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The Scottish Government, Edinburgh, May, 2010

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A GUIDE TO IMPROVING ACCESS TO RECOVERYFOCUSED DRUG AND ALCOHOL TREATMENT SERVICES IN SCOTLAND

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© Crown copyright 2010

ISBN: 978-0-7559-9364-2

The Scottish GovernmentSt Andrew’s HouseEdinburghEH1 3DG

Produced for the Scottish Government by APS Group ScotlandDPPAS10072 (05/10)

Published by the Scottish Government, May, 2010

The text pages of this document are printed on recycled paper and are 100% recyclable

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1. Introduction 1

2. Introduction to the HEAT A11 2waiting times target

3. Improvement and service redesign – 5key principles

4. Examples of good practice from 12the United Kingdom

a. England (London) 13

b. Scotland (Dumfries and Galloway) 15

c. Scotland (Aberdeen City) 17

d. Scotland (Lanarkshire) 19

5. Useful documents 23

6. Acknowledgements 24

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Contents

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Nobody likes to wait, especially when it is for helpwith a problem. For people with a drug or alcoholproblem, getting treatment that enables them torecover from their problem at a time of need iscrucial. We need to make sure that people do nothave to wait an unacceptably long time for treatmentand we want to ensure that this is the same foreveryone in Scotland regardless of where peoplelive. That is why we have, for the first time ever, atarget to make sure the NHS reduce waiting times fordrug treatment services and we will extend thistarget to alcohol treatment services in April 2011.

Reducing waiting times for treatment is not new tothe NHS. Successes have been made in reducingwaiting times for a range of treatments includingcancer services, Accident & Emergency andOutpatients. While the needs of clients may bedifferent, there is learning that we can take from howservices have changed the way that they operate tomake significant improvements for their client group,ensuring that access is quicker, while notcompromising on the service quality.

We also have a lot to learn from drug and alcoholtreatment services throughout the UK. In England, theNational Treatment Agency (NTA) has a 3 weekreferral to treatment indicator and in 2008/09 93% ofall clients waited less than 3 weeks to start drugtreatment. In Scotland, there are strong examples ofgood practice where Alcohol and Drug Action Teams,now Alcohol and Drug Partnerships (ADPs), and theirpartners have worked to redesign their localtreatment services to improve access and reducewaiting times.

This document is for NHS Boards, ADPs andspecialist substance misuse service providers. It aimsto share learning from across the country on goodpractice to improve access to treatment and reducewaiting times through service redesign. Thisdocument provides:

> Clarity on what the drug and alcohol waitingtimes target is and who it applies to

> An explanation of the principles supportingimprovement support and service redesign

> Case studies of services and partnerships thathave successfully reduced waiting times throughservice redesign

It is our hope that over time we can expand on ourexamples of good practice that are taking placeacross the country as we make a true difference forpeople with drug and alcohol problems in Scotland.The case studies included in this document shouldprovide evidence that positive changes can be madethrough reviewing and redesigning the way thatservices work. They are not extensive reviews ofprocesses but instead provide a flavour of issues thatservices and partnerships worked through together.

If you want to find out more about specific issuesflagged up in this document then please contact theScottish Government Drug Delivery Team for moreinformation [email protected]. As we discovered through compiling these casestudies, there is a great deal of knowledge,experience and willingness to share.

SECTION 1:Introduction

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HEAT stands for Health improvement, Efficiency,Access to services and Treatment. It is an internalNHS performance management system that includestargets that support National Outcomes, from theScottish Governments National PerformanceFramework. NHS Boards are accountable to theScottish Government for achieving HEAT targets.

The HEAT A11 target

In 2008, the Scottish Government announced a newHEAT target ‘to offer drug misusers faster access toappropriate treatment to support their recovery’.During the spring of 2009, Scottish Governmentofficials within the HEAT A11 Project Team consultedwith NHS Boards and a range of stakeholders on atarget that was achievable, that was best for peoplewith drug problems and the possibility of the targetbeing expanded to alcohol treatment services. Thisresulted in the following target being approved byMinisters in November 2009:

By March 2013, 90% of clients will wait no longerthan 3 weeks from referral received to appropriatedrug treatment that supports their recovery

Waiting times appropriate to alcohol treatment willbe defined and incorporated into a target coveringboth drugs and alcohol by April 2011

As a milestone to deliver 3 weeks from referral todrug treatment by March 2013, by December 2010,90% of clients referred to drug treatment willreceive a date for assessment that falls within 4 weeks of referral received; and 90% of clients willreceive a date for treatment that falls within 4 weeks of their recovery plan being agreed

What the HEAT A11 target means forpeople with drug problems in Scotland

In some parts of Scotland, people with drug problemsare waiting too long for specialist treatment. ThisHEAT target is based on the principle that peoplewith drug problems are entitled to the same level ofcare as other patients in the NHS. Reducing waitingtimes for drug treatment services will mean thatpeople with drug problems will be able to accessservices, at the point of need, to support theirrecovery.

