Scottish Government

Drug Treatment Services for Young People: A Research Review

CHAPTER 3 CURRENT PROVISION IN SCOTLAND

This chapter sets out the findings from the mapping survey of DATs and practitioners, conducted from September to December 2001. The aim of the survey was to establish the nature and scale of provision for children and young people across Scotland. It also provided an opportunity to start to identify some of the issues associated with provision which were then followed up in the case studies and treatment pathway interviews. The responses were also important in selecting the case studies.

General Features of Provision in Scotland

The key findings concerning provision are as follows:

• There is a limited but significant base of existing provision. Details of 42 services which include some provision for children and/or young people were collected;

• This provision is distributed unevenly across Scotland. The 42 programmes were based in twelve of the 22 DAT areas, meaning that ten DATs did not provide any details of relevant provision. On further enquiry these ten confirmed that they were not aware of any relevant programmes in their areas;

• There are therefore large areas of Scotland (predominantly rural) where there is no drug related treatment and care available with any degree of specialisation for children and young people;

• Where services exist, their coverage is often confined to the immediate locality rather than the entire DAT area, or to specific target groups. Coverage is usually incomplete even in the DAT areas with relevant services;

• Existing services display varying degrees of specialisation in their targeting of and capacity to deal with children and young people;

• There is also great variety in terms of the aims and methods involved. There is much interesting practice but there is little overall consistency of approach across Scotland;

• DAT plans include the introduction or expansion of relevant services, and many of the current services have been in operation for one or two years only; this is a rapidly developing area of provision;

• The survey indicated that over 400 children and over 800 young people (16-18) accessed the 42 services during the twelve months to autumn 2001.

Two additional points can be made based on the mapping survey and supporting findings from the case studies:

• Current services exist to a great extent in isolation from each other. DAT officers are not necessarily very familiar with the details of services, and services within a DAT area or across DAT boundaries may have only limited contact with each other;

• As a result, there has so far been limited opportunity to exchange ideas and disseminate effective practice between services.

Each of these findings is supported with evidence from the survey in the remainder of this chapter. Gaps in service provision, and the need for further guidance mentioned by respondents, are also reviewed. More detail on the information collected is set out in separate appendices available from the EIU on request.

A Limited and Uneven Base of Provision

Eighteen DATs identified a total of 45 services. Two of the service providers in question returned blank forms on the grounds that the services provided were not relevant to our survey. This leaves 43 services, two of which (the Adult Care Substance Misuse service and the Cumbernauld and Kilsyth Addiction Services in Lanarkshire) are only mentioned in the response of another service and are thus not available for analysis. There are therefore 41 services of which we have some details. One additional service which was not included in the mapping responses, but was covered as a case study, was the Glasgow Looked After and Accommodated Children's service - this brings the total of relevant services to 42.

The DATs identifying services, and those reporting no relevant provision within their areas, are shown in Table 1. Most of the services operate in mixed urban/rural areas based in local urban centres with the exception of services in inner city Glasgow and Edinburgh, and the Aberdeen City urban services.

Source: Mapping Survey

There are examples of services in most semi-urban and city areas, although the number and range of services varies widely. The relevance and coverage of these is likely to be very patchy. It should be remembered that many areas, especially in large cities, will possess many other drugs related services, but these were not seen as being relevant to our study of services for children and young people.

There are some examples of services in predominantly rural areas where there are smallish towns. However, there are many similar towns where there is no indication of any relevant service.

Services in very rural areas are rare. This often reflects rare and small scale demands for drugs misuse services (as opposed to alcohol related services) in these areas. Some services which centre on alcohol abuse rather than on illegal substances would be available to children and young people. However, there are also likely to be out of area arrangements which enable services in these rural areas to refer to specialist provision elsewhere.

Incomplete Coverage within DAT Areas

Services frequently targeted specific client groups rather than making the service generally available to children or young people. This means that others outside the target group may not have access to services. For example, the Fife Youth Drug Team selects from referrals on the basis of likely benefit. Referrals are all individuals with an offending record as the focus of the service is on reducing offending behaviour.

In some areas, services are available only for looked after and accommodated children, with few or no corresponding services for children not under council care. There are plans to extend service availability in many of these areas. In other cases, a service may be open access but only available in a relatively small part of the overall DAT area.

Degrees of Specialisation

Very few projects are targeted exclusively at our core group of children with drug misuse problems. Our questionnaire asked projects to classify themselves by degree of specialisation on children or young people. The results are shown in Table 2 below.

