Scottish Government

Chapter 5: Moray Drug and Alcohol Action Team Area

Action Team: The Action Team in Moray is known as the Drug and Alcohol Action Team or DAAT. The DAAT meets quarterly. The membership of 21 includes local authority staff (6), local authority elected members (5), health (3), integrated post (2), prison (1), police(1), Forum (1), Licensed Trade Association(1).The team was chaired by the Director of Community Services for Moray Council.

There was one sub-group and a local forum.

The team was supported by one full-time and one part-time officer. At the time of the inspection, a Drug and Alcohol Development Officer post was vacant.

5.1 Key Outcomes

In both written submissions and in discussions during fieldwork, Moray staff recognised that they had very limited evidence to support outcome-focused practice. The limited nature of this evidence, together with the concerns about the practice which we found in both the file reading and fieldwork, led us to conclude that Moray performed to a WEAK standard on this measure.

Prevalence profile

A prevalence study published in 2005 estimated that Moray had a prevalence rate of problem drug use of 0.66% of the population, well below the national average of 1.84% There were 98 new people with substance misuse problems who presented to specialist addiction services, mostly in relation to opiate use. The active caseload was just over 300 across the range of services, including Progress 2 Work. There were two Elgin-based services which accounted for 90% of these 'new cases'. While we were told by staff that there was a culture of 'elastic capacity' to prevent people having to wait to be assessed for services, there were difficulties in accessing substitute prescribing and Moray had not met targets to reduce waiting times.

The contact rate for people going to their GP for help with an alcohol problem was 14.9 per 1000 of the population, considerably lower than the national figure of 24.3. for the same period. The rate of alcohol-related offending was close to the national average, with a slightly higher incidence of drink driving.

Under-age drinking patterns were comparable to the Scottish average and did not indicate particular concerns. Numbers of young people referred to the Reporter on substance misuse grounds remained in single figures from 2003 to 2005.

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.

According to the CAP, Moray did not meet its target in its 2005-06 performance contract with the Scottish Executive relating to numbers of new clients accessing the direct access service by March 2006, as there were delays in setting up this service, which began in June 2006.

Culture, change and communities

Moray set up a three-year jointly funded information post in 2006 to focus on sensible drinking campaigns. This post was concerned with co-ordinating all prevention and early intervention work. The information and communication functions of the post were to include press releases following DAAT strategy meetings.

In the most recent CAP, Moray DAAT measured its performance in reducing binge drinking by using numbers of drunkenness offences. These had reduced by over a third in the last three years. However, this measure did not distinguish gender, unlike the national target, nor did it relate to the incidence of adults exceeding weekly drinking levels. The DAAT should take steps to remedy these shortfalls and set clear targets regarding mainstream population drinking patterns.

Regarding the national priority to reduce drug and alcohol related crime, Moray used comparative figures over time on a range of offence types. Drink driving offences had fallen, while Misuse of Drugs Act offences had increased slightly.

Prevention, education and young people

In 2005 the Action Team and the Community Safety Partnership commissioned a needs assessment in relation to harmful drinking by young people. The subsequent report recommended that services should be developed specifically for young people, rather than an add-on to adult services. Funding had been made available to provide this service.

We heard good reports about the use and the value of a mobile information bus. This toured the rural areas and attracted an average of over 2000 young visitors per year. Workers distributed information materials and conduct a range of workshops. 'Before' and 'after' evaluations suggested increased knowledge and awareness of issues and risks associated with substance use. The DAAT had also supported a number of consultation events with young people, although we did not find evidence that this had influenced the development of services in the area.

Operation Avon was the DAAT, Community Safety and Grampian Police commitment to a series of discrete initiatives focusing on under-age drinking hot spots. Eighteen such initiatives resulted in the police referring 30 young people with problematic use to services for young people. The perceived success of this joint venture for individual young people and for the community, had resulted in a continuation through to 2007, with more visible partnership working on the ground.

In view of these promising developments it is disappointing that Moray provided no hard information on performance in its CAP relating to the national priorities to reduce hazardous or at risk drinking by children and young people. Indeed, the figure quoted in relation to under 16s being admitted to hospital following alcohol misuse, suggested that this was not an improving picture. Moreover, the figures quoted in relation to child protection registration were not set in any comparative or policy context.

The failure to gather this information to inform performance management was a source of concern, and the DAAT must take steps to set the above information and initiatives within such a framework.

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

Provision of support and treatment services

Moray had persistent problems with waiting times and capacity issues within treatment services. In the light of this they undertook to commission a direct access service which would serve to support people waiting to access prescribing and continue in a supportive counselling role for those on substitute prescriptions. There were a number of delays but the service opened for business shortly before the fieldwork phase of the inspection. Early signs indicated that service users saw the service as worthwhile.

Moray had met the annual target of increasing the number of drug misusers in contact with treatment services by 10%. However, over the last two years they had not significantly reduced waiting times for people entering treatment. Forty four per cent of service users now waited less than 21 days, as opposed to 42% in 2004-05. The number of planned discharges from addiction services had not changed in two years and had not been set beside unplanned discharges. It is therefore impossible to gauge whether there had been any positive change in this regard. This was another area which the DAAT had intended to address through service development plans and performance indicators, but these were not yet in place.

