Rights, respect and recovery: alcohol and drug treatment strategy

Chapter 5: Developing Recovery Oriented Systems of Care

Outcome: People access and benefit from effective, integrated person-centred support to achieve their recovery

Commitments to achieve the outcome
Invest in advocacy services through the National Development Fund to support a human rights-based approach.	R1
Ensure people in need have good access to treatment and recovery services, particularly those at most risk.	R2
Ensure people who experience problem alcohol and drug use receive effective services and interventions which support them to reduce harm and achieve their recovery.	R3
Listen to the voices of lived and living experience are central to our work to develop, design and deliver treatment and recovery services, interventions and approaches.	R4
Improve access to key interventions which will reduce harm, specifically focusing on those who inject drugs.	R5
Develop person-centred approaches across treatment, recovery services and health and social care services which work with people with alcohol and drug problems.	R6
Support the growth and expansion of Scotland’s recovery communities into wider community settings.	R7
Develop trauma-informed approaches in alcohol and drug treatment and recovery services.	R8
Build on our public health surveillance and ensure that service design is informed by data, intelligence and academic evidence.	R9
Commission an up to date resource providing information and guidance on equalities issues for alcohol and drug prevention and treatment services.	R10
An action plan will be co-produced with key partners to deliver these commitments and supporting actions.	R11

Introduction

1. People with alcohol and drug problems have the right to health and life. 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. This chapter sets out the commitments to improve the access to, and quality of, a range of services and interventions within a recovery oriented system of care (ROSC).

2. People also have the right to a family life and as a result, this chapter needs to be read in conjunction with the commitments set out in Chapter 6 – Getting It Right for Children, Young People and Families, with a clear focus on developing family inclusive practice.

3. In recent times, Scotland has seen a significant increase in drug related deaths, mostly linked to injecting opiate use, while alcohol deaths have remained consistently high. Evidence suggests that Scotland has an ageing cohort of people who use drugs who are currently experiencing a range of social and health harms which are contributing to this increase. Alongside this, Scotland’s alcohol consumption has always been higher than much of the UK and Western Europe, leading to the high levels of deaths. Our public health surveillance also suggests that alcohol and people who use drugs experience a range of other harms, most recently and notably, manifested in the increase in HIV infections amongst those who inject drugs in the Glasgow area. The commitments in this chapter will improve access to, and quality of, key interventions and services which will support people into treatment and reduce their risk of harm and death.

4. People with alcohol and drug problems are also some of the most excluded people in society today. They experience stigma and, therefore, discrimination from others in their communities, the media and within our public services. This can directly affect access to the help and support they need to change their behaviour. The current levels of harm and the discrimination people and their families experience is unacceptable in modern day Scotland. This has to change.

5. Our aspiration is that people have a right to health and life, they are respected and achieve their recovery. This will require a person-centred approach, respecting that people’s recovery must be focused on their aspirations.

6. Recovery is clearly a journey for people away from the harm and the problems which they experience, towards a healthier and more fulfilling life. In this context, we need to continue to develop recovery oriented systems of care across Scotland.

7. In spite of the current increases in harm and existing levels of discrimination, recovery has become more visible in Scotland in recent times, particularly abstinence based recovery. We can see this through the rapid growth of recovery communities which have grown up alongside existing peer-led mutual aid. This has added a new dimension to Scotland’s response to alcohol and drug problems.

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. Clearly everyone has a right to life and health and we need to ensure this is the case for those who experience alcohol and drug problems. The PANEL principles are one way of breaking down what a human rights-based approach means in practice
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.
We need to apply this approach to how we respond to problem drug use, including service planning, development, delivery and regulation. We need to ensure that people have access to independent advocacy services to support this approach. The Scottish Government will invest in advocacy services through the National Development Fund to support the development of a human rights-based approach. (R1)

Delivering the Outcome

Eight-point Plan for Treatment and Recovery

8. The eight-point plan for treatment and recovery aims to support individuals to achieve their recovery and reduce alcohol and drug deaths by improving access to effective services and interventions.

