Scottish Government

Chapter 4: Aberdeenshire Alcohol and Drug Action Team Area

Action Team: The Action Team in Aberdeenshire is known as the Alcohol and Drug Action Team or ADAT. The team meets quarterly. The membership of 27 includes health (7), local authority officers (6), local authority elected members (2), police (2), prison (1), voluntary sector (1), Forum (3), Licensed Trade (1), ADAT (4). There are three forums in the shire, which cover North, South and Central areas and which are all represented at team meetings.

There are four sub-groups: Care and Treatment, Children and Young People, Criminal Justice, and Education and Prevention and Community Safety.

The team is supported by a Co-ordinator, two development officers and an information officer.

4.1 Key Outcomes

The ADAT had introduced a number of measures to promote outcome-focused practice and to commission and develop services on this basis. This was work in progress and there were occasions when the emergent evidence was not clear or robust enough at the time to support a firm judgement.

The balanced nature of evidence to date led to an evaluation of ADEQUATE on this performance measure.

Prevalence profile

Aberdeenshire had seen a steady increase in the number of residents seeking treatment, although there had been a levelling out over the period from 2004-06 at just over 500 people seeking help for specialist drug services. Nevertheless, the latest figures suggested that, at 1.10% of the population known to have problematic drug use, this was still well below the Scottish average of 1.84%. There had been a gradual increase in the number of service users describing a history of illicit drug use of 10 years or more. The figure for 2005-06 was 61% in respect of service users with an average age on presentation of 26 years. This had implications for the development of youth-focused services. Opiate dependency was the most common presenting problem. The waiting list of around 60 compared to an active caseload throughout substance misuse services of 855. Some people from south and central Aberdeenshire received clinical intervention in Aberdeen. Despite NHS Grampian and ADAT efforts to roll out the integrated service model from the north of the shire there were no such services available in central and south, and Aberdeen is more convenient to travel to than Fraserburgh.

Percentage figures from 2004-05 on 13-15 year olds who reported using illicit drugs, showed that 11% of 13 year olds and 31% of 15 year olds reported that they had been involved in drug use, an increase on the 2002 SALSUS figures. There had been a very slight increase in the number of referrals to the Reporter on the grounds of substance misuse between 2003-05.

There had been a sharp increase in the number of neonatal discharges where maternal substance misuse had been a concern, and an increase in the numbers of children on the child protection register where substance misuse was a major contributing factor.

With regard to alcohol problems, the figures for adult alcohol consumption across Grampian were similar to the Scottish average. The figures on patterns of under-age drinking showed that young people in Aberdeenshire exceeded Scottish averages on a number of key measures. The contact rate with GPs for alcohol problems was reported as 14 per 1000 of the population in 2004. This compared favourably to the national figure of 24.3.

Performance profile

In common with the other Action Teams, performance data on outcomes was being developed. The information which follows on performance is in relation to the priorities set by the Scottish Executive as well as emerging evidence on progress on planning and delivering services with a focus on measurable outcomes.

Aberdeenshire ADAT exceeded its performance contract with the Scottish Executive for 2005-06 relating to new clients, with 419 entering treatment [ SDMD 2006 p.11]. Between 2004 and the end of 2005 Aberdeenshire saw a reduction in the percentage of people who were seen for assessment within 21 days of being referred, from 26% to 23%. During the inspection we were told by a senior officer that 95% of people were now seen within four weeks of referral. Once assessed, there was an improving picture of treatment being in place within 14 days.

We found waiting lists were regularly reviewed and generally well managed, subject to the disparities that existed between the north and other parts of the shire. In the north, the first letter which was sent to people explained the reason for any delay and signposted them to the local voluntary sector service in the mean-time. No equivalent service existed in south or central Aberdeenshire.

Culture, change and communities

The ADAT had used its 2002 Adult Lifestyle survey to set out a baseline for the number of adults exceeding weekly sensible drinking levels. However, as this had not yet been repeated there was no more recent information by which to measure performance. The planned 2005-06 activity outlined in the CAP alluded to awareness raising, engagement with community forums, and health fairs in schools to target parents, but was vague on outputs and on measurable outcomes.

Aberdeenshire measured its performance in relation to drug and alcohol-related crime through numbers of a range of offences and police actions, some directly related to substance misuse and others not. There had been an increase in drunkenness offences but much of the performance information appeared to indicate an overall increase in drug-related crime and also police stop and search activity.

Management of social work criminal justice addiction services for Grampian was located in Aberdeenshire. The Aberdeenshire CAP was the only one of the three to note specific targets for this intervention, including increasing numbers being supported by criminal justice addiction workers.

Prevention, education and young people

Aberdeenshire figures on under-age drinking patterns exceeded the Scottish average figures on a number of key measures. We found some indications that Aberdeenshire was attempting - with variable success - to address the challenge of effective engagement with young people. A dedicated Children and Substance Misuse post had been made permanent, while a youth project previously contracted to deliver drug-focused interventions was re-launched in 2006 as a substance misuse initiative.