Services that the HEAT A11 target applies to

The HEAT target applies to NHS services and theservices NHS Boards fund to act on their behalf.However, since 2004, waiting times data have beencollated for all drug treatment services, includingthose within the voluntary sector services and localauthorities. This will continue, as the principle is toensure that a wide range of drug treatment servicesare available, at the point of need, to supportindividuals’ recovery. It is the Scottish Government’saim that all drug treatment services, no matter whothey are funded by, will work to ensure that peoplewith drug problems get access to the treatment theyneed within 3 weeks of referral.


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SECTION 2:Introduction to the HEAT A11 waiting times target


Enabling people with drug problems torecover

An early step in enabling people with drug problemsto recover from their drug problem is providing themwith access to treatment at the time they need it. Toachieve the HEAT A11 target in the context ofrecovery, NHS Boards will need to work closely withtheir partners in local authorities and the voluntarysector to ensure that their local recovery pathwayaddresses the needs of people with drug problems intheir area. This means ensuring that a full range ofhigh quality, recovery focused services are availableat the point of need to enable people to move on,when they are ready to do so.

Are alcohol services included in thetarget?

At present, waiting times information is not as robustfor alcohol services as it is for drug services.Therefore 2010–2011 is a developmental year foralcohol treatment services. A measurable target foralcohol treatment services will be based on theoutcome of a detailed audit of alcohol waiting timesduring April–June 2010. This means that an alcoholtreatment services waiting times target will beintroduced from April 2011.

Guidance

To support drug services to achieve the HEAT targetwe have consulted widely with a range ofstakeholders and developed Guidance on ReferralPathways (please see useful documents section).

This document embeds the reduction of waitingtimes in Scotland’s strategy to help individuals torecover, move on from their problem drug use, and beactive and contributing members of society. Theguidance also outlines what services the HEAT targetapplies to, how waiting times will be monitored andwhat the reporting mechanisms are.

Scottish Government officials are currentlyembarking on work to reaffirm and update theprinciples that underpin essential services for alcoholtreatment and support, taking into account thecurrent evidence base on effective interventions; howservices should be delivered, Integrated CarePathways (ICPs) and the outcomes that should bemonitored. The Alcohol Essential Services WorkingGroup will report in December 2010, informing futuredevelopment and delivery of specialist alcoholtreatment and support services.

How we know people with drug problemsare getting fast access to the righttreatment or that the treatment is of goodquality

The access to treatment target is firmly embedded inthe context of the drugs strategy, The Road toRecovery (please see the Guidance on ReferralPathways) as we are looking to improve access toappropriate treatment. The target applies to servicesthat deliver tier 3 and 4 interventions only, and weare currently consulting extensively on the definitionof the different types of intervention that clients mayneed. We want to reflect the full range ofappropriate services, so that we can understand howlong people are waiting for different types ofrecovery focused interventions.


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It is, however, for local services and localpartnerships to ensure, via quality improvementframeworks and performance managementarrangements, that the treatment is of good qualityand recovery focused.

How we find out if people are satisfiedwith the treatment they receive

Very simply, we need to ask them. Some servicesroutinely run user-satisfaction surveys; sometimes aservice’s perception of the quality of treatment canbe quite different from the service user’s, in whichcase it may become necessary to pin point why. Wewould advise local services to continually engageservice users in reviewing the effectiveness of theirservice.

How we can ensure that we look attreatment outcomes as well as access totreatment

The Scottish Drug Misuse Database will be able toprovide treatment outcome information for everyonein drug treatment in Scotland by December 2012. Ata local level it is important that services engage withclients as much as possible, to find out what theoutcomes of treatment were for them.


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To find further sources of help for undertakingimprovement work, please refer to section 5. A lot ofthe following information has been adapted frommaterials developed by the Scottish Mental HealthCollaborative as many of the principles andapproaches apply equally to drug and alcoholtreatment services.

What improvement work is all about

It would be naïve to imagine that none of us haveever been involved in service change, and that this isall something new. It can be helpful to consider whattype of service change you have been involved inbefore and what the process was like.