1	People access treatment and support – particularly those at most risk
2	People engage in effective high quality treatment and recovery services
3	People with lived and living experience are involved in service design, development and delivery
4	People access interventions to reduce harm
5	A person-centred approach is developed
6	The recovery community achieves its potential
7	A trauma-informed approach is developed
8	An intelligence-led approach future-proofs delivery

Point 1 – People access treatment and support – particularly those at most risk

9. In a strategy formed on a rights-based approach it is reasonable to assume that all people who require effective treatment have access to it. Much has been done already to improve access to services, particularly reducing waiting times. We need to build on this to ensure that those who are most at risk receive the support and help that they need to access and remain in effective treatment for as long as is needed.

10. Treatment services need to be well-publicised and accessible to all those in need in the community. Public Health Surveillance Data should inform our approaches to improving access for those most at risk. Approaches need to include low threshold outreach services and the pro-active offer of support following key events such as non-fatal overdose and hospital discharge.

11. Alongside treatment services, other health and social care services also play an important role in identifying these groups, as they may already be working with people who are at significant risk. This includes housing, employability, hospital, primary care welfare, mental health, children and families services amongst others.

12. Relapse is not uncommon amongst people in treatment as well as those who have moved on from treatment. This is a time of increased risk as it is likely that people’s tolerance to alcohol and drugs will have reduced. Arrangements will need to be in place to ensure that people have good access to treatment and other support in these situations, including assertive outreach.

People in need will have good access to treatment and recovery services, particularly those at most risk. (R2)

Identified actions

• Public Health surveillance will continue to enable services to understand who is at most risk and develop approaches to engage these groups.
• The key skills and expectations for staff working in broader health and social care services on engaging problem alcohol and drug users will be set out in the Workforce Development Framework.
• Good practice will be established in relation to:
• Assertive outreach to those at risk including those who have relapsed
• Alcohol hospital liaison, improving access to treatment and support

Point 2 – People engage in effective high quality treatment and recovery services

13. The evidence for effective medical treatment and psychosocial support for alcohol and drug problems is clearly established; currently this is set out in Drug misuse and dependence: UK guidelines on clinical management^[58] and Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence^[59]. Those involved in delivering treatment and recovery services need to ensure that this evidence underpins service delivery at a service and practitioner level.

14. Treatment and recovery services are under significant pressure to deliver effective services to people with a wide variation in their needs. This pressure may change over time and treatment services will need to develop approaches which enable them to manage their capacity effectively. This will include whole system approaches to redesign and the development of stepped care models of delivery.

15. A recent report from the Lead Psychologists in Addiction Services Scotland (LPASS)^[60] sets out a stepped care model for delivery for psychosocial interventions. The requirements of staff in terms of the delivery of psychosocial interventions and provides a framework to effectively match the needs of people using their services to the skills and abilities of the workforce.

16. We need to improve access to and the quality of medical treatment options. For those treated with opiate substitution therapy (OST), we need to ensure they receive optimal dose and are supported to remain in treatment for as long as it is needed. Alongside this to improve medical treatment options. For instance there is strong evidence that heroin-assisted treatment is more effective at retaining people in treatment for whom other forms of opiate substitute therapy (OST) has not been effective, and as a result reduces rates of death among this cohort^[61].

17. A quality improvement framework will enable us to improve our approach to measuring and improving service quality. The Quality Principles for Drug/Alcohol Services^[62] and the Health and Social Care Standards^[63] provide clear quality expectations for treatment and recovery services. The Care Inspectorate completed an external validation of the implementation of the Quality Standards in 2016^[64] which showed good evidence of compliance. Further external validation is required on an ongoing basis, with a broader scope to involve those with lived and living experience in this process as well as through independent advocacy. Alongside this we need a set of national benchmarks for treatment and recovery which can be used to assess progress at a local and national level on a regular basis.

People who experience problem alcohol and drug use will receive effective services and interventions which support them to reduce harm and achieve their recovery. (R3)

Identified actions

All treatment services in Scotland will implement evidence-based approaches as set out in Drug misuse and dependence: UK guidelines on clinical management and Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence including any updates to this guidance.

The Scottish Government will support ADPs and IJBs to use the evidence and learning from the LPASS report to evaluate current psychological interventions and support within a ROSC.