Planned activity in this area had stalled because of staff capacity problems. Nevertheless, the evidence from the CAP and our fieldwork suggested that the approach taken in Aberdeenshire was strategic, partnership-centred and sustainable. The emphasis was on capacity-building with those people and for those organisations, who had most day-to-day involvement with young people, such as Community Learning workers, youth workers and families. This was complemented by research-based projects targeting staff working with children at risk or hard to reach, for instance children's home staff and outreach workers.

Concerns about reported rises in the number of neonatal discharges led to Aberdeenshire conducting a training needs analysis for this group. They also took a decision to review the role of NHS Grampian Improving Health staff in schools and in the community, to develop their remit to respond to prioritised concerns.

Aberdeenshire used SMR 24 and SALSUS data as performance measures for the target to reduce the proportion of under 25s reporting illegal use of drugs. Numbers of under 25s reported as new clients in SDMD 2006 was 151, a dramatic increase on the 2004-05 figure of 66. There was also a markedly higher incidence of service users in their mid-twenties reporting substance misuse of 10 or more years standing. We saw very good examples of youth services which engaged with young people on a range of health and lifestyle issues but there were reports that they needed stronger links with treatment services. Their perception was that the waiting times were longer than the official data suggested.

Provision of support and treatment services

The national priority to increase the number of drug users in contact with treatment and care services has been met by the ADAT. Moreover, they had reduced waiting times and the percentage of unplanned discharges. Figures on drug misusers successfully completing treatment showed an increase from 33 for the year 2004-05 to 50 for the first nine months of the 2005 financial year.

These figures were encouraging but did not identify the extent of the disparities which existed between the north of the shire and south and central. We heard from senior staff that they were very conscious of the need to redress the balance of accessible services across the shire.

The ADAT had purchased or commissioned services from voluntary and independent providers. It had taken steps to ensure value for money, in that it sometimes commissioned part of a service which was primarily delivered for the city in the city. This was true of drug and alcohol service providers who had posts or sessions assigned to the shire, either on an outreach basis or attached to a particular base. This could be problematic when the main contract was under threat, as with the INCITE project for psychostimulant users. We also heard from some rural service users that they would rather access specialist services in the city to protect their anonymity.

The ADAT had secured temporary funding for three employment workers to engage specifically with people who had a history of substance misuse. The most recent figures showed that this project had some success in attracting referrals and translating those into personal development and health improvement gains. Within a year, 20 people had moved into full employment. We were told that the success of this project had exceeded expectations and, as a result, the workers were being prioritised by the Care and Treatment sub-group for permanent funding.

Performance summary

Overall, the CAP demonstrated considerable activity for 2005-06 and identified timescales and leads for all of the actions for the coming year. The measurable outcomes were often process measures. However, one of the actions was to produce outcome measures for all services by December 2006.

Aberdeenshire's self-evaluation questionnaire stated that the ADAT had developed a corporate approach to performance monitoring of drugs and alcohol treatment services. This was partially supported by our inspection findings. The key players in the ADAT and sub-groups all demonstrated a consistent understanding of the role and relationship between strategic and operational outcomes, and how the ADAT structures and processes were applied to monitor and report on progress.

However, there were evident deficits in management information systems which limited or slowed such processes up, and inconsistent IT systems across agencies, or unsophisticated systems within some agencies resulted in data for audit purposes being manually collected and harmonised. We were told that a recent survey of service users had attempted to capture how useful the service they used had been and the specifics of the difference made. These results were not available at the time of the inspection.

We also found that appropriate links were made between high-level strategic planning documents such the Joint Health Improvement Plan and Community Plans, but documentary evidence supplied by the ADAT on periodic reporting on treatment outcomes failed to set these in a strategic context, either in relation to national or local targets, or to inform strategic planning.

Evidence of progress on the ADAT's five current strategic objectives of quicker access to services, increased number of individuals starting treatment, improved retention in treatment services, decreased unplanned discharges and increased planned discharges was encouraging. There was increased access to services, people were experiencing health and lifestyle gains from their engagement with services, and the positive impact of the employment development workers had exceeded expectations.

The common shortcoming in outcome reports was the lack of context. In the absence of information concerning outcome targets, it was impossible to determine whether the outcomes were achieving or exceeding expectations, or falling short on a particular measure such as value for money.

Regarding individual gains resulting from engagement with substance misuse services, the local authority had begun employing the Christo impact tool, which can assist in sustaining motivation and focus on progress towards outcomes for both service user and worker.

There were strong and consistent signs that the ADAT and service providers shared a commitment to achieving effective performance on demonstrating outcomes for service users, but the means of evidencing this must now move to a higher level of harmonised reporting and performance management.

Recommendation 1
There is a recommendation on outcome and performance measures for all three Action Teams in Chapter 6.

In 69% of cases from the local authority and voluntary sector file sample the individual's circumstances were seen to have improved. Effective collaboration between services was considered to be a significant factor in this improvement in only 15% of voluntary sector files, but in 49% of local authority cases.

