Local authorities, health boards and voluntary and private sector providers should co-operate closely to ensure that rapid assessment procedures meet the needs of those with alcohol and drug problems. In order to do so, local authorities and providers should monitor from the outset their pattern of referrals so that appropriate arrangements can be made. Local authorities and voluntary and private sector service providers will together wish to have regard to the Department of Health's practice guidance "Assessment and Care Management for Alcohol and Drug Misusers" issued in February 1993.

23. Local authorities should consult other agencies on the type of service and access criteria required for an emergency service for people in urgent need. Local authorities may contract with a service provider about longer-term provision as soon as practicable. In cases of urgent need the area of ordinary residence of the person should not be a consideration. "The Care Management and Assessment - Managers Guide" issued by the Department of Health in collaboration with SWSG covers the arrangements for urgent admission to both residential and nursing home care.

Out of Area Referrals

24. Disputes about ordinary residence should not prevent people receiving the care they need. Local authorities should ensure that there are arrangements in place for responding to the following types of out of area referral:

a. Where people are ordinarily resident outside the area of the local authority undertaking the assessment, there will be a need to liaise with the local authority in the area of ordinary residence to establish responsibility for funding the care package.

b. Where people are in urgent need of residential care but are ordinarily resident outside the area.

c. Where a person's area of ordinary residence cannot easily be identified the local authority which is approached for help must assume responsibility for arranging the provision of necessary services. Where the person's place of ordinary residence may be in England or Wales it should be determined on the basis of the guidance which has been issued by Department of Health. In other circumstances it should be determined on the basis of the protocol agreed between authorities in Scotland. Where agreement between authorities cannot be reached an agreed statement of the circumstances should be provided to the Secretary of State who will make a determination based on the Department of Health guidance.

25. For some people with alcohol or drug problems who may be ordinarily resident in the area of the local authority undertaking the assessment, there may be benefit in being referred to a residential service away from the area in which they are experiencing their alcohol and/or drug problem. Local authorities are reminded that the Social Work (Scotland) Act 1968 (Choice of Accommodation) Directions 1993 advises that people who are assessed as needing residential care should be able to exercise choice over the place where they receive that care, provided that the place is considered suitable and that the costs to the local authority are no higher. Local authorities should ensure that resources can be identified for out of area placements.

Cross-Border Referrals

26. Local authorities should take account of the guidance mentioned at paragraph 24c. This guidance is consistent with that south of the Border.

Facilities for People with Alcohol and Drug Problems

27. Local authorities must ensure that people with alcohol and drug problems are referred to services suited to their needs. Consideration will require to be given to a range of service options. Services which Local Authorities might wish to consider are:-

27.1 Local authority or voluntary or private sector agencies based in the community. These agencies offer a wide range of services including; information, advice and support to people with alcohol and drug problems and their families, counselling and assessment services, individual and group counselling, street contact, advice on safer sex and safer alcohol and drug use, education and leisure pursuits including training for employment or acquiring new skills, health promotion, home visits and aftercare programmes. In addition there are a range of self-help groups offering direct support to users and families of alcohol and drug users.

27.2 Residential care including nursing home care. A number of different programmes are offered some including detoxification. Programmes vary in length between 3 weeks and 18 months. Some may offer after-care involving counselling and/or groupwork. Links should be established between residential and community agencies to ensure that people with drug and alcohol problems receive continuing support in the community. Crisis services for people with substance misuse problems are being developed in some areas.

27.3 The National Health Service. This provides a wide range of treatment options for people with an alcohol or drug problem, from early detection and intervention by members of the primary care team, through to specialist medical and psychiatric services provided on an out-patient, day-patient and in-patient basis. This includes home and hospital detoxification, treatment and rehabilitation and the management of other associated health problems, both of a psychological and physical nature.

27.4 Assistance provided by housing authorities and housing associations and the provision of suitable accommodation for people with alcohol and drug problems. Circular No. Env 8/1991 gives general guidance on the role of housing in community care, advice on housing authorities' role in community care planning and assessment; advice on the level of provision required and on sources for securing it, and advice on providing a range of services to meet the housing requirements of those with community care needs, including those with alcohol and drug problems. This circular is being revised.

28. Local authorities can obtain information about the various services available for alcohol and drug misusers in Scotland both locally and nationally in publications from the Scottish Council on Alcohol and the Scottish Drugs Forum. Through the community care planning machinery local authorities and other agencies should, assess the adequacy of facilities within their own area and those outwith their area to which they make referrals, with a view to jointly establishing adequate service provision for people who misuse alcohol or drugs.

Monitoring

29. The Scottish Office Drug Misuse Database has a key role in developing an accurate assessment of the drug misuse problem in Scotland and predicting developing drug misuse trends. It is important for local authority social work departments, medical services and other relevant agencies, to make regular returns.

30. Local authorities are responsible for monitoring and evaluating the arrangements for the assessment and care management of people with alcohol and drug problems within the community care framework. These responsibilities are referred to in Circular No.SW11/1991 on 'Assessment and Care management', and section 2 of 'The Managers Guide to Care Management and Assessment', published in 1991 by SWSI/SWSG. These arrangements should be capable of identifying both unmet needs (so that they can be taken into account in future planning) and the views of users and carers. Local authorities may also wish to ensure that they obtain value for money when purchasing services. The quality and cost-effectiveness of services and agencies' ability to achieve stated targets and goals in respect of service outcomes are important factors to consider in the contracting process.

31. The Scottish Office will be monitoring the implementation of the community care reforms generally. This will include examination of the provision of services under the new arrangements for people with alcohol and drug problems. The revised monitoring arrangements will be set out more fully in an update of SW Circular 21/1991. In addition, SWSG will be taking action to monitor the effectiveness of this particular circular.

32. Further copies of this circular and any information or advice concerning this Circular may be obtained from Neil Rennick, Social Work Services Group, Room 22, James Craig Walk, Edinburgh EH1 3BA (telephone 0131 244 5389).

Yours sincerely

LESLEY CLARE

ANNEX

COMMUNITY CARE IN SCOTLAND

CIRCULARS AND GUIDANCE

Note: This is the situation at 17.2.95. Further circulars are under reviewfor inclusion later.