The Scottish Government will make resource available to local areas through the Corra Foundation to support system redesign to increase capacity and improve access to effective services.

The Scottish Government will develop specific national guidance and standards for asset-based assessment and case management, linked to Quality Principles and the Health and Social Care Standards.

The Scottish Government will establish a Quality Improvement Framework to set expectations for treatment and recovery services. This will include:

A set of numerical benchmarks to assess service delivery

The approach to inspection and regulation of all services

A workforce development framework which set out the expectations and skills, abilities and competence of the workforce

Point 3 – People with lived and living experience will be involved in service design, development and delivery

18. There is recognition of the benefits of involving people with lived and living experience across health and social care services. We need to build on existing approaches to this work to ensure that people who have experience of problematic alcohol and drug use and recovery, as well as their family members and carers, are involved in the planning, development and delivery of services.

19. Approaches to involving people will vary across the country, however, these approaches will all require the commitment of key professionals and the investment of resources to ensure that they are successful. By involving and listening to people with lived and living experience, being prepared to be challenged by their views and handing over power to make changes, we may find that the solutions do not lie in traditional approaches.

We will make the voices of lived and living experience central to our work to develop, design and delivery treatment and recovery services and interventions. (R4)

Identified actions

The Scottish Government will work with partners to develop a national approach to involving people with lived and living experience in policy and strategy development; and link this to the models that are already developed at a local level.

The Scottish Government will work with partners including those with lived and living experience to ensure there is an effective role for people in our quality improvement framework.

Our workforce development framework will include training and development for people with lived and living experience to enable their involvement in service planning, development and delivery.

Point 4 – People access interventions to reduce harm

20. As noted already, Scotland still experiences high levels of alcohol and drug-related harm. A comprehensive approach to harm reduction needs to be embedded within ROSC, in ways which ensure that people have access to the interventions and supports in settings which meet their needs.

Safer drug consumption facilities

Safer drug consumption facilities are services at which people can consume drugs, obtained elsewhere, under the supervision of trained health professionals. They offer a compassionate, person-centred service which focuses on reducing the harms associated with injecting drug use and helps people access appropriate services to meet their needs. By doing so, they are able to reach an extremely vulnerable group who often do not engage with our existing services. There are more than 90 of these facilities operating across Europe, North America and Australia. There is evidence to suggest that these services reduce the spread of disease through unhygienic injecting, prevent drug-related overdose and deaths and connect people who use drugs with treatment and other health and social care services^[65].

Public health surveillance in Glasgow has identified a significant increase in HIV diagnosis and other harms amongst those who inject drugs in central Glasgow, mostly amongst the homeless population. The evidence gathered has led to the conclusion that a safer drug consumption facility would meet a significant public health need in the city by reducing the risk of the further spread of HIV, drug-related overdose and deaths^[66].

The Scottish Government’s Programme for Government 2018 is supportive of proposals of this nature which are in response to clear evidence of need and are in line with a human rights-based and public health-led approach. Drug legislation is currently reserved to the Westminster Parliament, and the Scottish Government will continue to press the UK Government to make the necessary changes in the law, or if they are not willing to do so, to devolve the powers in this area so that the Scottish Parliament has an opportunity to implement this life-saving strategy in full.

21. Although much has been achieved in the ways that harm can be reduced among people who inject drugs, there is still more to do. For these people we can still improve the following:

• Injecting equipment provision – all services must deliver in line with Guidelines for services providing injecting equipment: Best practice recommendations for commissioners and injecting equipment provision (IEP) services in Scotland^[67];
• Naloxone – provision to all people at risk of opiate overdose, as well as their family members, partners and associates. Alongside this we need to find ways to support people to carry Naloxone about their person;
• Wound care – easy access to wound care within services already used by those who inject drugs;
• Testing for all those at risk of contracting blood-borne viruses and support to access follow up treatment and support.

22. These interventions need to be delivered from services and venues and in ways which are accessible to people who are at risk. This includes treatment services, housing and homelessness services, key physical and mental health services, primary care and hospital services amongst others. Needs assessment work, the evidence base and the involvement of people with lived and living experience will guide the development of these approaches.