4.2 People Who Use Services, Staff and Other Stakeholders

In Aberdeenshire, people who used services were generally positive about their experiences, and some support for carers was developing. The staff survey results were mixed. We found staff to be positive on the whole in our meetings with them. Aberdeenshire faced significant challenges regarding the impact of substance misuse on comparatively small communities. The evidence varied as to how well they had engaged in addressing the concerns of communities whilst engaging with them in decision-making around the provision of services. We consider that Aberdeenshire performed to a GOOD standard in this measure, demonstrating important strengths.

Experience of people who use services, their families and carers.

This section includes some findings from the peer research specific to Aberdeenshire, as well as findings from observed practice and our meetings with service users and carers during field work. We found it more difficult to identify carers, and the experience of those related here cannot be assumed to be typical.

Thirty one of the 36 service users who took part in the peer research made evaluative comments about their experience of accessing and using services. These can be roughly grouped as follows:

Fieldwork meetings with service users

Service users we met with were very positive about the services they were receiving. Some told us they would not have known how to go about accessing specialist services if the services had not come to them following court appearance. Some service users told us about long waits for substitute prescribing.

In our observed practice sessions we were impressed with the extent to which service users seemed to be fully engaged in decision-making around their care in treatment. This was confirmed by them in subsequent discussion. They spoke highly of the main service they were engaged with and we found more frequent instances when service users were clear that their key worker/care co-ordinator actively sought input from other agencies or mainstream resources, to support a comprehensive care plan.

All of the service users felt that they had achieved some positive changes as a result of their engagement with services.

There had been a recent survey of service users views on services but the results were not available at the time of the inspection.

Experience of carers

In common with what we heard from carers in Aberdeen, carers in the Shire had taken a long time to seek support after it became evident that the person they cared for had a dependency problem. In smaller towns they felt exposed to recognition and possible speculation if they were seen to pick up information about support in a public setting.

A web-site had been developed for the area, which was affiliated to the national carers group. However, the reported means by which carers had found out about help was one of two family support groups. We understood that one had been disbanded. The group we attended was supported by two local authority facilitators.

Experience of support within the group was extremely positive but there had been varied experience of their involvement in assessment and care planning processes in respect of the person they cared for.

Recommendation 2
There is a recommendation for all three Action Teams about the involvement of users and carers in developing services in Chapter 6.

Training opportunities relating to substance misuse were opened up to carers. We heard from one carer about his experience of attending a conference funded by the group and finding that he was the only non-professional there. There was also access to alternative therapy training through the group, and a carer had been trained in a particular technique, which the carer was then able to use to therapeutic effect with the person they cared for.

Experience of staff

We received 25 responses from staff employed by Aberdeenshire Council substance misuse services, a 78% response rate of the total number of staff.

Motivation and satisfaction among staff were high. We had evidence that staff enjoyed the work they did. Managers spoke very highly of staff and the survey results indicated that nearly all staff who responded felt valued by their managers and well supported in situations where they may have faced personal risk. The majority agreed morale had been good in their team for the previous six months. Staff, including administration staff, spoke positively about training and development opportunities available to them.

Staff expressed some frustration about inadequate staffing levels in some services or teams, temporary contracts rather than permanent ones, and time spent on paperwork rather than direct contact with service users. The area which staff were most concerned about, however, was gaps in services and the implications for those with substance misuse problems unable to get the help they needed. Common themes were that staff felt they were doing their level best in a difficult field, and some exasperation that strategic bodies like the Scottish Executive and the ADAT seem unable to address resource issues systematically and sustainably.

"We did get exhausted sometimes as problems were very often life or death."

"Waiting list was too long, there were limited staff to deal with the desperation people were in at times."
(Quotes from staff survey)

Most of the 25 respondents in our survey agreed that more effective collaborative working between all the agencies represented in the Action Team structure had resulted in improved outcomes for service users. Aberdeenshire achieved the highest rating in the file reading results for partnership working appropriate to the needs of service users. Some partnerships were perceived to be working better than others.

Partnership working

Concerns were expressed in our focus groups about weak partnership links with mental health services.

Almost all of the 20 staff who responded to the question agreed that where service users had parenting responsibilities, their team was proactive in sharing information and engaging in joint assessments with all relevant agencies. A similar number felt that they worked effectively with social work child care where there were parenting/child protection concerns However, the file reading results highlighted the need for improvement in this critical area. Only 4 of 11 files contained an initial assessment where there were children living in the same household.

All 25 of the staff who responded agreed the service provided had a positive impact on the lives of service users and their families and their team promoted recovery and routes out for people who use services.

It was noteworthy that half of the 20 staff who responded to the question disagreed that their working conditions were expected to improve over the next 12 months.

Around half of the staff who responded agreed that substance misuse services were highly valued by elected members and by the NHS Board. Most of those who responded agreed that there was top level commitment from health, social work and the voluntary sector to work together to continually improve services.