> As someone directly providing services to clients,were you consulted about the changes that weremade and did you feel you had a chance to sayanything about what might be best?

> Did you make use of information about how theservice worked at the time to inform whatchanges to make?

> Did you keep measuring how things worked asyou made changes; could you tell which changeshad an impact in a good way and which maybedid not?

> Did you ever test out an idea for a week to see ifit really worked before it became the ‘new way’?

> Did you involve service users in discussions abouthow to change things for the better?

If your answer is yes to all of these, then you may notneed to read any further; however, if your answerwas no to one or more of these questions, you willfind it useful to read on.

Current thinking about improving the quality ofservices for clients is based on some key principles:

> Those who provide services and those that usethem are involved in developing ideas forimproving things, testing out these ideas andimplementing those which are successful

> Understand what actually happens at the momentthrough looking at services from the stand pointof the client; how do they move through theprocess or system? How are things organisedaround them?

> Information is collected that illustrates what isactually happening in order to understand what tochange

> Develop a clear idea of what the service shouldlook like, based on the needs of your clients; localneeds assessments, strategies and policiesshould help with this

> Before making any changes, work out what tomeasure to understand whether a change ishaving the desired effect

> Changes are broken down into small, easily do-able parts where possible in order to test outwhether something works and to give people achance to get used to a new way of working

> There is much you can do to reduce long waitingtimes, improve the way clinics run and reducewhat seems like wasted time chasing paperwork,without having any more resource and withoutanyone having to work harder and faster

The rest of this section is a brief guide to give you anintroduction to some of the ways you can begin to goabout making changes to your services. This is not anextensive improvement guide, but in section 5 we haveadded some links to other resources you can make useof if you want some more detail.


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SECTION 3:Improvement and service redesign – key principles


Getting started – bringing everyonetogether and understanding whathappens at the moment

Health and social care systems and processes areoften complex and fragmented. It is unlikely that asingle member of staff would fully understand thecomplete pathway or process that a clientexperiences when they make their way through drugtreatment services.

Bringing people together who work across all thedifferent agencies that are involved in providing drugtreatment services in your area is a powerful way tobegin to understand how clients and information flowthrough the health, social care and voluntary sectorsand how various parts of the system link together.

Think about how your services currently work andbring together people who are involved at each stageof the client pathway. This will include those whohave direct contact with clients, and those thatprovide the vital administration processes thathappen along the way. You will not be able to geteveryone together, just make sure that someone fromeach step is involved. You can always share theresults with those who could not be there.

The aim is to first develop a shared understanding ofwhat you are setting out to achieve. What outcomeare you aiming for in providing drug treatmentservices? For example:

> More service users recover from problem drug use

> Service users have a less chaotic lifestyle

> Service users stop/reduce drug misuse and drug-related harm

> Service users have improved employmentopportunities

It is useful to have this discussion; people fromdifferent parts of the health, social care andvoluntary sectors will have different outlooks fromeach other about the purpose and structure ofservices. It is important that before you begin tochange the way your services work, you havediscussions about what you are aiming to achievethrough that change. This includes what you areaiming at beyond improving waiting times, as untilyou have a clear picture of what the service is for, itis difficult to design it to work. Think about reducingwaiting times in the context of helping an individualachieve their full potential, enabling them to recoverfrom their drug problem.

Understanding the client pathway at thispoint in time

Bringing everyone together is an opportunity toproduce a map of the client’s journey as a visualrepresentation, which illustrates how the clientmoves through the drug treatment pathway and howthe administrative processes are linked to thispathway.

The map should shows how things often are andwhat happens, rather than what should happen.


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You will find that you will want to be able to checkany map you generate against some real lifeexamples in your local area – it is really useful tohave some information attached to this map thatgives you information about the process.

For example, looking at the sample pathway:

> How many different routes are there throughwhich clients access services?

> How many different agencies provide assessment?

> How long do people wait for an assessment?Does this vary? And how long does anassessment take?

> How long do people wait between assessmentand their first treatment appointment?

> Who undertakes treatment?

> What types of treatment are available?

> What proportion of clients receive each type oftreatment?

> How long do people stay in treatment?

> How do staff decide that clients can move onfrom their care?

> What happens after the client’s treatment iscompleted? Who do the clients move on to?

> Do clients have to wait to move on?

> Which staff groups are doing which tasks? Areeveryone’s skills being appropriately used?

> Do you prioritise people and if so, how and why?What impact does this have on those people thatare never a priority?

