Residential Rehabilitation Working Group: drug and alcohol residential treatment services - recommendations

Residential Rehabilitation Working Group: recommendations on drug and alcohol residential treatment services

Purpose

This paper provides a set of recommendations to the Scottish Government and other partners involved in reducing the harms caused by problematic use of alcohol and drugs – recommendations which will help meet the needs of people who would benefit from residential rehabilitation as part of their recovery journey.

The recommendations, set out at Annex A, are based on evidence, existing examples of good practice and the context of the problems being experienced now in Scotland.  These recommendations pave the way for further immediate work on improving access to treatment and better planning around the use of existing capacity.  In the medium term the Group is recommending a review of funding models, the establishment of shared principles on standardisation, sustainable, effective pathways to treatment with a view to having national guidance for treatment provision.  For the longer-term the Group is highlighting the need for significant changes.

The immediate actions being recommended would need to be underpinned by taking account of the voices of people who could benefit or have benefitted from this form of treatment.  These actions also require focused research and joint working across a range of partners.

Introduction

Residential rehabilitation treatment for drug and alcohol problems is a well-established intervention acknowledged in the Drug Misuse and Dependence National Clinical Guidelines as an important option for some people requiring treatment.  A recently published international review^[1] of residential treatment outcomes for substance use disorders, which included a methodologically strong study from Scotland, found evidence for the effectiveness of residential treatment in improving outcomes across a number of substance use and life domains.  It is important there is access to this intervention evenly across Scotland and that national models are developed around planning, value for money, commissioning, referral pathways, types of intervention, discharge and aftercare, what constitutes good or best practice and monitoring or regulation.

European evidence^[2] suggests that access to residential treatment is lower in the United Kingdom than in other European countries, although it is not clear if this is related to need or demand for residential services or the value placed on the intervention by service providers and planners.

What is residential rehabilitation?

Residential rehabilitation programmes aim to support individuals to attain an alcohol and drug-free lifestyle and be re-integrated into society.  They provide intensive psychosocial support and a structured programme of daily activities which residents are required to attend over a fixed period of time.^[3]  Similar aims are set by some specialist supported accommodation services which we have also included in our mapping assessment described later in this document.

Residential treatment may be considered for people who are seeking abstinence and who have significant comorbid physical, mental health or social (for example, housing) problems.^[4]

Decisions on the configuration of local services, including residential rehabilitation, as well as the level of resource, funding allocated and referral to them are made locally across Scotland by Integrated Authorities and Alcohol and Drug Partnerships (ADPs).   The infrastructure that is provided by Integration Authorities should facilitate both flexible and responsive commissioning of services to best meet the needs of their resident population. Decisions on the most appropriate treatment for alcohol/drug use must also be made by clinicians/practitioners, in partnership with their patient/client and their families.

Resources

The Scottish Government allocates funding for drug and alcohol services, including for residential services, on an annual basis to Integration Authorities to be spent through ADPs.  The total financial resource available in any given year is significantly higher than the direct contribution provided from the Scottish Government budget and includes contributions from the NHS Boards, Councils and other statutory partners.  In addition, a number of people are funded to attend rehabilitation services through insurance or their own resources.  Currently, the total spend on residential rehabilitation and the distribution of the spend across Scotland are not known.

Why do we need to do this work? 

It is important that there are a range of services available when and where people need them in line with the local context for service delivery, however, no one should be disadvantaged due to where they live.  It has been recognised that there is significant variation in access to residential treatment across Scotland creating questions around fairness and equality of opportunity.

The Scottish Government action plan^[5] (October 2019) to accompany the Rights, Respect and Recovery Strategy (November 2018) includes actions to support the development of more effective services across Scotland.  This includes a clear commitment to better understand the need and demand for residential services and to develop effective services to meet these needs.  The aim is to support local services to plan and deliver a consistent level of service, regardless of location, which is reflective of and best meets the needs of their population.