Impact on community well-being

In its self-evaluation, Aberdeenshire presented a very positive picture of its performance on this measure which was not wholly supported by the findings from the inspection. While we found evidence of good strategic planning and structural links, we heard from senior staff and from community representatives that the strategic focus had been skewed towards drugs when the problems confronting them were mainly concerned with alcohol. In fact, the most recent figures suggested a comparatively low rate of reported neighbourhood disturbances related to substance misuse.

There was little evidence to show that the ADAT had taken steps to engage with communities on substance misuse issues beyond those driven by national targets. While there was reference to the local press being invited to ADAT meetings, it was not clear whether this formed part of a corporate approach to community engagement, and if there were any feedback mechanisms from this.

We heard from staff that there had been neighbourhood resistance to substance misuse services being developed in their area. However, there was no evidence of those services, or those which were currently being developed or re-designed, being the subject of proactive community engagement early in the planning stages. We were advised that these concerns had quickly subsided when the services had been operating for a while without incident, but this does not address the central issue of effective community engagement. It was suggested that there was a particular need to engage with communities which had been associated with relatively high levels of substance misuse problems, where whole communities could feel stigmatised by the association.

Both senior management and elected members felt that there needed to be a re-balancing of substance misuse resources to reflect the fact that public fears about drug use were being allowed to mask far larger-scale problems with alcohol misuse. It was alcohol-related disturbance which adversely impacted on the communities they represented. The issue of increasing prevalence in relation to underage drinking was a particular source of concern, along with that of problematic parental drinking. These were areas that the ADAT were focusing on as outlined in the current Corporate Action Plan.

Example of Good Practice
We visited a youth project in small community in Aberdeenshire. The service model was a generic one, offering education on alcohol, drugs and safer sex, and we considered that the prevention work was a good example of responding to the realities of young people's lives. There was evidence of good links with all services in the community, including the local GP practice, the pharmacy and the police. The emphasis was on social inclusion activities, and the development of personal confidence and social skills.

Community planning consultations in Aberdeenshire resulted in the identification of three community safety priorities, of which reducing the problems arising from substance misuse was one. It was not clear to us how this was being taken forward with communities affected by the issues. The Community Safety Strategy Group was represented on the Criminal Justice sub-group of the ADAT and vice versa.

4.3 Key Processes

While services were patchy across Aberdeenshire and in the centre and south in particular, the integrated service in the north was well developed, and there was evidence of good integrated working among statutory and voluntary staff. We consider Aberdeenshire's performance in this area to be GOOD.

The journey of the service user and family through services

There was a useful Guide to Services for alcohol, drugs and sexual health in Aberdeen and Aberdeenshire, and individual services produced leaflets. Local community pharmacists also had details of substance misuse services. However, a recent local survey of service users identified the need for improved information about services available.

The health and social work staff at the Kessock Clinic were line managed by their own agencies but described themselves as an integrated team. We found evidence of joint weekly referral meetings and monthly meetings to discuss issues such as policy as well as evidence of integrated care plans. There were also good relationships with local voluntary agencies. Although staff in central and south Aberdeenshire also described good inter-agency relationships, they were not able to work in as integrated a manner as staff in the north and expressed frustration about this. Barriers to greater integration included lack of suitable shared accommodation bases and there was a plea for a resource like the Kessock Clinic to be available in central and south. All health and social work staff used the integrated assessment form but the voluntary organisations did not.

Seventy five percent of referrals to the integrated substance misuse service at Kessock Clinic were from GPs, while the majority of referrals to voluntary sector services such as Northern Horizons and AACS were self-referrals.

Waiting times to enter drug and alcohol services varied throughout north, central and south Aberdeenshire, but were reported to be reducing, and Aberdeenshire ADAT was taking active steps to address this issue. Staff told us that the north used an NHS Grampian/Council priority scoring system, but south and central did not, and "worked on generally agreed priorities". In the north the aim was for people to be on the waiting list for no longer than 12 weeks, whereas in the south, where there were 24 people on the waiting list when we visited, they may have had to wait for 6 months for a service. People on the waiting list were given information about other services for which there was little or no waiting list. For people who needed detoxification and rehabilitation we were told there could be additional delays until vacancies became available and funding secured. After two appointment letters to which there had been no reply, people were discharged from the waiting list.

There was general agreement among staff that this system was a product of the Scottish Executive requirement to reduce waiting lists. Some were unhappy about the inflexibility while others expressed the view that intervention was more likely to be successful if service users were motivated to attend. New referrals on the waiting list received a letter copied to the Community Substance Misuse Service team, who sometimes provided additional support, and the GP. One of the voluntary organisations wrote to everyone on the waiting list every two weeks and offered telephone support with a named worker.

While it was generally accepted that chaotic substance misusers with children required priority attention, staff agreed that there were risks in not assisting single young men who were unsupported, unemployed and had a poor quality of life, who could easily drop to the bottom of any waiting list. Teams told us that they would try to include some young men among priority cases. Other high risk groups which had low priority were liberated prisoners not on methadone.