We found good evidence about the Progress2 Work service, which helped people to overcome barriers to employment. The numbers of service users going on to education and employment, and testimony from service users themselves, suggested that this service was making a difference their lives.

Performance summary

Achievement of the key actions for 2005-06 was patchy with many actions delayed, often because of difficulties of recruiting to posts, and rolling over to 2006-07. Planned action for 2006-07 continued to be activity based and much of it was still concerned with identifying priorities for action, research and planning. The DAAT produced a CAP 2006-07 "Key Actions" document in August 2006. This document set out actions and measures by which Moray would be judged, but it lacked specific targets. Most actions were to be measured by numbers of people accessing services and no specific timescales were identified, nor persons responsible. There was little evidence of outcomes being identified. Developing a robust system of data collection and analysis was identified as a key priority and a performance indicator task group had been set up.

The self-evaluation questionnaire acknowledged that the Action Team had some way to go to develop a performance management framework which lent itself to measuring progress against national and local targets. We would encourage the DAAT to ensure that this reflects the 'root and branch' scoping, auditing and planning overhaul which would be most helpful in the circumstances.

At a strategic level there were acknowledged deficits in management information systems and performance management measures to accommodate and track the setting of outcome targets. The most recent JPIAF evaluation rated Local Improvement Targets as an area requiring substantive improvement.

The new direct access service had a service level agreement which listed a number of "definite and desired" outcomes. The Christo impact tool was to be used to measure impact. A number of other services had been established in the area for some time, and had had funding extended or increased specifically because of evidence of positive outcomes. One was the employability service and another was the alcohol counselling service available in GP practices. There were, therefore, some encouraging indications about the direction of travel now being taken by the DAAT to put outcomes at the centre of service planning.

However, our over-riding concern was the absence of evidence to show that this policy extended to all services, particularly core services. Less than half of local authority files contained a recognisable care plan, less than half of service users experienced an improvement in their circumstances resulting from service intervention and just over half had been helped to access mainstream services.

Recommendation 13
The DAAT should put processes in place to ensure that all services have outcomes as a priority. This should be clearly reflected in care planning processes and staff should be supported to achieve and sustain this approach.

5.2 People who use services, Staff and other Stakeholders

The picture in Moray was a mixed one. People who used services reported positive experiences in working with staff, but access to services varied, with most services concentrated in Elgin. Staff expressed similar levels of job satisfaction as the other areas but had issues in relation to co-location of health, social work and voluntary sector staff, with groundwork needed to promote and support integration. The Moray DAAT had linked with the community safety agenda effectively on a number of ongoing initiatives which aimed to tackle substance misuse within communities. We considered that Moray performed to an ADEQUATE standard on this measure.

Experience of people who use services, their families and carers

This section includes some findings from the peer research specific to Moray, as well as findings from observed practice and our meetings with service users during field work. We did not have the opportunity to meet with any carers in Moray.

Around two thirds of the service users (20) made evaluative comments about their experience of services. These can be roughly grouped as follows:

Field work meetings with service users

The few service users we met with were not quite as positive about their experience as we found elsewhere. The main concerns were about access to services or being "passed from pillar to post". There were concerns expressed that there were not enough services.

Pharmacies were said to provide a good service although we heard comments that supervised dispensing was not always discrete.

We observed practice where service users seemed to be engaging well in working towards agreed care plan goals. Service users subsequently confirmed that they had benefited from the intervention. We were impressed that staff readily responded to the need for some awareness raising and support work with family members, whether adults or children.

Moray had had a number of consultation events with service users, more than were evident in the other action team areas. They had also involved a voluntary organisation in work to promote user involvement.

While we did not meet with carers, Moray Council on Addictions worked with 'significant others' and Studio 8 were considering offering a service to carers.

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

Experience of staff

We received four responses from five questionnaires sent to staff employed by Moray Council substance misuse services. This number of responses was too small to provide statistically robust results, and the results were indicative only.

The four staff who responded to our survey agreed that they enjoyed their work. While all staff who responded agreed that the quality of service provided by their team has improved over the last twelve months, half disagreed that morale has been good over the same period.

The four staff who responded agreed the service they provided reduced the harm caused by substance misuse to people who used the service and their families and carers, made a positive difference to the lives of people who used services, their families and carers, and promoted recovery and routes out for people who used services.

Partnership working

Four staff who responded agreed they been involved in training and sharing good practice with staff from other services. However, half disagreed that they had a good working relationship with GPs practices, health professionals, social work, housing, other council services, local voluntary organisations or local independent organisations. There was some disagreement from staff who responded to our survey that they worked in partnership with people who use services, their families and carers to achieve agreed actions in personal plans.

Moreover, staff who responded disagreed that all staff could access all the records held on people who use services. Health staff completed single shared assessments but social work staff did not. There was uncertainty as to whether social work managers of health staff would have access to their staff's health files. Considerable support from senior management in both health and social work will be needed to harmonise policies and procedures and integrate staff.