> What are the connections between differentsections of the pathway?

You will probably not have all this information at thetime of your event; this is why you are likely to needto bring people back together again, to review themap and to begin to build a picture of how theservice should look.


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MULTIPLE ENTRY POINTS

Yes! Assessment

short wait

Treatment waiting for discharge

discharge into

PrimaryCare

CommunityCare

Limited Capacity

high priority

Specialist Service

low priority

is treatmentavailable?

No!

very long wait

PRIO

RITI

SATI

ONSocial Services

GP

Drop In

SpecialistService

IndefiniteMaintenance

?

St Elsewhere Drug Treatment services – high-level map of current service user pathway


This helps everyone involved see other people’sviews and roles. It can also help you diagnoseproblems and identify areas for improvement.

Deciding what you are setting out toachieve

Spend some time with the group working out whatthe pathway should really look like and how longeach part should take. Start to think about who doeswhat, when and why.

Get some agreement from the team about what youare setting out to achieve, for example – by December2010, 90% of clients will be able to access drugtreatment services through a single point of contact.This first contact will take the form of an assessment,and 90% of people will receive their first treatment 4weeks after this first assessment visit.

There is much to think about if you take thatstatement; who will provide the single point ofcontact? Does it need to be a health professional?What is an assessment; when does it start and end?How will you measure how long people are waitingat each stage of the pathway? What about the rest ofthe pathway; do you need to work out some similarstatements for each part of the pathway?

Once you have worked through what the pathwaylooks like at the moment and what it should look likein the future, you will also need to spend some timeunderstanding how you manage the amount of workthat flows through your service. This means lookingat the whole system to identify where blockages maybe or where people may remain in treatment forlonger than they need to be.

Understanding demand, capacity, activityand queues

Most of the targets our services face are aboutqueues. Queues are about managing servicedemand and service capacity. Requests to increaseservice resources are actually about increasingservice capacity. Does increasing resources solvequeues? Often not without work on demand andcapacity.

At first glance the world of demand and capacityappears to be full of jargon, but it can be kept quitesimple. For example:

> Demand is not how many people are referred, itis the time they need to be treated

> Capacity is not the number of staff we have, it isthe total resource available to do the work whichincludes staff and any equipment needed (such asrooms)

> Activity is not the same as capacity – activity ishow much work we actually do and is often lessthan we have the capacity to do (because so oftenwe spend time doing things we do not need to,such as chasing around trying to find notes, re-booking appointments etc.)

> Our waiting list is actually a Queue


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Why work on demand and capacity isimportant

It helps us understand what we do, who we do it forand how we work. Knowing this helps us to makesensible changes and think about whether we canmake better use of the resources we already have.

The Scottish Mental Health Collaborative hasrecently produced some very useful practical guideson understanding demand, capacity, activity andqueue; these are applicable to drug and alcoholtreatment services and can be found at:www.scotland.gov.uk/Topics/Health/NHS-Scotland/Delivery-Improvement/1835/74. Clickon the news/resources link on the left-hand side ofthe page.

These documents are very helpful in helping servicemanagers work out what demand there is for theirservice and how this can be matched againstcapacity within the system. The guides providetemplates that service managers can use to helpwork out what the actual demand for the service isand how that can be matched against capacity withinthe system.

PDSA is

> A simple tool for staff to test out ideas that willimprove health and social care systems andprocesses

> A structured approach for making smallincremental changes to systems

> A way of helping you to move to action, evenwhere some uncertainty exists about whether thechange will lead to improvement

> A full cycle for planning, testing, studying andacting on the learning gained from the first 3 phases

Principles of PDSA

> Breaks down change into manageable, bite-sizedtime-limited chunks

> A PDSA cannot be too small> Small changes can be tested without causing

upheaval to the whole system> If it does not work, try something different based

on your learning


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ACT PLAN

STUDY DO

Making changes – Plan, Do, Study, Act (PDSA)


Advantages of PDSA

> It is small in scope and builds incrementally –small rapid cycles lead to improvement

> It is highly effective, changes are quick andimmediately evident

> It is a powerful tool for learning; as much islearned from ideas that don't work as from thosethat do

For instance, you might be working in a servicewhere you wish to:

> Improve access to treatment> Reduce (Did Not Attend) DNA rates> Make best use of staff time, skills and expertise

Only once you are clear about what your aims are,can you actually then look at any baselineinformation and monitor against any changes thatarise from your improvement work.

How will you know that a change is animprovement?