All of the agencies delivering substance misuse services in Aberdeenshire had their own files. We read 62 social work and 24 voluntary sector files. NHS Grampian conducted an internal audit of 88 of its Substance Misuse Service files, a sample size not sufficient to allow analysis at the Action Team level. The results from the health file reading are discussed in Chapter 7.

We found that almost all of the social work and voluntary sector files contained an assessment. Seventy percent of social work files contained a single shared assessment but none of the voluntary sector files did, as the voluntary sector services did not currently use the integrated assessment form. Sixty seven percent of the social work assessments were rated as good or better, 22% rated adequate and 11% weak or unsatisfactory. Only 14% of the voluntary sector files were rated as good or better, 59% were rated adequate while 27% were rated weak or unsatisfactory. Eighty seven percent of the local authority files had a care and treatment plan or equivalent but this fell to half of voluntary sector files. In cases where risk to the service user or others in the household was identified, only 19% of the relevant social work files contained an up to date risk assessment and risk management plan while the figure was 40% for the five relevant voluntary sector files.

Recommendation 4
A recommendation on assessments and risk assessments applicable to all three Action Teams is made in Chapter 6.

The health members of the integrated team did not work with significant others unless the service users wished it, while the social workers did. There was a group in Banff for families affected by drugs or alcohol, and there was a plan to begin one in Peterhead. They also offered one-to-one work with significant others, including when the drug or alcohol user was not involved with the service. This service was also available in central and south Aberdeenshire.

AACS offered one-to-one cognitive behavioural therapy ( CBT) and some family support, focused on lifestyle, budgeting and welfare rights.

Example of Good Practice
Aberdeenshire employed three Employment Development Officers ( EDOs), although the posts were currently time-limited due to funding. The EDOs encouraged recovering substance misusers to access various schemes and projects to promote a more organised lifestyle, and connected them to mainstream services such as further education and leisure. Support workers encouraged, accompanied and helped people to keep appointments. Obtaining work experience, however, was very difficult. All staff interviewed spoke highly of the Employment Development Officers and their impact.

Multi-agency and multi-disciplinary working and integrated person-centred care

Aberdeenshire seemed to have made good progress in developing integrated care. There were joint multi-agency guidelines for information sharing, although only 60% of the social work and voluntary sector files we read contained evidence of consent to share information.

We analysed the care and treatment plans in the social work and voluntary sector files to determine to what extent they evidenced integrated care around individuals' needs. We found that 74% of the social work care plans completely or mostly evidenced integrated care and 26% did so only partially or not at all. However, only 31% of the 13 voluntary sector care plans we saw completely or mostly evidenced integrated care while 69% offered partial or no evidence of this. In 95% of social work files it was clear which agencies and professionals were involved while the figure for the voluntary sector was 67%. In 72% of social work files there was evidence of multi-agency working with clearly stated roles and responsibilities but this figure fell to 26% for the voluntary sector.

The ADAT commissioned an evaluation report on GOPR, and this report stated "there has been a change of focus for the majority of agencies, and this has led to challenges for staff in taking a more child-centred approach in their practice" and "the requirement to gather information about the children of service users was well understood by staff". However, we found that only a third of the 11 social work files and none of the four voluntary sector files where there were children in the household contained an initial assessment of the impact of parental substance misuse on the children. Managers and staff interviewed had some concerns about consistent practice in parenting assessments, a concern we shared from our file reading, where only one of the 16 social work and voluntary sector files where there were children in the household contained one. There was, however, a full-time child care post attached to the Integrated Substance Misuse Team in the north of Aberdeenshire.

Recommendation 5
A recommendation applicable to all three Action Teams on working with families where there are substance misuse problems is made in Chapter 6.

Frontline workers from statutory and voluntary organisations seemed to work well together to deliver integrated services. Although integration seemed to be better evidenced in the north of Aberdeenshire than in the centre and south, these teams were good examples of integrated working without integrated management. CPNs were based in some GP practices, but not in all of them. We attended a quarterly meeting of the Central Aberdeenshire Alcohol, Drugs and HIV Forum (one of three in the shire) whose purpose was to inform the ADAT what was going on locally, and ensure local agency involvement. The Kessock Clinic in Fraserburgh held integrated weekly staff meetings to review cases, consider discharges and look at new referrals, which were prioritised using a points system. Joint assessments were undertaken and service users could attend multi-agency case conferences. Users of services we spoke to agreed that they thought services worked well together to help them.

The involvement of, and partnership with, people who use services, their families and carers

The three drug and alcohol forums in Aberdeenshire encouraged service users to take part in their activities, and stakeholder days had been held for information and feedback purposes. Service user feedback was built into the integrated assessment process and managers felt staff were becoming more comfortable with the integrated assessment form. Sometimes they left it with service users between appointments so that they could complete some of it themselves. They had tried different ways of involving people in their own assessments. This was confirmed from the file reading where virtually all of the social work and voluntary sector files we read contained evidence that the views of the service user were taken into account. Eighty one percent of social work files and 59% of voluntary sector files contained evidence that the service user was invited to attend decision making meetings and reviews.