23. In the delivery of this strategy we take a particular focus on reducing the spread of blood-borne viruses and other infections. We know that individuals who experience problematic alcohol and drug use are at risk of poor sexual health outcomes and those who inject drugs are at significantly greater risk of blood-borne virus (BBV) transmission. Alcohol and drug services will support the forthcoming Hepatitis C Elimination Strategy and will work with services to ensure that relevant recommendations are taken forward.

24. We also need to look at the evidence behind new approaches to harm reduction for both alcohol and drug use. For instance we have seen the evidence for Managed Alcohol Programmes^[68] to improve the health and wellbeing of homeless dependent drinker by providing accommodation, health and social care support alongside supervised doses of alcohol.

We will improve access to key interventions which will reduce harm, specifically focusing on those who inject drugs. (R5)

Identified actions

The Scottish Government will work with experts to identify benchmarks for service delivery as part of the Quality Improvement Framework.

The Scottish Government will develop guidance and support all ADPs to carry out an assessment of their strengths and weaknesses in delivering key harm reduction initiatives to those at risk.

Point 5 – A person-centred approach is developed

25. The overall commitment in this chapter is to develop person-centred approaches across the range of health and social care services. Navigating these support services can be complex and we need to improve access and outcomes by bringing together the policy, planning and delivery of these services. Key to this are primary care, housing, mental health and employability services, however, this is not an exhaustive list and we need innovative approaches across the range of services which are used by people with alcohol and drug problems.

Primary care

26. Primary care plays a key role in treatment and recovery, delivering and placing alcohol and drug treatment within the context of broader health, and identifying and responding to both mental and physical health conditions. The new contract for primary care which came into effect in April 2018 provides for a new model of care that is local, multi-disciplinary and enables allied-health professionals and GPs to work in an integrated way with community services to ensure patients’ needs are met. This offers opportunities for more integrated approaches to the delivery of alcohol and drug treatment, alongside other health and social care services such as mental health, sexual health and blood-borne virus services.

27. Pharmacists also play a key role in providing healthcare services including harm reduction interventions as well as blood-borne virus testing and other healthcare interventions, particularly to those not in treatment. They are often the healthcare professionals who have the most contact with those receiving OST and are, therefore, in a unique position to provide a range of healthcare interventions, as well as identify and reduce the risk of harm. This would include effective liaison with other primary care and treatment and recovery services to support the delivery of treatment and recovery plans.

28. The Chief Medical Officer’s Realistic Medicine programme sets commitments for clinicians to build a more personalised approach to care, in partnership with people through shared decision making. This is in line with the person-centred approach in this strategy. To support this, guidance has been published on improving prescribing in relation to chronic pain^[69]. Clinicians must take care in prescribing these medicines to reduce risks around dependency, whilst continuing to meet the individual healthcare needs of people.

29. Further guidance has been developed to manage “poly-pharmacy” to improve outcomes where people receive a number of prescriptions to address a range of health conditions. This is a particular issue for people who require medical treatment for their alcohol and drug problems alongside treatment for other conditions.

Mental health

30. The links between problematic alcohol and drug use and poor mental health are well documented and can lead to individuals facing barriers to treatment for both issues. The Scottish Government’s Mental Health Strategy^[70] takes a human rights-based approach to improving mental health and includes two actions around alcohol and drug use, both of which were targeted at improving the services offered to those with a dual diagnosis. Alcohol and drug services are also well placed to deliver key mental health interventions and are well placed to deliver key commitments in Scotland’s Suicide Prevention Action Plan^[71].

Housing

31. Settled housing plays an important role in the prevention of, and recovery from, problematic alcohol and drug use. The Scottish Government remains committed to ending rough sleeping and homelessness, and our legislation around homelessness is some of the strongest in the world. The Scottish Government’s Homelessness and Rough Sleeping Action Group examined how our national commitment to prevent, tackle and end rough sleeping and homelessness can be achieved, producing a report with a series of recommendations^[72]. Alongside the findings of the Local Government and Communities Committee inquiry on homelessness, these recommendations have provided the foundation for the development of the Ending Homelessness Together High Level Action Plan, published in partnership between local and national Government on 27th November 2018. This strategy will support the delivery of this Action Plan by developing more joined-up approaches across homelessness services and alcohol and drug treatment services. Initially, this will be through a joint investment in Housing First^[73].