Nineteen services report that they apply specific criteria in determining client eligibility. These vary quite widely, examples include: 'young people who have been looked after by the social work service on or after their sixteenth birthday' and '12 to 18 year [olds] known to have problems with drugs/alcohol'.

Variety of Approaches

Figure 2 shows the number of organisations offering each type of intervention. Almost all services offer advice and counselling, (although these are distinct forms of support they were rarely distinguished in responses) although this appears to vary somewhat in nature and scope. CADS at Bannockburn offers 'a full range of drug related counselling interventions' including 'harm reduction …motivational interviewing...and child sexual abuse work'. In other cases the exact nature of the service is less clear but the general intent is evident; 'coping mechanisms, general support for families, friends and addicts'.

Many respondents also cite 'other services' which are in fact often variants of counselling and advice, or references to referrals to some of the other treatment interventions listed. There are however some treatment services in this category such as 'group work' and 'diversionary activities' which illustrate activities particularly relevant for younger clients or specific groups of clients, and which are worthy of further exploration in the case studies.

At first sight many services also appear to offer prescription services (almost always methadone based). However this disguises the fact that very few are likely to open these services to children under 16. This can also apply to other services. One service, for example, provides six month and nine month methadone reduction and detoxification, and needle exchange services but for over-16s only.

The least prevalent treatment intervention is residential treatment and/or care. Like other agencies, the Childcare Fieldwork Service in Aberdeen has some access to residential facilities; 'work with this client group may well involve child protection, statutory involvement with the Children's Hearing system, our own residential units, and outreach service'. However the residential units referred to here are generic rather than specifically to address drugs problems. Residential facilities for children, focused specifically on misuse issues, were not found in Scotland; however; the Royal Cornhill Hospital in Aberdeen notes that 'two known Aberdeenshire cases have used Middlegate Lodge in Lincolnshire'. Another (voluntary sector) service in a different part of Scotland comments that residential services are 'difficult to access due to funding sources'.

The survey data shows the types of intervention available within services, but does not indicate how many service users are actually accessing each intervention type. The figures indicate that the most prevalent intervention in services accessed by under 16s is counselling, followed by a range of other forms of support, access to legal advice or assistance, and detox and rehabilitation. For young people over 16, treatments based on prescription are more prevalent features of services accessed, as one might expect.

A Rapidly Developing Service Picture

Most current services are likely to be expanded in the near future, in terms of area, remit, or capacity. Other new or related services will be coming on-line during the next financial year. The overall prospect for these services is one of continued development and ongoing embedding and integration, in response to the likely continued development of need among children and young people.

Some examples of service development plans are given in the boxes setting out practical responses to delivery issues in Chapter 6.

The Scale of Provision

In discussing the scale of provision it is important to note that survey responses were not necessarily based on any routinely maintained records showing the age of young people accessing services. Some services interviewed made the point that in some situations it was difficult to obtain reliable information on age, and that estimates might have to be made. Therefore the status of this information is not the same as that provided, for example, via the Scottish Drug Misuse Database (SDMS) which is based on returns from services using a consistent data collection format.

The questionnaire asked for the numbers of under 16s and 16-18 year olds being treated, both in terms of average caseloads, and in terms of annual totals. For many respondents this was a difficult question to answer, indicating that record keeping in this area is very variable. However, 27 respondents were able, or attempted, to answer these questions in whole or in part.

Fifteen respondents gave numbers for the average caseload under 16. However, three of these gave a figure of zero, so there were twelve remaining cases, most of which reported an average caseload of ten or under. The two exceptions had average caseloads of 55 and 70, and bring the mean number for the under-16 caseload up to 16 per service.

Perhaps surprisingly, the mean figure for the average 16-18 caseload was slightly lower, at 15; sixteen services gave figures in this category, ranging from 1 to 50.

Seventeen services gave figures for the annual total of under-16s treated, and the mean for these was 24. In other words, in these seventeen cases, an estimated total of around 405 children under 16 were involved with a treatment service for drugs misuse in the preceding twelve months. There may also be additional children accessing services which have been unable to give numbers.

Figures from the SDMS for 2000/2001 show that 176 under-16s were reported as new contacts by Scottish services ('new' means that this was their first ever attendance at the service, or that there has been a gap of at least six months since their previous attendance). This was 1.7% of all new contacts reported by Scottish services in the year.

Given that they describe different things, and the very different methods by which they were generated, the figures from the SDMS neither contradict nor directly support those from the survey. It is, however, reasonable to assume that the annual total of children in treatment is by some way higher than the number of new contacts.

