Residential rehabilitation pathways: lived experience interviews

4. Conclusions

4.1 Overview

This report has drawn on qualitative interviews with people with lived experience of having accessed residential rehabilitation to explore, from their individual perspectives, the pathways into, through and out of residential rehabilitation across Scotland. As noted, this report complements the suite of reports published by the Scottish Government in November 2021 which explored these pathways through surveys of ADPs and residential rehabilitation providers.

While these accounts cannot be assumed to be representative of experiences across the sector given the small sample size, they provide a valuable insight into important aspects of residential rehabilitation. It is again important to caveat the accounts provided by noting that the majority of accounts relate to experiences of pathways into, through and out of residential rehabilitation prior to the recent increase in Scottish Government funding for residential rehabilitation across Scotland.

We would like to explicitly thank the people who kindly gave their time to share their experiences with us. We would also like to acknowledge the important role of the Scottish Recovery Consortium, Restoration Fife, and Lothians and Edinburgh Abstinence Programme (LEAP) for facilitating the link between the research team and individual people with lived experience of having accessed residential rehabilitation for the purposes of this research.

4.2 Considerations

This programme of research has been agile and dynamic and researchers have worked closely with the policy team and the RRDWG, reporting findings as early as possible to support evidence-based policy. As a result, the Scottish Government work streams to respond to the issues and considerations highlighted in this suite of reports are underway. This section presents the key considerations raised by the findings of the reports and the progress so far towards addressing them.

A number of considerations were made in the report summarising the pathways surveys undertaken with ADPs and residential rehabilitation providers, published in November last year. A number of these considerations are also relevant to the findings of this research:

• A need to develop standards regarding the pathways around access, assessment, referrals, funding, and aftercare – The ADP survey found substantial variation in the pathways into, through and out of residential rehabilitation across ADPs, and an appetite for greater guidance around pathways. The experiences which participants shared through interviews demonstrated the substantial barriers which they faced in getting referred to, and accessing, residential rehabilitation placements. The implementation of standards across each ADP, alongside guidance, would allow for the development of these pathways and the minimisation of geographic inequalities in access to rehab and aftercare.

• A need to minimise structural barriers which reduce equity of access – While it is necessary that certain entry criteria and person-centred clinical judgement are in place to ensure the safety and efficacy of rehab for the individual and others attending these facilities, the ADP and providers surveys highlighted that current referral and entry criteria sometimes include unnecessarily prohibitive barriers. Financial barriers are also apparent, as well as wide variation in funding mechanisms for individual placements. Such barriers were reflected in the accounts of participants interviewed for this report. These findings highlight a need to ensure clearer pathways and greater access to statutory funding for rehab placements across all areas, with specific work needed across the nine ADPs identified as having underdeveloped pathways.

• A need to establish a centralised list of approved rehabs – The ADP and providers surveys identified that only a few ADPs maintain a list of preferred rehab providers, and that there is more general need to improve communication between ADPs and providers. Interviews with those with lived experience of accessing rehab highlighted a lack of awareness of residential rehabilitation facilities among both individuals and families affected by problem alcohol and drug use, and among potential referrers. Further, some described the rehabilitation facilities which they initially attended as having not been appropriate for a number of reasons, but having benefited from subsequent placement in more suitable programmes. A centralised list of approved residential rehabilitation providers, made available both online and in physical form, could assist in raising awareness among ADPs and potential referrers of the specific offerings of rehab providers. This centralised list would help to inform choice regarding individual placements.

• A need to develop specific preparatory programmes – The ADP and providers reports highlighted significant variation in preparatory work for residential rehab, both in terms of programmes offered and the agencies responsible for this preparatory work. Participants' accounts here reflected this variation, and demonstrated the importance of preparatory work in allowing individuals to gain benefit from their placements. These reports have also highlighted an opportunity to learn from and share best practice, and to develop standards around preparatory work across Scotland.

• A need to establish structured links to detox – Poor access to detox forms a barrier to accessing rehab, particularly for those seeking recovery from benzodiazepine use or those who otherwise require complex detox. The providers survey highlighted that less than half of rehab facilities offer in-house detox, that there are long waiting times for external detox facilities, and that many of those accessing rehab detox without medical assistance, or through unknown pathways. The interviews reported on here similarly highlight wide variation in experiences of detox prior to placement. There is a need to increase detox provision, and for greater alignment with rehabs. Specific pathways for people taking high doses of benzodiazepines or engaging in complex poly-drug use may be beneficial.

• A need to ensure robust exit planning and continuity of care – Those who had been able to access aftercare highlighted its importance in helping to sustain recovery following a rehab placement. While the previous surveys found that most providers offer aftercare, and that aftercare is available in most ADP areas, they also demonstrated a lack of clarity around who is responsible for aftercare, particularly for non-local placements. This could heighten risk, particularly for those making unplanned exits. It is also vital to improve clarity around options to return to rehab. Evidence-based guidance regarding if and how re-admittance should be arranged would support decision making.

In addition to these considerations, the interviews undertaken with people with lived experience have led to the development of a number of further considerations, as follows:

• A need to further understand person-centred suitability for referral – The interviews captured a range of experiences prior to referral, with prior levels of motivation – on which referral and admission often hinges – at times seemingly unrelated to people's engagement with the programme, and subsequent outcomes. These findings highlight a need to further understand the concept of 'rehab readiness' in order to explore who may benefit from rehab, and at what time.

• A need for further research to explore what aspects of rehab work for different people – These interviews identified a number of aspects of residential rehabilitation which participants felt had been useful in helping them to sustain recovery during and following their placement. While those interviewed formed a relatively representative sample of those accessing rehab across Scotland, the small sample size makes extrapolating these findings to particular population groups challenging. Further research may explore what aspects work for particular population groups.

• A need to improve knowledge and choice in relation to different rehab programmes – Findings here demonstrated that participants sometimes found aspects of rehab programmes unsuitable for them, while gaining greater benefit from their placement at other facilities. These findings highlight a need for greater access to knowledge of different rehab programmes involve prior to referral in order to ensure that individuals and referrers work together to identify facilities which are suitable for the individual.

• A need for development of knowledge of residential rehabilitation across potential referrers – The accounts of some of those interviewed highlighted a poor and variable knowledge of residential rehabilitation facilities among potential referrers, including both primary care providers, and drug and alcohol services. These findings highlight a need to develop this understanding among potential referrers in relation to the availability of residential rehabilitation services are available across Scotland, and of how to identify individuals as potentially suitable for potential referral.

• A need to further explore the impact of rehab placements, and which specific outcomes measures to use – Participants described a wide array of positive outcomes following their placement. Some of the people who took part in interviews suggested that they had briefly returned to problem substance use following their placement, but that the tools which they had learned during their placement had allowed them to keep these periods of use relatively brief. These findings highlight a need to further understand the short- to longer-term outcomes for individuals following placements, and how to measure these in a way which captures this complexity.