Employment

32. No One Left Behind: Next Steps for the Integration and Alignment of Employability Support in Scotland 2018^[74] describes the next steps for the integration and alignment of employability support with a particular focus on health, justice and housing services. It puts an emphasis on the role of Health and Social Care Partnerships and Alcohol and Drug Partnerships in developing stronger links between local services and national employability services. The Scottish Government will work with local partnerships to encourage them to join up with local and national employability provision to respond to the educational, volunteering and employment needs of people in recovery.

Person-centred approaches will be developed across treatment and recovery services and the range of health and social care services which work with people with alcohol and drug problems. (R6)

Identified actions

• The Scottish Government will work with local partners to develop integrated models within primary care settings which address alcohol and drug related harm.
• The Scottish Government will work with providers to identify good practice in reducing polypharmacy for people with alcohol and drug problems.
• The Scottish Government will work with local and national experts to explore and develop new approaches to assessment and referral pathways for people with both problematic alcohol and drug use and mental health diagnosis.
• The Scottish Government will support and invest in Housing First pathfinders within our main cities with a particular focus on problematic alcohol and drug users with complex needs.
• The Scottish Government will work with local partnerships and employability provision, including providers of the devolved employment service - Fair Start Scotland - to provide an integrated response to the educational, volunteering and employment needs of people in recovery.
• The workforce development framework will set out clear competencies and expectations in identifying and responding to alcohol and drug use amongst those working in health and social care services.
• The Scottish Government will make resource available to local areas through the Corra Foundation to support system redesign to increase capacity and improve access to effective services.

Point 6 – The recovery community achieves its potential

33. Scotland has thriving recovery communities which we must continue to nurture as they extend their positive influence into communities. These groups, and the recovery activists within them, are best placed to lead on the development of recovery capital and reducing stigma within communities, as well as making a positive impact more broadly on their local community.

34. Recovery communities and mutual aid fellowships are essential to the development of ROSC in Scotland. Many people find the support they need to address their problem alcohol and drug use solely through these groups. Treatment and support services have a key role to play in connecting people in recovery to these networks as a part of their core offer. There are already many examples of this in Scotland, including how prisons have tackled the challenge of connecting people in prison with others in recovery.

35. We are well aware that isolation and loneliness are significant issues for those using alcohol and drugs and this can continue during an individual’s recovery. Recovery communities provide safe places for people to socialise, connect with others in recovery, and maintain their personal recovery journeys.

36. In addition, recovery communities can be at the heart of any proposals around reducing stigma as they provide a visible face of recovery as well as insight into addiction and harm, and for this reason alone should continue to be celebrated and supported. These cafes and groups all have a part to play at normalising recovery and provide a safe space for anyone within the community that would like to access them.

37. These groups also provide countless hours of support to individuals all across the country and, in an area in which Scotland appears to be leading the way internationally, it is vital that we continue to back them and help them grow further.

The Scottish Government, national support and local partnerships will continue to support the growth and expansion of Scotland’s recovery communities into wider community settings. (R7)

Point 7 – A trauma-informed approach is developed

38. Many people who access treatment and recovery services will have had an experience of trauma, as an adult or a child or both. Many will have used alcohol and drugs as a means of coping with, and managing, these experiences.

39. Taking a trauma informed approach is not about treating trauma, but rather trauma-informed services taking into account an understanding of trauma in all aspects of service delivery and placing priority on the person’s safety, choice and control. This means that services need to ensure that approaches are built into all policy and procedure and that those working in treatment and recovery services are able to recognise the signs of trauma and develop approaches which are safe, build trust, offer choice and build empowerment. Consideration also needs to be given to specific cultural, and gender issues.