The ADAT was looking at ways of collecting information from the assessment form to use in the planning of services. Treatment services were developing service user satisfaction data collection. In the integrated service they had just completed a cross-Aberdeenshire service user evaluation.

Family support groups were beginning to be established in Aberdeenshire and sustained over time. A member of the Aberdeenshire carers group represented carers on the Drug and Alcohol Forum. However, involvement of users and carers still had some way to go, with service users reporting that they did not feel involved in strategic planning or service development. The peer research conducted by SWIA may have given some impetus to this process.

Inclusion, equality and fairness in service access and delivery

As stated previously, services across Aberdeenshire varied, with the north being seen as being better served than central and south. Of particular concern was the lack of access to GP prescribing services, with key areas of Aberdeenshire having no GPs prepared to be involved in the enhanced care scheme, notably Peterhead, Inverurie and Stonehaven. Some outreach rural services and home visits had been developed where geography was an issue in accessing services. Carers interviewed reported a "post-code lottery" in the response and support they received when they sought help.

4.4 Strategic Management and Leadership

Staff and stakeholders stated the ADAT provided a clear vision for developing services for people with alcohol and drug misuse problems. Joint commissioning arrangements were seen to be good, and the range and quality of services was particularly good in the north, but the south and central parts of the county were somewhat behind the north in provision. The ADAT had begun the process of collecting information to improve performance.

We found performance in this area to be GOOD.

Vision

During our visit, staff and other stakeholders we spoke to stated there was a clear vision for substance misuse services in Aberdeenshire. Staff and managers of substance misuse services said there was a clear direction of travel, although at times they found the pace of developments frustrating and they felt constrained by Scottish Executive funding.

The main overall priority for funding in the ADAT's Corporate Action Plan ( CAP) was increasing the capacity of treatment services to achieve:

• Quicker access to treatment;
• Increased numbers of individuals starting treatment;
• Improved retention in treatment services;
• A decrease in unplanned discharges; and
• An increase in planned discharges.

Elected members on the ADAT were knowledgeable about the substance misuse agenda. Those we spoke to were clear that the three major priorities requiring attention were young people, a greater emphasis on tackling alcohol misuse and addressing "local service deprivation". They also said that the ADAT should be more accountable to the local authority in terms of its performance reporting and monitoring arrangements and that it should be better linked with the community planning structure.

Joint planning and development of services

Aberdeenshire's second Community Plan (2006) had five themes, and drugs and alcohol were included under community well-being. There were no alcohol or drug-related objectives under this theme nor was the ADATCAP listed under the key strategies. However, there was an indicator for community safety which was about reducing the number of alcohol and drug-related offences. There was a link to the Community Safety Strategy 2005-08 which had a priority theme of tackling problems arising from substance misuse. The first key task in the Aberdeenshire Community Safety Partnership Action Plan 2004-05 was to 'positively affect alcohol and drug misuse' and the ADAT was identified as the lead agency. The stated outcome measures were:

• reducing admissions to A&E for excess alcohol consumption;
• reducing the misuse of alcohol and drugs;
• a reduction in levels of violent crime;
• a reduction in referrals to the Children's Reporter; and
• an increase in 'Good Citizen' inputs and youth diversion schemes.

No specific targets were set but it was intended to measure outcomes by counting numbers.

Alcohol and drug misuse is an issue that cuts across many areas of Local Authority activity and needs to be included in a number of different strategic and action plans. In Aberdeenshire we saw alcohol and drugs featured in the community plan and the community safety partnership action plan. However, whilst the ADAT was mentioned in the latter we thought there needed to be a better relationship between the objectives in the ADAT's corporate action plan and the community planning process.

Recommendation 6
There is a recommendation on strategic links applicable to all three Action Team areas in Chapter 6.

Commissioning arrangements

The ADAT set the broad strategic objectives in Aberdeenshire whilst the Care and Treatment sub-group was the main planning and commissioning body. At the time of the inspection Aberdeenshire Council outsourced 53% of its services including some substance misuse services. Some negotiations had been undertaken jointly with health. One service provider stated that Aberdeenshire provided good contracts and contrasted this with one year funding in other areas. However, staff commented that funding decisions could take a long time even when the money was available through the Scottish Executive and this was a cause of frustration. There was some evidence that outcome setting in service level agreements could be improved.

Range and quality of services

Aberdeenshire health and social work services were delivered by 11 CPNs based at the Kessock Clinic at Fraserburgh and a Community Substance Misuse Service comprising a team manager, a senior social work practitioner, five care managers and two support workers based in Fraserburgh, Peterhead and Banff. The staff complement in central and south Aberdeenshire was 1 service manager, 4.5 care managers and 2.9 support workers. There was also a criminal justice addiction team. This team was composed of a team manager, a social worker and a throughcare support worker based in Peterhead and Strichen. The primary voluntary provider was the Turning Point service "Northern Horizons" in Peterhead, although Aberdeenshire shared some of the voluntary services with Aberdeen.