We live in a constantly changing world – but howwill you know if the changes you are making areactually resulting in an improvement? Is it possiblethat the changes have actually made things worse?We know it is not always easy to measure the impactof what we do and all measures have theirlimitations. However, used appropriately, data can bereally helpful. And what is the alternative – keepmaking changes in the absence of any measurementabout whether they work?

It is best to use quantitative and qualitative data tosee if the changes being made are actually making adifference – including views from those who use ourservices. If you are worried that a change to improveone bit of your service might make other thingsworse, then you need to collect data to see if thathappens. And remember, it is not a research project,you only need to gather enough data to learn if thetest was an improvement. For example:


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ACT PLAN

STUDY DO

What changes arewe going to makebased on ourfindings?

What exactly arewe going to do?

What werethe results?

When and howdid we do it?

Start with three key questions

PDSA cycles are the second part of ‘a model forimprovement’. The first part consists of 3 fundamental questions that need to be consideredbefore you do any improvement work (though you cananswer them in any order).

What are you trying to accomplish?

Improvement work requires clear aims that will guidethe work and focus your efforts. Ideally you want tobe able to measure whether you have achieved youraim and for it to have clear timescales.


So for the below example, what is happening to theDNA rate as we make changes? You might be concerned that actions to improve yourDNA performance will increase demand to the pointwhere service capacity cannot cope, i.e. you are soused to 40% of your clients routinely not turning up,that if most people do start arriving for appointmentsas planned, your queues – and waiting times – willincrease. You will need to be able to measure yourDNA rate, the activity you undertake, the capacityavailable, the number of people in your queue andwaiting times to understand if you are having anadverse impact anywhere in the system.

What changes can you make that willresult in improvement?

So now you know what you are trying to achieve andwhat data you will collect to know if you have achievedit. The next step is to think about what actual changesyou are going to make to deliver those improvements.Ideally you want to involve everybody who might haveto make the change in generating ideas for change.

It is often difficult to know in advance what theimpact of a change will be – and even if somethinghas worked in one area – it does not mean it will

work for you. This lack of certainty about whether achange will work and a fear of the consequences if itdoes not, can lead teams to just talking over thesame issue again and again. One way through this isto use PDSA cycles to initially test the change at asmall scale.

More information about undertaking small tests ofchange and choosing what to measure can be found athttp://www.improvingnhsscotland.scot.nhs.uk.Click on the improvement tools tab.

The last few pages have been a brief practicalintroduction on how to go about undertakingimprovement work. Over the coming months, we willbe working to develop some materials that arespecifically tailored to support teams to apply theseideas to improving access to drug and alcoholtreatment services.

If you and your team would be interested in workingwith us to develop these resources, we would like tohear from you. You may have already undertaken thiskind of work and if so, we are interested in learningfrom your experience. Alternatively, you may wantsome support in getting started. Either way, yourinput would be really valued. Please contact us [email protected].


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Improvement and service redesign is not a newconcept to many drug treatment services across theUK. Drug treatment services in England are currentlymeasured against a 3 week referral to treatmentperformance measure and some services in Scotlandhave also made significant improvements in makingservices more accessible to individuals with problemdrug use through redesigning their processes andsystems.

Over the past year, Scottish Government officialshave identified several areas where improvementshave been made in waiting times through serviceredesign. We are conscious that there is much morework that has, and continues to, take placethroughout the country. We are therefore keen forservices and ADPs to share their experiences of howimprovements were made, the challenges that werefaced and how these were overcome. This section shares some experiences from drugtreatment services that reduced waiting timesthrough service redesign, what they went throughand what they learned.

This is a live document. We welcome yourinput for future development. If you would liketo share your experiences please contact uson:[email protected].


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SECTION 4:Examples of good practice from across the United Kingdom


How things were…

Seven years ago Camden had a very traditionalservice with very long waits for treatment. At theworst, the average length of wait for treatment was18 months. Assessment appointments were all basedon ‘booked in’ appointments and the DNA rate wasas high as 60%. Something needed to change as thiswas not an efficient way of operating.

The process we went through to improveour situation…

The NTA’s ‘Opening Doors’ workshops introducedchange management techniques to partners and thiskick-started service redesign to improve access totreatment.