Neither figure can be taken as an indicator of the scale of need across the country, since they only show service users. These may be outnumbered by those who for various reasons are not accessing available services, or who do not have services available to them due to the area in which they live or the fact that they belong to a non 'targeted' group.

The survey figure for the total of 16-18 year olds accessing services during the preceding twelve months is 831 - an average of 33 young people per annum in 25 services.

Of the new contacts with services notified to the Scottish Drug Misuse Database in 2000/2001, 16% reported they were under 15 years of age when their drug use first became a problem, with 44% aged 15-19 ('Drugs Misuse Statistics Scotland 2001', ISD Scotland, 2002).

Isolation of Services

From survey responses it was not evident that services enjoyed regular or close contact with other agencies outside their DAT area. The difficulty experienced by DATs in providing details of some services suggests that even within some DAT areas, communication between services is limited beyond the operational level.

Service Gaps Identified in Survey Responses

DAT contacts were asked to comment on any services for which there is an identified need but which are not currently available. Those that had conducted needs assessments were usually able to make some suggestions:

Residential services, particularly detoxification, but also rehabilitation therapy etc. Particularly difficult to find services of this kind for under-16s. [The] identified need is small - perhaps only 2-3 under 16s per year and potentially 10-12 16-18 year olds. Housing for 16-18 year old substance misusers is very problematic. Provision of education/employment training for this group is also problematic. (Dumfries and Galloway).

The needs of young people are currently anecdotal, hence the commissioning of the research [audit and gap analysis of current services for under-16s]. In general terms alcohol, chaotic use of various substances and generally difficult behaviour cause services working with young people some anxiety. Areas for further development could include further development of stable accommodation and alternatives to custody/diversion schemes. (Lanarkshire).

This theme of anxiety or uncertainty about what might be involved in working with young misusers is echoed elsewhere. 'Some practitioners get over cautious when dealing with young people and tend to over-react. While child protection remains paramount, there can be a tendency to take issues to extremes'.

It is worth noting that no services targeted at young ethnic minority users, and none specialising in working with children of either gender, were reported. Subsequent case study work in Aberdeen did confirm the existence of specialist facilities for pregnant girls or women, and outreach to sex industry workers (see Chapter 6).

Need for Further Guidance

A number of respondents believe there is a need for further guidance:

[Guidance should cover] young people with established substance misuse; young people leaving care with substance misuse issues; how young people's substance misuse impacts on families and generic social work services;

Confidentiality; joint assessment; young people's needs alongside issues of substance misuse;

How to do it!

These comments suggest that there is considerable interest in the treatment of drug misuse problems in children and young people, and that some research and thought is already taking place to address this. However, there appear to be uncertainties about the issues involved, which may relate to doubts about the policy and statutory framework. These are issues which were explored further via the legal framework review (Chapter 5) and in the case study and treatment pathways work (Chapter 6).

Other Service Characteristics

In addition to the key findings outlined above, the survey provides information on other service characteristics, as follows:

• Lead organisation: nine of the services are local authority run; eleven are NHS run, and two are described as a local authority/NHS partnership. Sixteen projects are run by voluntary organisations, and three categorise themselves as 'non-statutory services';

• Time established: the length of time for which services have been established varies between 20 years and six months (some services responded only 'many years'; this has been interpreted to mean ten years). Six had actually been operating for less than a year. The mean age of services, subject to the above assumption, was 6.7 years;

• Budgets: the total annual spend by the 28 services responding to this question is at least 6,535,000, an average of 233,000 per service per annum. But only a very small fraction of this sum is likely to be directly applied to work with drugs misusers under 16. Services specifically for this group tend to be working with much smaller budgets - for example one such service has a projected first year spend of only 50,000;

• Security of funding: twenty-five services enjoyed relatively secure funding; in some of these cases, secure 'core' funding was supplemented by additional project-based funds on a shorter term basis. As one would expect, most local authority and NHS run services received secure core funding, while voluntary sector services were more likely to be dependent on shorter term funds. However there were cases of voluntary sector projects which were long established with secure funding;

• Staffing: there were 499 staff (FTE) in total across the projects, with an average complement of 14 staff each. However numbers vary widely, and are likely to be misleading. It is probable that only a very small minority of these staff have regular or even occasional contact with children under 16 who have drugs misuse problems.

• Research and needs assessments undertaken: some DATs or DAT partners have undertaken needs assessments or other research exercises relevant to the study. These exercises are a reflection of the recent increase in policy and project funding focus on young misusers, and are associated with service development plans for young people, as evidenced in the corporate plans of most Scottish DATs.