Resource constraints in the face of increasing demand for services had prompted a review of service provision to try to ensure that all services were being utilised to maximum effect. Substance misuse care management processes had been refined to ensure that qualified social workers focused on assessment and complex intervention, while more regular contact and support was provided by support workers.

Resources were being targeted efficiently, in that some posts were part-time and there were also part-contracts with voluntary sector services from the city. These measures allowed localised access to substance misuse services. The challenges of providing services in rural areas whilst not exposing service users to stigma were referred to throughout the inspection, and were found to be particularly acute in south and central areas.

Aberdeenshire had recently agreed to fund specialist GP sessions to help address the gaps in prescribing services in some areas. However, as there had been no recruitment or identification of a location for the post, the ADAT had just agreed to recruit a doctor on an SMS staff grade and space had been identified in Huntly and Portlethen. There was also a lack of needle exchanges, particularly in central and south Aberdeenshire.

Recommendation 12
Aberdeenshire should continue to take steps to develop services in the south and central area of the county to the standard of those in the north, based on identified need.

There was an independent provider of both alcohol and drug rehabilitation in Aberdeenshire and one supported living service for alcohol. Aberdeenshire tended to use these facilities. These services are subject to regulation and inspection by the Care Commission, although the supported living service had only recently been registered and there were no published inspection reports. The most recent 2006 inspection report on the independent provider contained no requirements and one recommendation. It was noted that the recommendations in the previous report had been addressed, and there was a reference to a comprehensive audit of the service having been conducted by an officer of the local authority the previous year. The report included very positive feedback from service users.

Quality assurance and continuous improvement

Aberdeenshire substance misuse services had recently sent out 300 questionnaires to people using their services. A third of them had been returned. Most responses were positive and made a number of constructive suggestions for improving services. Criminal justice had exit questionnaires although the return rate tended to be poor.

We were told that the issue of measuring performance outcomes had been discussed by the ADAT. Services had reflected on this discussion and then agreed that the integrated assessment and review form would be the tool for services which used it and Christo would be the tool for those who did not. The pilot of the assessment form for this purpose was at an early stage. However, the framework contained a scale of 1 to 10 for each part of the service user's life, e.g. health, family and addiction. Services were asked to record these scores at the initial assessment and then again at the person's review. This should give an indication of progress in each of the areas.

We attended an event organised by the Aberdeenshire BBV Forum which provided a good opportunity for networking and sharing of good practice across the area.

Example of Good Practice
The ADAT & North Alcohol, Drug and HIV Forum conference. We sat in on a conference, attended by a number of agencies, one of a series over a 10-month period, which had involved the police, specialist services and a theatre company in making presentations. The conference was fully interactive, and included a series of workshops. There were a number of display stands with information on agencies available to delegates.

Management information

The ADAT stated that a waiting times database was well established across all treatment services, who were reporting on service inputs and outputs on a quarterly basis. Administrative staff at the Kessock Clinic recorded referral, waiting list, caseload, discharge and re-referral information on electronic databases. They acknowledged that this could be improved. They were also hampered by the system 'crashing' regularly as there were inadequate telephone lines. The further development of outcome data was an ADAT priority for 2006 and 2007.

Recommendation 8
There is a recommendation for all three Action Teams on management information in Chapter 6.

4.5 Partnership Working

We found that while Aberdeenshire's structures were not integrated, there was evidence that partners worked well together to provide a service to people with substance misuse problems. Aberdeenshire had taken a lead in the development of policies and practices for children in families where there was substance misuse. The ADAT was in the process of reviewing how funding streams were being used. We considered performance in this area to be GOOD.

Partnership arrangements

Aberdeenshire had less formal integration of both strategic and operational structures than Aberdeen City and Moray. Despite separate accountability arrangements, most of the people we spoke to said the ADAT worked well, although they acknowledged this depended on the ability of key individuals to work together. The ADAT was linked to the CHP through the Chair, which rotated among the main agencies. The police were not members of the CHP but could be co-opted on when it was their turn to Chair the ADAT to maintain this link.

The Chief Executive of the local authority described good relationships with health. However, some staff said that health dominated decision-making about substance misuse services. They stated that effective partnership working was sometimes hindered by a lack of transparency about the decision-making process and there was a lack of ability to take account of external influences. Aberdeenshire elected members also described good partnership working in the area, although they acknowledged there was "still some way to go" to get everything in place. They described good links with the NESCPC and using the Community Justice Authority to enhance links with the police and prison services, which they felt to be crucial for substance misuse services.

Development and review of joint policies, procedures and protocols

Aberdeenshire used Grampian information sharing policy and protocols across agencies. Integrated drugs and alcohol services were well established in North Aberdeenshire, and the use of integrated assessments, information-sharing, joint care plans and case reviews had been agreed and implemented.

Aberdeenshire had an operational protocol between the Criminal Justice Addictions Team, Supervised Attendance Order Workers and APEX.

