Residential rehabilitation - service mapping: report - 2019 to 2020

3. Referral Pathways and Funding Routes

3.1 Funding Routes

The facilities described accepting residents funded by a range of sources.

• Alcohol and Drug Partnerships (ADPs) – Four facilities accepted places funded by local Alcohol and Drugs Partnerships (ADPs) in 2019/20. Only the statutory residential rehab facility (LEAP) stated that ADPs funded all of their 81 placements. ADPs funded 57% of places at Phoenix Futures, while funding a minority of places across Hebrides Alpha Support (40%) and Abbeycare (3%). The majority of facilities (n=57%) reported receiving no ADP funded placements.
• Self-Funding – Three facilities accepted places which were self-funded. Self-funded places made up the majority (92%) of places at one facility, and less than half at another two (41% and 26%).
• Private Insurance – Two facilities reported that 5% and 59% of their placements were funded by private insurance.
• Other – Places across eight facilities were funded by a combination of Social Security payments (primarily Housing Benefit) and charitable funding. For six of these facilities, this formed the sole source of funding. One described receiving a small number of placements from Local Authorities across the rest of the UK.

Table 3.1 – Estimated percentage of individuals accessing facilities by different funding pathways across sectors, 2019/20 (13 facilities, n=1144)

      *Social Security Payments; Charitable Grant; Local Authority Funding from Rest of UK; Subsidised by Facility

Table 3.1 shows that self-funding was the most common (36.8%) funding pathway to residential rehabilitation across the thirteen facilities for which survey data was available. Other sources of funding (primarily Social Security payments in the form of Housing Benefit and charitable grants) contribute over a quarter (27.4%) of places across Scotland, with private insurance making up around one in five (22.0%) places. ADP funded places made up little more than a tenth (13.2%) of the total; higher only than those subsidised by the facility (0.4%).

3.2 Residential Rehab Admissions by ADP

ADP Annual Reports for 2019/20 were available from 22 of a total of 31 ADPs at the time of writing. ADPs were asked about the number of referrals taking place within their area. These 22 ADPs reported that they were aware of a total of 495 referrals taking place for the year 2019/20. In the ADPs for which Annual Reports were available, 62% of those starting residential rehab treatment during 2019/20 were male and 32% female, with 6% not specified (Figure 3.1).

There is a large variance in the numbers referred for treatment across these 22 ADP areas which is not fully explained by their different population sizes or estimated need. 77% of the total number referred to residential rehab facilities came from five ADP areas; Glasgow City, West Dunbartonshire, City of Edinburgh, Fife and South Ayrshire.

If the rate of referral in the ADP area with the greatest referral rates (122.6 per 100,000) was applied to the rest of Scotland, there would be an estimated 6,695 individuals referred to residential rehab facilities across the country. Caution should be applied when drawing conclusions from this estimate given the array of factors which likely contribute to the huge diversity seen in rates of admission to residential rehab across ADPs. These factors include the proportion of the population engaging in harmful alcohol or problem drug use across each area and the geographic distribution or availability of rehab facilities. Further, it is possible that, given the open ended nature of the question in the Annual Report, there may be variation in terms of how this question has been interpreted.

3.3 ADP Referral Pathways

Of the 22 ADP annual reports received so far 20 (91%) stated that they had specific pathways to access residential rehabilitation during 2019/20. The two areas which did not have specific pathways in place were both gave details of how this area is being developed and both areas did report that people had started a rehab placement during that year.

The ADP Reports detailed how referrals could be made by a number of agencies. Referral could be made by a number of professionals including NHS and other health professionals (such as GPs), voluntary sector and social work. In some cases people were able to self-refer. A number of ADPs described arrangements for referral via criminal justice pathways, including social work or direct from prisons. In some ADPs a range of professionals are involved in the assessment of referrals. In some cases the individual is also involved in the assessment process.

Three areas reported having a pathway in place, but that no people had started residential rehab during that financial year.

3.4 ADP Funding Criteria

ADPs were asked to broadly give details around their residential rehab pathways as part of the 2019/20 ADP annual report. While not providing a comprehensive record of all pathway details, the responses reveal a number of common features for funding criteria.

• Exhausted local options – a number of ADPs mentioned that people would only be considered for rehab if local community options had been unsuccessful and they had been unable to manage their recovery in a community setting.
• A clear goal of rehab/recovery and be engaged with services – several ADPs highlighted the need for an individual to express a clear goal of recovery and positive engagement with residential rehab. Some cited specifically that being engaged with services is a pre-requisite. 
• Abstinence / post detox admission – some ADPs specified a period of abstinence or a detox process as a perquisite for admission to rehab.
• History and background of the person – considerations include a drug and alcohol history, social history, medical history, family history criminal justice history and forensic history and toxicology.

3.5 Funding Arrangements and Partnerships

ADPs described a number of different funding arrangements they held with the NHS and local authorities. These funding arrangements take a number of different structures across ADPs. Four of the ADPs for which data was available described three specific forms of funding arrangements.

• Funding is provided by the NHS Exceptional Referral fund, occasionally supplemented by Social Work;
• The detox phase is funded by NHS and the rehab phase by the Local Authority;
• The first 6 weeks are funded by, with the following 6 weeks funded by the Local Authority.

ADPs also described a range of partnerships with specific rehab providers. Five ADPs (North Ayrshire, South Ayrshire, East Ayrshire, Highland and MELDAP) described partnership arrangements with specific rehab providers.

• North, South & East Ayrshire - Five short term elective dual addictions / mental health residential rehabilitation beds are available within local NHS Addictions Inpatient Unit;
• Highland - Eight beds commissioned through one facility (two short stay and six 14 week placements);
• Midlothian & East Lothian (MELDAP) – Commission 20 places annually at one facility.

3.6 ADP Expenditure

ADPs were asked to detail how much they spent on residential rehab as part of their Annual Report. Understanding expenditure in this area is problematic and not recorded in a uniform way, therefore ADP spend figures are unlikely to be an accurate representation or provide comparable data.

Because of the different funding and partnership arrangements detailed above, spend will not always flow through the ADP. Data is still being collected and some ADPs could not provide details as funding structures do not allow for this disaggregation. However, the available data does provide insight into the marked variability of funding across ADPs:

• Total funding reported varied from £2000 to £4.2 million;
• three areas reported they had no expenditure on residential rehab (Orkney,  Dumfries & Galloway and Renfrewshire);
• expenditure per place varied from £0 to £34,000; and
• the average expenditure per place (where any expenditure was reported) was around £7000.