Drug and alcohol services - improving holistic family support

2. A Whole Family Approach and Family Inclusive Services in Scotland

"I would not have dealt with what was happening if you had not supported me and could have been really ill, I now feel can change the situation with ongoing help."

(Adult affected by another's substance use)

This section describes the commitments and vision from Scotland's alcohol and drug strategy Rights, Respect and Recovery and makes connections to:

• Adverse childhood experiences (ACEs) and trauma.
• Getting Our Priorities Right (GOPR), Scotland's guidance for services working with children, young people and families affected by substance use.
• Quality Principles: Standard Expectations of Care of Care and Support in Drug and Alcohol Services: Quality Principle 8 – Services should be family inclusive as part of their practice.
• Positive outcomes for children through a strengths-based approach and joined up to their families through the GIRFEC approach and national practice model.
• Strategic cross-sector work to improve holistic family support across Scotland.
• Statutory requirements to work in partnership to plan, deliver, review, and report on the extent to which outcomes have been improved for children, young people and families through delivery of services and support to improve wellbeing through each area's Children's Services Plan (Pt 3 Children and Young People (Scotland) 2014 Act)^[2].

2.1 One of Scotland's Public Health Priorities is to reduce the use of and harm from alcohol and drugs, with a particular focus on reducing alcohol and drug related deaths^[3]. RRR published in November 2018 sets out Ministers' commitments to reduce alcohol and drug harms with a detailed vision:

"Scotland is a country where 'we live long, health and active lives regardless of where we come from' and where individual, families and communities:

• have the right to health and life free from the harms of alcohol and drugs
• are treated with dignity and respect
• are fully supported within communities to find their own type of recovery"

2.2 Within RRR there is a specific focus on the needs of children, young people and their families who are affected by alcohol and drug use. RRR highlights that parental/family alcohol and drug use is a commonly recognised adverse childhood experience (ACE), which (without support) can have potential long-term impacts on children's wellbeing into adulthood. RRR emphasises that understanding and addressing this impact is crucial to safeguarding children's current and future wellbeing. In Scotland our approach to improving outcomes for children, young people and families is based on Getting It Right For Every Child (GIRFEC) with a statutory definition of wellbeing in part 18 of the Children and Young People (Scotland) Act 2014 of:

• Safe,
• Healthy,
• Active,
• Nurtured,
• Active,
• Responsible,
• Respected,
• Included.

2.3 RRR calls for the development of a whole family approach, underpinned by family inclusive practice, across alcohol and drug services, children's services, criminal justice and other settings where individuals and families affected by substance use seek help or are protected. RRR sets out to define the intent of developing whole family approach/family inclusive practice in Scotland by linking the needs of individuals experiencing difficulties with alcohol and drug use with those who may be directly or indirectly affected:

"Alcohol and drug use by a loved one can also cause trauma and distress for their children and families, often leading to relationship breakdown and increased caring responsibilities for the child(ren). The impact of parental alcohol and drug use is far-reaching, it can increase the risk of abuse and neglect and negatively influence wellbeing throughout life – from antenatal development through to adulthood each family is unique and their experience and journeys are all different, however, they all require support, compassion and understanding. Effective, high-quality treatment and a family-inclusive approach for people affected by drug and/or alcohol use is vital and can have significant benefits for those around them."

2.4 This approach is reinforced by Getting Our Priorities Right (GOPR) Scotland's guidance for services working with children, young people and families affected by substance use. This document recommends that "All child and adult services should focus on a 'whole family' approach when assessing need and aiming to achieve overall recovery. This should ensure measures are in place to support ongoing recovery".^[4] GOPR sets this within the context of the GIRFEC national practice model and professionals in the Team Around the Child and Family working together to coordinate support through
a Child's Plan.

2.5 In 2014, Quality Principles: Standard Expectations of Care and Support in Drug and Alcohol Services for Alcohol and Drugs Services' were published by the Scottish Government^[5]. Quality Principle 8 reflects the need for services, as part of their wider commitment to recovery, to take a family inclusive approach and sets out the conditions and expectations of services. These include involving family members, with agreement, to participate in individual recovery as well as recognising "… the needs of members of your family and those you live with and, if needed, seek support for them."

2.6 The relationship and effective working arrangements between adult alcohol and drug services and children and families services are critical to the delivery of a whole family approach, at both a frontline practice and strategic planning level. Despite the existence of long-standing local protocols and procedures, at a system level, the RRR Strategy, among other authoritative sources,^[6] recognises that "there remains scope for improvement" in relation to effective, consistent information sharing and joint working between adult and children's services in supporting families and protecting children.