Aberdeenshire had led the implementation of GOPR in Grampian. Training had taken place for GPs and health visitors, speech and language therapists and school nurses, as well as staff from other services such as housing. There had been limited success in involving GPs.

Recruitment, deployment and development of staff

We were not made aware of any significant recruitment or retention issues in Aberdeenshire. Some staff, however, complained that there were too many short term contracts. Staff in central and south Aberdeenshire expressed frustration at not being able to achieve greater integration on a par with their colleagues in north Aberdeenshire. Nonetheless managers and staff appeared to be a stable and motivated group. All the work of the public agencies in Aberdeenshire was with both alcohol and drugs.

There was a GOPR training and familiarisation strategy for staff, headed by a named officer. Voluntary sector staff whose service covered more than one Action Team area felt that the shire had had the most systematic and inclusive approach to this. The measures may have been effective in raising awareness and forging connections with child care workers, but it should be noted that these were not reflected in the file reading results. There was a commitment in the CAP to report on progress and improve implementation of GOPR in the spring of 2007.

Staff were satisfied with their training and continuing professional development opportunities. These included team days, which were seen to be valuable, STRADA courses, the post-graduate course at Paisley University and multi-agency training days, one of which the inspection team attended. There had been a recent development day which involved training for all staff in motivational interviewing. Staff also described informal learning from working in a multi-disciplinary team. Joint training on GOPR and Hidden Harm had been offered to all staff. Staff suggested that more joint training would be valuable. Social work staff training needs were identified through the council's appraisal system and supervision with line managers. The Aberdeenshire ADAT was undertaking a training needs analysis. Staff were generally satisfied with their supervision arrangements. Turning Point staff described good staff policies, review and appraisal systems and excellent opportunities for continuing professional development.

Joint budgeting and use of financial resources

The ADAT was currently reviewing how the money for substance misuse services was being used and attempting a breakdown of all of the funding streams.

We understood that health and social work budgets for drugs and alcohol treatment were not pooled but had been aligned/shared between ADAT agencies. The budget for alcohol rehabilitation had historically been both separate from and larger than the one for drugs rehabilitation. The service managers hoped that from April 2007 there would be one budget for both. Aberdeenshire jointly commissioned a number of services through the Care and Treatment sub-group of the ADAT, but the SEQ stated that "all new resources for drugs and alcohol treatment services have to be agreed by the ADAT".

The Aberdeenshire ADAT submitted its Corporate Action Plan ( CAP) for 2006-07 to the Scottish Executive in April 2006 and received feedback on the CAP in November 2006. Our review of Section F of the CAP, which gives details of drug and alcohol direct spend by partner organisations, noted the following:

• Drug Specific Spend - there was £568,000 of Scottish Executive funding made available to the ADAT for use in 2005-06. In addition, a further £1,049,000 of funding was available from partner organisations of the DAAT, £527,000 from Aberdeenshire Council and £522,000 from NHS Grampian for 2005-06.
• Alcohol Specific Spend - there was £288,000 of Scottish Executive funding made available to the ADAT for use in 2005-06. In addition, a further £603,000 of funding was available from partner organisations of the DAAT £426,000 from Aberdeenshire Council and £187,000 from NHS Grampian for 2005-06.
• Combined Drug and Alcohol Specific Spend - there was £6,000 of Scottish Executive funding made available to the ADAT for use in 2005-06. In addition, a further £694,000 of funding was available from partner organisations of the DAAT, £583,000 from Aberdeenshire Council, and £111,000 from Lloyds/ TSB grants for 2005/06.

In 2005-06 the total expenditure incurred was £3,128,000 against the total funding available above of £3,208,000, resulting in an underspend to 31 March 2006 of £80,000. No particular reasons were given for the underspend. £862,000 of this spend was from Scottish Executive allocation and £2,266,000 in contributions, largely from health and council partners. In addition, the total projected spend for 2006-07 was estimated at £3,575,000.

Recommendation 11
There is a recommendation on financial arrangements for all three Action Teams in Chapter 6.

4.6 Capacity for Improvement

The evaluation of capacity for improvement is based on three key factors: demonstrable improvements in outcomes for people who use services, quality assurance and performance management, and the effectiveness of leadership at all levels in health and social work services.

The ADAT had introduced measures to begin to promote outcome-focused practice and to commission and develop services on this basis. Services in the central and south of the area had some way to develop to reach the standard, quantity and quality of those in the north. We found examples of good integrated working, strategic leadership and partnership working. Staff and managers agreed there was a clear vision for services. Joint commissioning was being developed through an Action Team sub-group. Attempts had been made to obtain the views of service users about services, and services for carers were more developed than in the other two Action Team areas. The ADAT was in the process of developing agreements on spending of drugs and alcohol money. Aberdeenshire has a GOOD capacity for improvement.

Factors which will underpin and support change were identified. These included the model of integrated working identified in the north of Aberdeenshire, which could be rolled out across the central and south, and good strategic leadership, as well as the beginnings of joint commissioning practice.