Context and challenges

In recent times, Scotland has seen a significant increase in drug-related deaths and a high level of alcohol-specific deaths.  The Scottish Government vision is of a country where "we live long, healthy and active lives regardless of where we come from"^[6] and where individuals, 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.

One of Scotland's Public Health Priorities^[7] is to reduce the use of and harm from alcohol and drugs, with a particular focus on reducing alcohol and drug deaths.  The 'Rights, Respect and Recovery Strategy' sets out Ministers' commitments to reduce and alcohol and drug harms.  This includes developing recovery orientated systems of care (ROSC)^[8] with the outcome that 'People access and benefit from effective, integrated person-centred support to achieve their recovery'.  

The Group draws attention to the following context and challenges in relation to residential treatment.

• Recovery Orientated Systems of Care (ROSC): Clearly everyone has a right to life and health.  For many this will mean that they require good access to effective treatment, support and other interventions which will enable them to live longer and healthier lives.  Residential treatment should be part of a ROSC so that people can benefit from effective and integrated treatment and care to support their recovery.  The part that residential treatment services may play in reducing drug and alcohol deaths requires further investigation^[9].
• A human rights-based approach:  Taking a human rights-based approach is about using international human rights standards to ensure that people's human rights are put at the very centre of policies and practice.  A human rights-based approach empowers people to know and claim their rights.  It increases the ability of organisations, public bodies and businesses to fulfil their human rights obligations.  It also creates solid accountability so people can seek remedies when their rights are violated^[10].
• PANEL principles: The PANEL principles are one way of breaking down what a human rights-based approach means in practice.  Scottish Government has made a commitment to apply this approach to how they respond to problem drug use, including service planning, development, delivery and regulation^[11].

Participation

• People must be involved in decisions that affect their rights.

Accountability

• There should be monitoring of how people's rights are being affected, as well as improvement action taken.

Non-discrimination and Equality

• All forms of discrimination must be prevented and eliminated.  People who face the biggest barriers to realising their rights should be prioritised.

Empowerment

• Everyone should understand their rights, and be fully supported to take part in developing policy and practices which affect their lives.

Legality

• Approaches should be grounded in the legal rights that are set out in domestic and international laws.

• Services need to be person-centred, trauma-informed and better integrated: Many people attending alcohol and drug services are known to have a history of trauma.  Studies have consistently shown a high prevalence of comorbidity of mental disorders in people who have problems with alcohol and drugs and clear connections with homelessness and interactions with the criminal justice system^[12].  Recent research^[13] on residential treatment suggested that better outcomes are experienced when mental health treatment is integrated into residential treatment.
• Equality and diversity: It is essential that services are accessible and deliver high quality interventions to people regardless of age, gender, disability, ethnicity, sexual orientation, religion, nationality or socio-economic status.  This is equally important in residential services.
• Whole family approach: The whole family approach looks at tailored support for all people who are affected: adults on their recovery journey and children, young people and other adults in their family who also need to recover.  It is widely acknowledged that growing up in a household in which there are adults experiencing harmful alcohol and drug use is an Adverse Childhood Experience (ACE)^[14].  However, parental absence is also widely accepted as a potential risk to children's wellbeing and development.  Residential rehabilitation treatment offers the potential for recovery to benefit the whole family, however, treatment also involves absence from the family home.  The impact of each parental or carer absence must be understood and factored into how treatment and support is designed and delivered so as not to preclude anyone from accessing this recovery option or inadvertently negatively impacting families.  

Residential Rehabilitation Working Group

Remit

In summer 2020, Joe Fitzpatrick MSP, Minister for Public Health, Sport and Wellbeing, established the Residential Rehabilitation Working Group, Chaired by Dr David McCartney of the Lothians & Edinburgh Abstinence Programme (NHS Lothian).  The Group was asked to map the provision of residential rehabilitation services across Scotland and to make recommendations to Scottish Government for the strengthening referral pathways, capacity planning and developing models of good practice for funding and delivery.