As a result of reviewing the process for how peopleaccessed treatment, Camden removed the need foran appointment for the initial assessment and set upclinics with a structured drop-in service; this meantpeople were seen within 24 hours. This is particularlyimportant, as it allowed people to be assessed attheir highest point of motivation. This change‘eradicated waiting times overnight’. This took acultural change in the staff, as they needed to makethe nursing staff and drugs workers much moreaccessible, removing all possible barriers to

accessing treatment. Motivating partners was keyand it was essential that there was buy in at everylevel. As the majority of service users are heroinusers, many needed a methadone prescription as astarting point, to help stabilise their chaotic lifestyle.It was, therefore, particularly important to getmedical staff buy-in.

Understanding demand and flow are very importantand can be as simple as knowing your service islikely to have a rush in demand on, for example, aTuesday morning, as this is when service userscollect benefits at the office nearby. Staff thereforeneed to plan for this and also need to cope withhaving a varied workload.

There used to also be fairly rigid requirements ofservice users in treatment. As a result of the serviceredesign, this is no longer the case with servicesbeing more flexible to accommodate that it can takea number of months for people to stabilise. For thosewith complex needs there is more intensive one-on-one support within the first 12 weeks. This initialphase of treatment is used to allow service users toget used to coming into treatment, attendingappointments and getting the methadoneprescription right. Once stabilised, it is ourexperience that clients are much more ready toengage in structured casework and address otherissues going on in their lives.


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CAMDEN

Camden has, in the recent past, had the highest number of individuals with problem drug use in treatment ofany London Borough. The NHS sees approximately 1500 people with problem drug use per year. If you includefigures from other sectors, the number in treatment each year is closer to 2000. It has one of the highestprevalence rates in London, with an estimated 4000 individuals with problem drug use of which the majorityare heroin users.



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Example of a client’s journey

To maintain continuity, ideally the person who first completes the triage, becomes the keyworker for the client.

TOP TIPS

> Changes need to be sustainable rather than one off

> All stakeholders need to understand what is in it for them

> If it doesn’t work do something different

> Should have been more radical with re-design earlier in the process

Drop in Clinic

24 hours Initial Assessment

5 Days

Medical AssessmentClient+ Key Worker+ Doctor

12 Weeks

InitialCare Plan

Medical Treatment

Psychiatric Interventions

Other

ResidentialRehabilitation

6 MonthsReview

Annual Review

Monthly AftercareClinic

Treatment+ Stabilisation

Formal Care Plan agreedincludingMental

Health Support

CLIENT JOURNEY


How things were…

In 2005 one NHS Board covered the whole ofDumfries and Galloway. Nurses had a limited caseload and when nursing capacity reached saturationthis caused the waiting lists to rise.

Some people were waiting up to 22 weeks forassessment.


In 2006 the service applied for Scottish Governmentfunding to deal with drug waiting times. In April2006 the voluntary sector took over the role ofassessing people for treatment and set up 5 localities. They set a target of referral toassessment in 4 weeks. Turning Point Scotland andAlcohol and Drug Support South West Scotland didall the assessment work. They took all referralsincluding self-referral, GP referral, social workreferral and criminal justice referral.

Training was offered to staff through ScottishTraining on Drugs and Alcohol (STRADA).

Within a year, waiting times were reduced to 2 weeks from referral to assessment.

Partnership working

Case managers identify agencies to refer clientsonto. The service works closely with Job Centre Plus,the Benefits Maximisation Team, Housing Supportand the Citizens Advice Bureau. The focus is onempowering the individual. People are encouraged tocontact the agencies themselves.

Flexibility is key to improving the service. It isimportant to focus on the needs of the individual.Staff have a lot of autonomy to tailor their approachto the needs of the individual.

Forming strong relationships with the nurses and thevoluntary service at management and ground level isvery important.


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DUMFRIES AND GALLOWAY

Dumfries and Galloway is a very large and very rural area with an estimated 1200 problem drug users.

In the Stewartry and Nithsdale area 72% of referrals are for heroin. In the east of the region, towards Carlislethere is a slightly higher percentage of cocaine usage.


Sustainability

Sustainability has been achieved through continuousdevelopment of drug treatment waiting times.

1) We started dealing only with time from referral tofirst assessment and psycho-social treatmentinterventions.

2) Then we looked at freeing up nurses’ caseloads toimprove time from assessment to medical treatment.

3) This meant shared care between voluntary sectorand NHS.

4) Then we introduced stabilising prescribing byvoluntary sector with a GP delivering and issuingprescriptions.

5) During the anthrax outbreak, we movedeverything again to ensure that assessment isdone on the day of referral and now no one waitsmore than 6 days for prescribing and a fullmedical check up.


