Integrated Care for drug users: Principles and practice
Chapter 1: Introduction
Introduction
The Effective Interventions Unit (EIU) at the Scottish Executive was established in June 2000 to identify what is effective and cost-effective in the field of drug misuse prevention, treatment, rehabilitation and availability. The EIU also has a role in disseminating effective practice to policy makers, DATs and practitioners and supporting service providers to deliver effective practice. In autumn 2000, the EIU consulted on its first Work Programme. In the course of the consultation process, the development of integrated care services for drug users was highlighted as a priority.
During the 1990s, there had been an expansion of shared care arrangements across Scotland, mainly involving GPs and primary care staff, pharmacists and specialist drug services. However, Drug Action Teams (DATs), managers and practitioners were keen to involve a wider range of agencies and service providers from both the statutory and voluntary sectors to address the needs of individuals with drug problems. This would potentially include social and criminal justice services, housing and homeless services, employment, education and training services.
The EIU undertook to review research evidence and current practice with a view to identifying the principles and practice that would underpin the design and delivery of an effective integrated care approach, building on the current experience of shared care arrangements.
The purpose of this document is to set out for Drug Action Teams, service commissioners, managers and practitioners in the statutory and voluntary sectors
the rationale for integrated care, its definitions and principles
effective practice in planning, designing and delivering integrated services
practical guides and tools (where possible)
Background and context: from Shared Care to Integrated Care
The development of shared care arrangements for the treatment, care and support of drug users in Scotland followed from the recommendations of the Ministerial Drugs Task force in 1994. They advocated a partnership approach between GPs and specialised central services. This was followed in 1997 by the Scottish Office report 'Planning and Provision of Drug Misuse Services' which provided guidance on effective planning and provision and reviewed the relationship between the guidance and the national objectives (Scottish Office 1997). This report was primarily aimed at the health service.
In more recent policy and practice initiatives there has been a move towards broadening the number and range of agencies involved in providing treatment, care and support to drug users. The Department of Health Guidelines: Drug Misuse and Dependence - Guidelines in Clinical Management (1999) promoted shared care as a 'model that can be applied to any close co-operative work between agencies or services which directly improves the treatment of the individual drug misuser'. The Guidelines emphasised the need for collaboration across a range of services including social services, voluntary sector and the criminal justice system.
Also in 1999, "Tackling Drugs in Scotland - Action in Partnership" identified the provision of effective shared care arrangements and integrated drug misuse services as a priority for action. On 1st December 2000, the Executive set out targets and standards for tackling drug misuse. This included a new national standard on shared care which requires every LHCC and Primary Care Trust to have a locally approved shared care (or equivalent) scheme by 2004. Information from the Corporate Action Plans indicates that all DATs have schemes in place or arrangements in hand to meet the target date.
In February 2001, the EIU produced Initial Guidance on Shared Care arrangements (EIU 2001). The focus of this Guidance was on shared care but it signalled the intention to do further work to examine the principles and key elements of integrated care services that would encompass the wider range of services that could be involved in the treatment, care and support of an individual. Following the publication of the guidance a series of consultation workshops was held around Scotland. The purpose was to consult with commissioners, managers and practitioners about the key elements of service identified in the Guidance and to seek views about the desirability and feasibility of promoting a more integrated approach to the treatment, care and support of drug users.
There was a strong view from a significant number of participants that the term 'shared care' described a service provided largely by the NHS and was not well understood or recognised within other agencies. As a result, a shared care service was regarded as primarily a 'medical' service. Another view from all the workshops was that the term 'shared care' had different meanings in different sectors. For both these reasons, the use of the term was potentially a barrier to providing a co-ordinated or integrated approach to the care of the individual whose needs could extend across benefits, housing, family problems and unemployment.
The general view was that the term 'integrated care' was recognised and understood by a wider range of the agencies who should be involved with the treatment, care and support of drug users. It was seen as a more proactive term indicating action and enabling the participation of a range of services and the individual drug user and their family in the overall planning and delivery of care. The concept of integrated care as a way of supporting and promoting progress and recovery for drug users has been supported by our further consultations and review of the research evidence. It encapsulates a proactive approach to treatment, care and support; enables the participation of a range of services; and involves the individual and their family in the assessment and planning of care.
One of the overarching themes from the EIU consultation workshops and the research evidence is that the focus of integrated care should be on the individual, often described as a person-centred service. Much of the content of this document is about how to achieve a person-centred service: for example, by taking account of the views and wishes of the individual during the assessment process. However, while there was support for the objective of a service focused on the individual, the workshops also highlighted concerns about how to address organisational and institutional barriers. Within this document, we have tried to provide practical information about how to tackle some of the key issues that impact on the delivery of a person-centred service such as accessibility, information sharing and agencies working together.
The core of a person-centred service is that the individual will get the treatment, care and support that meets their needs. However, another concern was that this could lead to an expectation by drug users that their own wishes about treatment would automatically be met: for example, a higher dosage of methadone. In this document, we have placed the individual at the centre but within a context of an assessment and planning process that examines wider needs and circumstances and reflects them in an integrated care plan. Above all, the individual should be encouraged and supported to participate as fully as possible in discussions about their treatment, care and support at every stage.
Recent developments
In recent years, there has been a number of developments in policy and practice at national and local level that have an impact on the planning, design and delivery of services to people who have drug misuse problems. Overall, these complement and support the development of integrated care for drug users.
In particular, the provision of care to people with drug misuse problems takes place within the wider context of Community Care and involves a number of services within local authorities, NHS Boards and NHS Trusts. In 1998, the Scottish Office published 'Modernising Community Care - an Action Plan', which identified important aims for the future:
The lack of mainstreaming of these initiatives led to the Scottish Executive's Joint Future agenda. It promotes a number of measures to improve joint working that local partners should adopt. The principles outlined in the Joint Future agenda apply equally to the management of drug misuse services and should underpin an integrated care approach for drug users. The Joint Future agenda will be a key driver for change in community care as a whole and drug misuse specifically. The key principles informing this document are closely aligned with those that underpin the Joint Future agenda. These principles are set out in Chapter 2: Integrated Care: Definitions and Concepts.
Next steps
While the scope of the work on integrated care has been wide, it so far does not cover all aspects of effective practice. There are some topics where it might be helpful to do some further, more detailed work. These include:
integrated care pathways (planned for later in 2002)
needs assessment (planned for early 2003)
quality standards
advocacy
service response for those with co-morbid mental health problems
It is also the case that the development of integrated care for drug users will be a continuing process around Scotland with more lessons to be learned from monitoring and evaluation. We would welcome comments and ideas about the potential for further work on these or other related topics. You can contact EIU at the address at the front of the document. There will also be an opportunity to discuss a wide range of issues at the EIU dissemination seminars planned for November 2002.
Finally, The Executive has now set up an Implementation Group drawn from Health, Social Care, criminal justice and representatives of the voluntary sector to consider the principles and practice that we have identified. The Group's remit is to advise on implementation; to ensure that it is linked to other strategies and planning processes; and to advise on monitoring, evaluation and accountability. The Implementation Group will be chaired by the Executive's Director of Health Improvement.