The agreed remit is as follows:

1. advise Scottish Ministers on a programme of work to ensure for the provision of drug and alcohol residential rehabilitation services across Scotland.  This will ensure that everyone who requires this has access to it.  This will include summarising existing drug and alcohol residential rehabilitation services across the 31 IJBs in Scotland and identification of good practice examples;

2. deliver a review of existing pathways in, through and out of drug and alcohol residential rehabilitation, including identifying barriers and opportunities;

3. set out models of funding and delivery of residential rehabilitation treatment;

4. provide practical advice to Scottish Ministers on evidence and tools to anticipate service demand and uptake to support capacity planning;

5. provide support to the Drug Deaths Taskforce in tests of change work to reduce deaths and improve access to residential rehabilitation;

6. explore the potential for a national approach to measuring the success of residential rehabilitation services.

Membership of the Group is set out at Annex B.

The Group met three times between July and November 2020, following this schedule: 

• 30 July: Agreement of TOR and review of existing pathways
• 10 October: Scoping of mapping exercise and good practice guidance
• 17 November: Present summary of mapping exercise, finalise recommendations and report

The report

The Group agrees with Ministers expectation that residential rehabilitation drug and alcohol treatment services should be available equitably across Scotland.  This report presents findings and a set of recommendations at Annex A.  A data summary of a national mapping exercise reviewing existing service provision, pathways and funding models which informed the report is summarised in the sections that follow.  The full findings are available to read on the Group's pages of Scottish Government website at https://www.gov.scot/groups/residential-rehabilitation-working-group/.

Reviewing progress

The Group notes that the COVID-19 pandemic has posed challenges to Scottish Government and drug and alcohol residential rehabilitation services throughout the lifespan of the Group.  The priority has been to respond to the immediate challenges to support vulnerable service users and maintain treatment options, wherever possible.  As a result, the Group has worked with Scottish Government to prioritise asks and review timeframes.  The recommendations within this report set out where the Group consider that further research is required.

Mapping process

A scoping exercise identified a total of 18 residential rehabilitation and specialist supported accommodation services in Scotland for problem drug and harmful alcohol use.  This scoping exercise involved discussion with key stakeholders and an online search.  A survey^[15] was distributed to all 18 of these organisations.  13 (72%) of these facilities had completed the survey in the month prior to the 23 November 2020 closing date^[16].  These 13 facilities contribute the majority of beds/referrals across Scotland.  The survey data was supplemented by data from the 22 ADP Annual Reports 2019-20 available at the time of writing.

Key findings 

• The mapping exercise found a total of 365 residential rehabilitation beds across 18 facilities across Scotland, with around 100 of these beds estimated to be taken up by those resident out-with Scotland during 2019-20.
• The majority of residential rehabilitation facilities in Scotland are provided by the third sector, with relatively few provided by private or statutory providers.  Across these facilities, around half (48%) of the beds/places were provided by third sector organisations, around a third (33%) by private companies, and a small minority (6%) by statutory providers.
• There is wide variation in the range of services, the length of programmes and associated costs across these facilities.
• The majority of facilities have a waiting list for their services, ranging from a few days to a year.
• Aftercare and links to mutual aid and recovery organisations are offered by the majority of surveyed rehabs.
• A wide variety of outcomes tools are utilised across these facilities.
• Residential rehabilitation placements are funded in a number of ways.  For the thirteen facilities for which data was available, self-funding contributed over a third (36.8%) of placements in 2019-20.  Around a quarter (27.4%) were funded by Social Security payments and charitable funding, while private insurance was used to fund around one in five (22.0%) places.  Alcohol and Drug Partnerships (ADPs) funded just over a tenth (13.2%) of those accessing beds across the surveyed facilities.
• ADPs reported a number of different funding arrangements with NHS Boards, local authorities and residential rehabilitation facilities.

The Work Of The Group

Process

The working group examined evidence for residential rehabilitation impact and existing guidance on its place and provision, identifying from multiple sources (European^[17], UK^[fn][fn], Scottish^[18]) that there should be provision for residential treatment as part of a menu of options available to those who may benefit from it.  There was agreement that residential rehabilitation should be integrated into recovery orientated systems of care (ROSC) in Scotland as outlined in 'Rights, Respect and Recovery'^[19].