Client’s journey through the pathway:

10 weeks1. Client in Assessment

Clients had to wait 10 weeks due to the GP surgery they registered with and the nurses’ caseload.

6 days 7 days2. Client in Assessment Treatment

The waiting time was still linked to nurses’ availability so we moved again to improve.

1 day 1 day 3. Client in Assessment Treatment

Client comments I would have referred myself here earlier if I had realised how quick things were.

I’m glad my girlfriend made my referral, I thought I would still have to wait ages and didn’t seethe point.

You actually are helping me this time, it is not just about methadone.

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TOP TIPS

> There must be honesty about what people are good at and what people are employed to do. Remember,nurses are there to nurse

> Look at everyone’s expectations, fears and hopes

> Service user engagement is key, find out what service users want from the service

> Deal with shared care first

> Deal with the more stable clients first



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How things were…

In April 2007, 799 people were waiting for drugtreatment – some of whom had had to wait a numberof years for treatment. Whilst a number of serviceswere on offer across the city 90% of referrals werefrom individuals looking for substitute prescribing.Analysis showed that demand for treatmentoutstripped capacity by 50% therefore the problemwas projected to get worse. Once people had beenassessed, generally 90% were starting treatmentwithin a few days.


A number of initiatives were undertaken to addressthe issue. Broadly these fell into 3 categories:

> Physical – we invested in temporaryaccommodation and a further £3.5m in a purposedesigned and built treatment and rehabilitationcentre due to open in Feb 2011

> Structural – we redesigned the structure ofservices along a process based model and intosmaller cluster-based teams. Moved from 27 routes into treatment to one central point ofaccess and reduced the process time by 50%

> Staffing – NHS Grampian invested an additional£500k in staffing capacity and we haverestructured the nursing and medicalestablishment. Aberdeen City Council invested anadditional £500k in social work family support,rehabilitation services and the routes out oftreatment

What improvements have been seen…

The number of people waiting has reduced from 799 to around 30. The number of people beingassessed within 28 days of referral has moved from9% to 53% as of the end of December 2009 withfurther targets established.

Sustainability…

The redesigned services are more cost effective andcost efficient and offer a better mix of clinical andnon-clinical supports. Appointments of team leaderstaff and investment in the infrastructure supportedthe redesign.

ABERDEEN CITY

Aberdeen City has an estimated 2597 drug users (1.8% of the population) with an estimated 2246 injectingdrug users (1.5% of the population)1.

1 Estimating the National and Local Prevalence of Problem Drug Misuse in Scotland



18

TIM

ELI

NE

S HEAT

PROCESS

OBJECTIVE

28 DAYSREFERRALASSESSMENT

28 DAYSASSESSMENT -TREATMENT

16 WEEKS

STABILISATION MOVING ON

16 WEEKS – 3 YEARS PLUS

MOVING OUT: LONG TERMRECOVERY

Client’s journey through the pathway

Client benefits:Clients have indicated a high level of satisfaction with the service

How happy are you with the service?



19

How things were…

Until service re-organisation in 2004, nurses hadcaseloads of more than 100 and were reachingsaturation point. Staff kept taking more people on,but found it difficult to discharge from the service.

The Scottish Waiting Times Framework begancollecting information on the activity of specialistalcohol and drugs services from April 2004. At thattime, waiting time for assessment and treatmentwithin Lanarkshire varied widely from team to team.Whilst some locality teams were able to see 100%of referrals within 3 weeks, in others no-one wasseen within 3 weeks of referral. Waiting times alsodiffered significantly for alcohol versus drug referrals.


Service redesign began in 2004. Teams in NorthLanarkshire became integrated, with nurses,occupational therapists, psychologists, psychiatrists,addiction workers and social workers workingtogether on the same site. It became clear thatproviding a service was more than medicallystabilising someone and providing a prescription formethadone or antabuse. With the publication of theNTA’s “Methadone and More” document, it wasrecognised that psycho-social interventions were asimportant, if not more so, than medication. Staffwere therefore encouraged to spend more time withpatients, asking about their mental health and

well-being. Nurses, in particular, felt this gave themmore job satisfaction than simply handing out aprescription.

It was clear that the focus should be on more thansimply stabilising drug/alcohol use, and beyondmental health to look at housing, benefits andgeneral welfare issues. Staff are offered supervisionto help them with the more difficult clients. Moreeffective ways of using non-statutory agencies werefound and resources were used more effectively.Through the ADP the service has a good relationshipwith other services.