Alcohol and drug treatment and recovery services must develop trauma-informed approaches. (R8)

Point 8 – An intelligence-led approach future-proofs delivery

40. In Scotland, we regularly publish a number of national reports to support our public health surveillance and inform our approaches to addressing alcohol and drug harm. This includes reports on alcohol and drug deaths, access and use of treatment services, alcohol and drug prevalence, and the use of injection equipment provision amongst other areas.

41. A public health approach requires us to bring a greater clarity to how we use and link existing and new data to answer key policy questions as well as to identify key harms and emerging trends across Scotland. We are committed to improving the quality of data on the use of treatment and recovery services through the implementation of the Drug and Alcohol Information System (DAISy).

42. Our intelligence-led approach also needs to recognise that the use of drugs and alcohol is a dynamic activity and there are a number of emerging trends and challenges which we need to respond to now, and there will continue to be more in the future. It is also possible that the issues that will cause us the most concern in five years’ time may currently be undetected.

43. For instance, a recent Public Health England report has identified that the recent reduction in treatment numbers in England has had a disproportionate impact on those with alcohol problems^[75]. As we bring together our response to drugs and alcohol we need to monitor these and other impacts to ensure that we maintain effective services for all those with alcohol and drug problems.

44. We recognise the importance of the role evidence plays in developing both practice and policy decisions; the Drug Research Network Scotland and the Scottish Alcohol Research Network provide a co-ordinated link to the wealth of research and expertise in this area. This strategy will support the ongoing development of shared priorities for these networks and those working in service planning and delivery.

The Scottish Government and local partners will continue to improve our public health surveillance and ensure that service design is informed by data, intelligence, and academic evidence. (R9)

Identified actions

• The Scottish Government will work with partners to review our current data and reporting on alcohol and drugs with a view to rationalising and enhancing public health surveillance and intelligence.
• The Scottish Government in partnership with the Drugs Research Network Scotland review and update the Research Framework.
• The Scottish Government will work with local areas to implement DAISy and also to develop reports which inform our understanding of the impact of treatment services at a local and national level.
• The Information Services Division of NHS National Services Scotland will develop a programme of data linkage enabling a broader understanding of the needs of those with problematic alcohol and drug use.

Recognising the needs of different equalities groups

45. In a human rights-based approach we need to ensure that the commitments in the eight-point plan apply equitably across the population. While every person is individual there are clear characteristics and challenges which are specific to particular groups of people. It is important that services are accessible and deliver high quality services to people regardless of age, gender, disability, ethnicity, sexual orientation, religion, nationality or socio-economic status.

46. While men are more likely to use alcohol and drugs and to experience health harms as a result (for example males account for around 70% of drug-related deaths and alcohol specific deaths^[76]), it is important to understand the treatment and care needs of women in what can be a male dominated environment. While there are some commonalities there are also marked differences in the motivations and antecedents for alcohol and drug use amongst men and women and differences in their care needs, particularly in relation to parental roles.

47. The recent disproportionate rise in drug-related deaths amongst women is a particular concern and a report commissioned by the Scottish Government specifically examined the reasons for this rise and recommended a number of actions that could be taken in response including the adoption of ‘gender mainstreaming’ practices in substance-use policy and practice^[77].

48. Making sure that services are accessible to people with disabilities is also a key priority. It is widely recognised that many people with problematic substance use have a high incidence of mental and physical health problems as a result of, or concurrent with, their substance use. This is particularly acute among growing numbers of older people with alcohol and drug problems.

49. It is also important to understand different patterns of substance use by different equalities groups and ensure that services are responsive. For example, younger people are now less likely to be presenting for treatment for heroin and more likely to be using new psychoactive substances. Similarly, there is increasing anecdotal evidence of increased harms from chemsex among some men who have sex with men.

50. Similarly people from religious or cultural minorities will also have their own cultural context for their substance use. Services must be mindful, respectful and accessible to all those who need them.

51. A full Equalities Impact Assessment has supported the development of this strategy and a full report will be published in due course. We need to ensure that we take into account these differences when developing, delivering and evaluating services for people with problematic alcohol and drug use.

The Scottish Government, in consultation with partners, will commission an up-to-date resource providing information and guidance on equalities issues for alcohol and drug prevention, treatment and recovery services. (R10)