With support from the Scottish Government, the Group developed a mapping template to gather information across a wide range of residential providers to broaden our understanding of the current residential treatment landscape.  We wanted to capture information pertaining to providers; location; bed numbers; programme types and duration; referral criteria and support; waiting times; staffing; costs; involvement of families; regulatory framework; outcomes; relationship to mutual aid and community recovery resources and admissions and discharges.

Data from the mapping exercise were supplemented by information from Alcohol and Drug Partnership 2019-20 annual reports.  This was further augmented by work by Scottish Government researchers and from evidence heard by the working group.  Consequently, we began to develop an emerging picture of the current landscape.  The Group sees the evidence at the heart of our report as preliminary in nature.  The exercise raised many questions, and further focused work remains to be done.

The Group recognised that some of the work in our recommendations could be supported in the future by this group or by a separate group.  The Group would seek ongoing support from the Scottish Government.

Provision, capacity, access and demand

The Group identified a wide range of residential services across Scotland available to support those with alcohol and drug dependence.  We were able to identify 365 residential rehabilitation beds across 18 facilities in Scotland, with an estimated 100 of these places occupied by those normally resident out-with Scotland in 2019-20.  Of the total of 365 beds/places, 173 were provided by third sector organisations, 122 by private organisations and 22 by statutory organisations.  In addition, small numbers of service users are referred annually to specialist providers in England.  It is noted that the coronavirus pandemic will have reduced current bed availability.

It is estimated that a total of around 1340 individuals started a residential rehabilitation placement across all 18 facilities identified by the mapping survey in 2019-20, with around 830 of these individuals estimated to have been resident in Scotland prior to their placement.  These estimates were calculated by extrapolating the ratio of beds to individuals starting residential rehab placements across the 13 facilities for which data was available to all 18 facilities.  This estimate must be treated with caution, however, given the lack of data on programme lengths for a number of the facilities for which complete data was not available.

The Group found there were nearly 40,000 individuals starting drug and alcohol treatment in 2019-20, meaning that just under 5% of all drug and alcohol treatment referrals are for residential rehabilitation.  European data indicate that on average across 20 EU member states, residential treatment represents 11% of all treatment episodes.

Although the Group found evidence that a wide range of professionals can refer individuals to residential rehabilitation, we found that access across Scotland is not even.  The Group heard evidence of areas where there was little or no access in practice, with the only option locally being self-funding.  There is evidence that the majority of ADP areas have residential rehabilitation pathways in place.  However, there is variance in the numbers referred for treatment across the 22 ADP areas for which we had data.  This is not fully explained by their different population sizes and 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.

Availability was not the only barrier to access.  The Group found there is a range of factors, including attitude of referrers, ease of seeking funding, funding criteria and models of funding, referral criteria, waiting lists, availability or otherwise of advocacy support etc.  All of these can be influential.  It is noted that referral rates vary by area, discipline and even between practitioners within services.  In a recent survey, almost half of service users reported difficulty in accessing residential rehabilitation information and funding^[20].  The Group's discussions and mapping exercise identified multiple possible funding sources.  The Scottish Government's drug and alcohol strategy, 'Rights, Respect and Recovery', emphasises the importance of including individuals in the decision-making process about what treatment is right for them.  However, the Group believe that individuals, and professionals too, are currently likely to encounter difficulty understanding and navigating the routes to residential rehabilitation.

The finding that all but one of the facilities who responded to the Group's mapping exercise had waiting lists suggests that demand currently exceeds capacity, though this needs to be further explored.

Pathways in and out of treatment

The Group wanted to explore comprehensively the pathways in and out of rehabilitation as well as the assessment tools, preparation and aftercare that are employed by services.  Ninety-one percent of ADPs whose annual reports were available said they had pathways to access residential treatment in 2019-20.  Referrals were made by a broad range of agencies across the piece, but the detail of this varied by area and service.  Of concern is that three areas who have pathways did not see any referrals.  Further work is required to map and understand this. 