"I would not have dealt with what was happening if you had not supported me and could have been really ill, I now feel can change the situation with ongoing help."

Adult affected by another's substance use

2.7 Most families have the resilience, strengths and capabilities they need for recovery and these should be nurtured and supported to ensure both children and adults can thrive and prosper. Many, perhaps the majority of families are not receiving support from formal services. However services and agencies should share a common understanding that people often develop substance use problems in an attempt to cope with past or current trauma in their lives, including the impact of adverse childhood experiences (ACEs). It is therefore crucial that responses to substance use include trauma-specific interventions where appropriate, but also ensure that every aspect of service design and delivery is trauma-informed and trauma-responsive. The Scottish Government has committed to developing trauma-informed workforce and services across Scotland and funds the National Trauma Training Programme led by NHS Education for Scotland (NES)^[7], which provides freely available, evidence-based training and resources.

2.8 The CORRA Foundation's review of relationship-based practice developments^[8] found that "whole family work was more often perceived and described as involving multiple practitioners with different family members…" and that "most charities reported working collaboratively with different services, while few reported working collaboratively with multiple family members", suggesting there is still some way to go in Scotland in developing cohesive, co-ordinated approach to supporting the whole family in their experience of substance use.

2.9 Rights, Respect and Recovery acknowledges this limited and inconsistent progress. It prioritises the need for Scotland to:

• More effectively support the positive contribution family members can make to a person's recovery journey.
• Recognise the importance, and at times complexity of family relationships in supporting or undermining positive change.
• Helping family members who also need support to build their own resilience and recover themselves.

2.10 Public Health Scotland and the Drug Deaths Task Force published the Medication-Assisted Treatment (MAT) Standards for Scotland – Access, Choice, Support in May 2021.^[9] Key components of these standards are:

• People can get a prescription or other treatment support they request on the day they present to any part of the service. People have the right to involve others, such as a family member or nominated person to support them in their journey through care. Staff will help people to do this if they choose this form of support.
• People are informed of independent advocacy services that are available and feel able to use them to discuss the issues that matter to them.
• People are aware that treatment is not conditional on abstinence from substances or uptake of other interventions.
• People who have stopped accessing MAT or who have undergone detox are supported to easily come back into services for the care they need.
• If people miss appointments, services do not discharge them and actively get in touch to find out what people need to continue in treatment.
• People are made aware that abstinence is offered as a choice along with other treatment options.
• People will be given information and advice on recovery opportunities within their community.
• People can expect support from community pharmacists, dentists and GPs as part of their care plan, including being able to ask to move their drug treatment to their GP when appropriate.
• People are clear about what choices are available to them throughout their journey through services and are aware of their right to make their own decisions about their care plan.
• People feel listened to and involved in all decisions. They understand the different medication options available, including appropriate dose options.
• People feel able to talk about and review the choices they have made with their worker at any time. They have support if they choose from advocacy or a family member or nominated person and are encouraged to do so.
• People feel able to provide feedback, including complaints, to the service on the way they have been treated, through formal or informal channels.
• People can expect a service that is welcoming and treats them with dignity and respect, working with them to improve their health and wellbeing.
• People can get treatment and care for as long as they want to.
• People can expect that different organisations will work together to meet their needs and that information about them will be shared and stored appropriately.
• People feel involved in the design, delivery and evaluation of MAT service.

2.11 In addition to this, the MAT standards set out what the standards mean for families or "nominated persons".

• The service will ensure people are aware of their right to have someone, such as a family member or nominated person, to support them while they are in MAT, and staff will actively assist and support people who choose this option.
• Family members or nominated persons are welcomed at visits and treated with dignity and respect. Their own experiences and points of view are acknowledged and valued when people request that they attend.
• Family members or nominated persons feel involved in choices about care plans and are encouraged to support the person in following their treatment plan.
• Family members or nominated persons are confident that if they contact a service with immediate concerns for the safety of their loved ones, of themselves, or of those around them, including children, they will receive appropriate and timely support.
• There are clear pathways that enable family members or nominated persons to use independent advocacy to raise concerns if, for example, they feel they have not been fully informed in decisions about the person's care.
• Family members or nominated persons have a named worker as a main point of contact with services and are confident that services are working together and sharing information appropriately.
• Family members or nominated persons feel involved in the design, delivery and evaluation of MAT services.
• Family members or nominated persons feel able to provide feedback, including complaints, to the service on care planning and treatment, through informal or formal channels.

The MAT standards are an important component in an integrated Whole Family Approach and Family Inclusive Practice.