In Lanarkshire, there are now 10 locality teamsproviding specialist addiction services. Six of theseare integrated addiction teams in North Lanarkshire.In South Lanarkshire, the remaining 4 NHS teams,along with social work substance misuse teams, arein the process of exploring what integration will looklike.

Lanarkshire ADP has recently published a documentoutlining plans to develop a recovery-based approachto services. This recovery strategy sets outLanarkshire’s vision for a recovery orientated systemof care and is available athttp://www.lanadat.org.uk/ladat/440.202.220.html

Lanarkshire also have a clinical governanceworkplan, which incorporates regular casenoteaudits designed to improve the quality of treatment.Care plans are regularly reviewed, with service usersplaying an active role in their treatment and care.

LANARKSHIRE

Approximately 1800 service users receive Methadone, with another 300 prescribed Suboxone.

The majority of substance use involves alcohol or heroin, although many people have poly-drug use problemsand mix heroin with alcohol and benzodiazepines. There is limited use of cocaine.


A lot of work has been done to build relationshipswith primary care. The service has a well developedspecialist GP prescribing service, based around full-time, part-time, and sessional doctors. This iscomplemented by a number of community pharmacistsupplementary prescribers. These have proven to be

an excellent resource as they know the patients verywell, given daily contact at pharmacies. Both thespecialist GPs and the pharmacist prescribers areintegrated into addiction services, linked via theGPASS system which facilitates both appointmentscheduling and prescribing.


20

Access to initial assessment

Num

ber o

f clie

nts

offe

red

asse

ssm

ent

0

500

1000

1500

2000

2500

Number offeredinitial assessment

% within 14 days

Jul - Sept 08

1604

34%

Jul - Sept 09

2155

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

% w

ithin

14

days

Percentage of people offered assessment within 14 days of referral

Num

ber o

f clie

nts

offe

red

asse

ssm

ent

Jul - Sept 08

874

86%

Jul - Sept 09

1096

91%

Access to treatment

84%

85%

86%

87%

88%

89%

90%

91%

92%

% w

ithin

14

days

83%

Number offeredinitial assessment

% within 14 days

Percentage of people offered initial treatment within 14 days of assessment

What improvements have been seen…



21

TOP TIPS

> Work with the ADP and get to know the people in it> Understand the needs of the service users, and work to remove roadblocks to effective, efficient treatment

and care> Recognise that recovery often begins outwith formal services> Support community recovery champions> Make use of non-statutory services> Psychosocial services are important in moving clients along the road to recovery> Clients require a holistic package, encompassing medical, psychological, social, welfare, vocational, etc.,

support



22



23

The Road to Recovery: A New Approach toTackling Scotland’s Drug Problem 2008: http://www.scotland.gov.uk/Publications/2008/05/22161610/0

Changing Scotland’s Relationship with Alcohol:A Framework for Action 2009:http://www.scotland.gov.uk/Publications/2009/03/04144703/0

Scotland Performs Website: http://www.scotland.gov.uk/About/scotPerforms

HEAT A11 – Guidance on Referral Pathways: http://www.scotland.gov.uk/Topics/Justice/law/Drugs-Strategy/deliverystrategy/HEAT/referral-pathways

NHSScotland Healthcare Quality Strategyhttp://www.scotland.gov.uk/Publications/2010/05/1010230710

The Scottish Mental Health Collaborative:http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/Delivery-Improvement/1835/74

NHS – High Impact Changes:www.ogc.gov.uk/documents/Health_High_Impact_Changes.pdf

Essential Care SACDM 2008:http://www.scotland.gov.uk/Publications/2008/03/20144059/0

Integrated Care for Drug or Alcohol Users:Principles and Practice Update 2007:http://www.scotland.gov.uk/Publications/2008/05/27154207/0

National Quality Standards for SubstanceMisuse Services 2008:http://www.scotland.gov.uk/Publications/2006/09/25092710/0

ISD Waiting Times Reports: http://www.drugmisuse.isdscotland.org/wtpilot/reports.htm

Drug Misuse Statistics Scotland 2009:http://www.isdscotland.org/isd/6164.html

Local Alcohol Profiles: http://www.alcoholinformation.isdscotland.org/alcohol_misuse/statisticssection.jsp

SECTION 5:Useful documents



24

The Improvement Support Team and the Scottish Mental Health Collaborative for sharing theirexpertise in improvement support on which much of this document is based.

Special thanks to colleagues working in Camden, Dumfries and Galloway, Aberdeen City, and Lanarkshire forsharing their experiences.

SECTION 6:Acknowledgements


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