Aftercare was offered by the majority of the residential services and all reported in-house mutual aid.  Referral to external mutual aid (and other community recovery resources) was consistently reported.  These resources are known to be important in recovery maintenance.

A variety of inclusion and exclusion criteria to residential treatment were reported by responding services.  There is a concern in particular that some people may be excluded from mental health services due to continuing drug and alcohol use, but may also be excluded from a number of residential settings due to their mental health diagnoses.

We heard evidence of good practice from the Fife service where preparation, assessment and aftercare are reportedly of high quality.  Fife's FIRST service has run a successful service since 2014 and this has been highlighted in the Dundee Drug Commission Report^[21].   We believe that this has been down to the model set out below and merits further consideration: 

(a) robust assessment 

(b) extensive preparatory work 

(c) ongoing liaison with the client in rehab and their family for the duration of their stay and 

(d) immediate support from the community rehabilitation service linking the clients into recovery supports on discharge from the residential unit.  

The Prisons to Rehabilitation Pathway was discussed and welcomed as an initiative.  This project was funded by the Scottish Government (£150,000) to allow people leaving prison to access residential treatment to continue their recovery journey.  At the time of this report, 8 people from four different prisons have been referred as part of the early release protocol and pathway.

The Continuum of Recovery for Near-Fatal Overdose (CORNFO) project has recently been funded by the Drug Deaths Taskforce.  Facilitated by the Scottish Recovery Consortium and hosted by South Lanarkshire ADP, this pathway is targeted directly towards those people most at risk from drug related death who have experienced a near-fatal overdose.  It combines an urgent community-based response with a residential rehabilitation service. This is a proactive partnership approach involving local planning and commissioning, community treatment services, residential rehabilitation services and the individual at risk.

The chair heard evidence from a clinician on a test of change project targeting people who were using opiates in a high-risk way, helping them to stabilise, introducing them to peers in recovery and referring a significant number to residential rehabilitation where retention has so far been excellent.  This raises the bar in terms of expectation and offers an opportunity to develop and evaluate such work. 

Models of treatment, treatment episodes and vulnerable groups

The group identified several models and components of rehabilitation across Scotland including Therapeutic Community, 12-step and mixed psychological therapies.  Of those responding to our mapping survey, 70% provide a therapeutic community approach.  The majority of services which answered the survey reported provision of cognitive behavioural therapy, with most utilising motivational interviewing in addition.  Six responding services provide detoxification in-house.  As indicated, the majority provided aftercare, though this varied widely in type and duration.  Many of these also provide peer support, with a number of facilities offering training programmes for peer volunteers and employability support for those with lived experience of harmful alcohol and/or problem drug use.  Around two thirds of facilities reported offering family programmes.  The survey found wide variation in staff compliment and roles, programme duration and waiting times.  To further our comprehension of residential rehabilitation services across Scotland, it is important to also understand the services offered by non-responding organisations.

There is a high level of consensus from existing guidance that residential rehabilitation treatment is best suited to those with higher problem severity.  Discussion around excluded groups, the disadvantaged and those with complex needs, including complex trauma took place, exploring whether current pathways meet their needs.  This requires further investigation.

Treatment completion and adequate duration are strongly associated with treatment success^[22].  In our mapping survey there was a wide variation in completion rates - from 24% to 88%.  It should be noted, however, that this is based on data from only 5 of 13 facilities.  Further, this variation is likely to be due to differences between facilities in programme duration, admission criteria, services offered and/or additional factors.  In four out the five facilities, more than two thirds of residents completed treatment. Factors moderating completion rates deserve further attention.

