Integrated Care for drug users: Principles and practice
ANNEX 2C
FORTH VALLEY INTEGRATED CARE SERVICES
Background and history
Services for dealing with substance users in Forth Valley were previously delivered in a relatively unco-ordinated fashion. The SAT was attended by numerous representatives from each commissioning authority. The group reflected the state of planning and inter-agency relationships at the time. The size and scope of its remit made effective action difficult. Like most such groups its membership was not consistent and the development of trust and an ability to work effectively together was slow. Despite these restrictions the SAT did successfully bid to the Scottish Executive for funds to support a pilot project of an alternative to custody scheme. A Forth Valley SAT Strategy was also produced & published before reorganisation of the SAT was undertaken, with a view to increasing its effectiveness & local impact, in 1999.
The key problems:
Service delivery
Delays & waiting lists for effective interventions
A lack of a range of available interventions
Poor co-ordination of existing resources & associated activity
Collaborative working patchy with little organisational support
Strategy - SAT
Large unwieldy committee with inconsistent membership and large remit
Poor communication with local forums
Little evidence of effectiveness - though some successes
Perceived as distant and unaccountable by communities
Integrating Services to improve outcomes
Strategic change
It was recognised that the SAT needed to improve its effectiveness and local accountability. In 1999 the SAT partners embarked on a process of re-organisation. Each partner agreed to have one senior SAT representative. The SAT also recruited a local community representative for the first time. A process of team-building involving "away days" facilitated by consultants experienced in public sector organisational development and community engagement was undertaken. Subsequently a restatement of the Forum structure was made with the forum becoming the recognised route for dialogue between the communities and the SAT. The aim was to develop an effective "bottom-up" approach to planning and service delivery.
The Tiered Approach - Development of an Integrated System of Service Delivery
In 2000, Forth Valley SAT set up a multi-disciplinary group to consider the need for a new street-level treatment service. This group delivered an options paper which was consulted on widely through the SAT forums and at a multi-agency away day involving all local partners. This process identified the need to consider a way of organising services which would deliver a range of treatment options to drug users when they needed them, with minimal waiting times and improved accessibility. Services would be placed within a continuum of "Tiers" (Diagram 1). Tier 1 would be the direct access (street) level at which basic assessment would be undertaken. The person could then be managed within Tier 1 if their needs could be met there or would be referred on (using agreed criteria) to the most appropriate service for their needs.
Each Tier would deliver specific interventions which would imply the training & skill requirements of staff. Protocols using agreed criteria would facilitate the rapid movement of individuals through the system. 4 Tiers were agreed:
Tier 1 - direct access including self-referral; assessment using common shared assessment tool; access to harm reduction services; general counselling & support
Tier 2 - referral only; specialised assessment; specialised counselling interventions
Tier 3 - referral only; specialised medical interventions
Tier 4 - referral only; rehabilitation (community & residential); shared care
Delivery - New Services
The SAT partners used the Tiered system to inform their subsequent commissioning of new services. All new funds are agreed by SAT. Services commissioned have included:
Signpost Forth Valley
The first element of the Tiered approach was the delivery of a Tier 1 Service. Funding was through new local authority "Rehabilitation" funds which were pooled and administered through the Health Board.
Forth Dimension & 4D Structured Day Programme
A process of development involving New Futures funding and local partners led to the funding of a new model of community rehabilitation. New SAT funds for "Rehabilitation" were successfully bid for allowing the development of an attached structured day programme.
CADS Shared Care Service
New SAT "Treatment" funds were used to enhance the existing Shared Care model in Forth Valley.
CSCA becomes CSSAD
The Central Scotland Council on Alcohol altered its constitution to become the Counselling & Support Service for Alcohol & Drugs. This better reflects activity and places CSSAD in the Tiered system.
Delivery - Processes of Care & New Systems
Service providers have used the structure underpinning the tiered approach to examine the key elements required for effective service delivery and develop processes of care to deliver improved outcomes for drug users. This process has included:
Service providers group: All service providers (including generic providers) meet regularly to discuss issues of integration, problems around inter-agency interfaces etc.
Process of care group: All specialist providers are involved in the development of clear & agreed pathways of care which will support the development of protocols and agreements ensuring patients are being managed in the most appropriate service for their needs.
Shared common assessment tool & Service Directory: The SAT Co-ordinator led a multi-agency group (including GPs) which developed & agreed a new assessment tool and information pack containing up to date information on Forth Valley Services.
Information-sharing policy: A multi-agency group developed a Forth Valley information-Sharing Policy which has been examined & accepted by the local Caldicott Committee & other responsible parties in all partner agencies.
Key Positive influences for change & difficulties encountered
Positive influences
A number of important elements have facilitated the progress in Forth Valley:
SAT team development & stability: the commitment to invest in development of the SAT as a unit has been crucial. This has resulted in an improved culture of trust among the partner organisations and has allowed a true partnership approach to evolve with a real focus on improving outcomes for drug users.
Strategic Commitment & agency accountability: The resulting commitment to a corporate approach from all partners has enhanced the ability to "join up" resources & services.
Community engagement & communication: The community has been positively engaged by recruiting a community representative onto the SAT and ensuring that all SAT decisions are informed by discussions at the forums.
Difficulties encountered
Despite the considerable progress there have been areas of difficulty, some of which are still being negotiated:
Commitment to & sustaining the joint SAT approach: Initially (& still on occasion) it has proved difficult to keep all agencies committed to the joint approach. Pressures on the health system or political disagreements within local authorities can have the potential to divert resources from their agreed targets. Such issues must be honestly addressed at the SAT.
Culture: As in most areas, FVSAT emerged from a local culture which included a lack of trust among agencies as well as a belief within the community that the SAT would not respond to their opinions regarding service delivery. These issues have been overcome by the SAT engaging in real community consultation (eg regarding the Tier 1 service which was ultimately awarded to a community consortium).
Communication problems - SAT & Community forums: The forums required a lot of development work & support to empower them and ensure they functioned effectively. Previously they saw themselves simply as "pressure groups" and they required to make considerable culture change.
Information sharing - organisational "preciousness": The development of the information-sharing policy generated considerable resistance from some agencies. This may simply have reflected a fastidious approach to policy but can easily be related to agency preciousness.
Over-commitment of a small number of key agencies: with such considerable development there has been a need for agencies to be involved in many meetings - which can over-stretch staff.
National funded projects: Nationally committed funds can appear in an area with no attempt to relate these to local planning or systems of service delivery. The SPS throughcare service is one example which has not been helpful in Forth Valley.
Conclusions
In recent years the Forth Valley SAT has endeavoured to improve interagency working and planning to better engage their community and deliver services which are more likely to meet the needs of drug users.
The Tiered Approach