Substance use disorders and mental health problems commonly occur together.  In a 2020 survey^[23] of 70 Phoenix Futures service users, 92% reported emotional or mental health issues. Recent evidence^[24] suggests that residential rehabilitation outcomes are better where mental health issues are specifically addressed.  The Group acknowledged the importance of good mental health provision in relation to residential rehabilitation, particularly to support and treat those with complex mental health needs. In line with guidance, every setting needs to incorporate trauma-informed practice.  Nine of the thirteen residential rehabilitation providers who responded (from a total of 18 identified) detailed the provision of mental health services within their service, though the detail of this and how it aligns with existing good practice guidance is not known.  As mentioned, it was concerning to note that some providers exclude certain mental health conditions.  It would be helpful to better understand the reasons for this and to explore potential solutions.

Costs and funding

The cost of rehabilitation treatment also varies substantially, ranging from a few hundred pounds per week to several thousand.  This depends on the nature of the programmes offered, the staffing mix and the funding model of the facility.  While there is peer-reviewed evidence to support positive outcomes from residential rehabilitation treatment, there is no clear way currently of determining value for money.  Our data suggest an average minimum cost per treatment place in Scotland in 2019-20 was around £17,800, though there are caveats to this calculation given the very large variation in costs across the services and differences in their content and duration^[25].  A review of the evidence in 2017^[26] found that although seen as expensive, residential rehabilitation's initial costs are to a large extent offset by reductions in subsequent healthcare and criminal justice costs.  Further research into the health and social economics of the intervention would help to inform decision making.

From our analysis of the thirteen services for which data were available, we ascertained that Alcohol and Drug Partnerships fund only a small proportion of treatment places and have a variety of partnerships with specific providers.  Self-funding contributed over a third (36.8%) of placements.  Around a quarter (27.4%) were funded by Social Security payments and charitable funding, while private insurance is used to fund around one in five (22.0%) places.  ADPs funded little more than a tenth (13.2%) of those accessing beds across the surveyed facilities.  This complicated picture is likely to be confusing to both clients and professionals who are trying to navigate pathways.  More work is needed to gain a further understanding, and to consider whether there might be advantages to rationalising funding.

All facilities responding to our survey reported that they operated within regulatory frameworks.

Good practice, outcomes and research

We explored the issue of what constitutes evidence-based 'good' practice in residential rehabilitation settings.  We discussed evidence which suggests that ideally a minimum period of three months' treatment is recommended.  It was agreed that a sub-group be set up to work on other elements of good practice in more detail.  This group will report back to the Scottish Government in 2021.

All of the responding residential services reported monitoring short-term outcomes, with around two thirds (62%) using specific tools.  There was less evidence on longer term outcome evaluation.  While short term outcome measurement is to be welcomed, there is no conformity on outcome measurements and no central way of gathering and analysing data.  By addressing this there is an opportunity to broaden learning and evidence around residential rehabilitation.

From the Group's own discussion of the evidence base it was acknowledged that there remains a dearth of research into residential rehabilitation and recovery outcomes in Scotland as identified in the Scottish Government's Research for Recovery publication^[27].

It was recognised that many questions remain unanswered and require further consideration.  This is acknowledged in our recommendations.

Other views

The Group's chair made informal contacts with key figures from the Scottish Drugs Forum, FAVOR UK, Scottish Health Action on Alcohol Problems and the Drug Deaths Task Force who expressed a variety of views which were broadly in line with those of the Group, particularly around equity of access.  There were also interests expressed in areas such as: central funding for rehabilitation, review of treatment services generally, including residential rehabilitation; increased investment in alcohol treatment; clarity on who is suitable for residential treatment; assessment of the quality of services; integration of rehabilitation into every treatment system with treatment free at the point of delivery; appointing a national rehabilitation coordinator; rebalancing of resource allocation; residential rehabilitation for MAT patients; assessing for whom residential rehabilitation works best; ensuring treatment was affordable and taking advantage of moments of opportunity to access rehabilitation when individuals were detoxed in an unplanned way in acute care settings.  There are likely to be advantages in wider stakeholder consultation to add to these views.  This should involve those with lived experience; family members; referrers; professionals, commissioners and policy makers.

This report sets out the Group's recommendations to Ministers which were informed by the findings of the mapping exercise and group meetings.  Full recommendations are set out in Annex A.