However, where service users had children, all staff who responded agreed that their team was proactive in sharing information and engaging in joint assessments with all relevant agencies. In addition, they all agreed their team worked effectively with social work child care services where there were child protection or parenting concerns. In the six files we read where there were children living in the household, half did not contain an initial assessment of the impact of parental substance misuse. There were 38 files where it was considered by inspectors that the service user was vulnerable to abuse or exploitation or posed a risk to others. Only one contained an up-to-date risk assessment.

One of the issues which staff felt strongly about was a perceived shortage of social work staff, including administrative support, and a more general feeling of being under-resourced. Only half of the staff who responded agreed they could manage their workload within their contracted hours. The issue of suitable and sufficient premises for individual and group work was also raised.

All four staff who responded agreed that they had a good understanding of the role of the DAAT and that the Action Team had effectively communicated their plans for substance misuse services in the area. They agreed that these plans and targets reflected local needs. They also agreed that there were effective planning structures which involved all stakeholders, including people who use services, their families and carers. This was consistent with our findings about the comparatively greater level of consultation in Moray.

All four staff who responded agreed that substance misuse services were highly valued by local elected members and by NHS board members.

Impact on community well-being

We found evidence that there were a number of co-ordinated activities concerned with community engagement and with community safety in Moray. These corroborated the information supplied in both the self-evaluation questionnaire and the Corporate Action Plan that these were areas where there had been a number of successes in progressing these agendas.

The Mobile Information Bus used to disseminate positive health information to young people across a large rural area appeared to be very well used and popular with young people, and workers in the field regarded it as a very worthwhile initiative. We also heard about the work of detached youth workers in engaging on issues of substance use prevention and harm reduction.

It was made clear to us in several fieldwork meetings that Moray worked hard at engagement and consultation. The DAAT had commissioned a voluntary sector agency to develop community engagement and find meaningful and sustainable ways of ensuring that the voice of substance users, was heard in planning processes. A Development Day had taken place and work was ongoing on the action plan resulting from this.

There seemed to be regular consultation events which were open to the general public, as well as publicity campaigns on specific aspects of substance misuse, often as part of national awareness drives. Neighbourhood forums had recently been established to feed into community planning processes and these, together with Patient Participation Forums, were attended and supported by officers and elected members. The DAAT was going to collaborate with Community Safety and Health Improvement on a Drug Communication Plan.

For their part, elected members spoke with some confidence about promoting community well-being through their involvement in co-ordinated strategic planning bodies.

As part of the remit of the recently established direct access service in the centre of Elgin, staff provided information to any member of the public. They aimed to be responsive to emergent trends and would develop specific support initiatives with particular communities of interest, such as family members, if this emerged as an unmet need.

The DAAT was committed to supporting the Community Safety Plan, and appeared to have taken this commitment further than the other Action Teams, in that performance measures between this plan and the DAAT strategic plan were to have a single harmonised system of performance reporting.

In 2005-06 there were 18 joint operations with police to tackle alcohol-fuelled anti-social behaviour by young people. This resulted in a number of referrals to specialist services, and confiscation of alcohol from under-age drinkers resulted in a referral from the police to social work. Between 2002-04 there was an upward trend in underage drinking reports by the police and a reduction in 2005 was tentatively attributed to the impact of these initiatives, but this has not continued into 2006 and therefore required a re-think. There was clear evidence that the DAAT was actively engaged in and supportive of the Community Safety Partnership in examining the way forward.

5.3 Key Processes

The appointment of a single manager for health and social work staff to an integrated service gave some cause for optimism that joint working might improve. However, the differences in the use of assessments among the three parts of the service, and the relationship of the Moray Council on Addiction ( MCA) to the integrated service will need to be addressed, as well as the involvement of GPs, before the service could truly be described as integrated. It was suggested to us that our findings on the weaknesses in the files on sharing of information were not indicative of the quality of the relationships between staff and services. However we did not see clear evidence that this was the case.

We consider that Moray performed to a WEAK standard in this area.

The journey of service users and their families through the service

Moray provided a good range of leaflets in their advance information, but we were uncertain how available they were to the general public and potential clients and families. The Studio 8 direct access service had literature available and could signpost people on to other services. The pharmacy in Elgin dispensing methadone only allowed their company's leaflets to be on display. There was a service directory of addiction services in Moray, and a Moray drug telephone line.

Example of Good Practice
Moray has a direct access service, Studio 8, to help people into the services, offering literature on drugs and services, signposting to other services, one-to-one support and group sessions. This service had recently opened, but seemed to be providing quick access to services for users.

At the main office of the Moray Drug and Alcohol Team, situated at one end of Elgin High Street, there was no external sign for the service, and one sign was propped up on the floor, only visible through two sets of glass doors. While the service was described as "integrated", it had two parts. The social work part comprised a team of three, one of whom also had senior social worker responsibilities for the other two, and a criminal justice social work addiction worker, located separately. The team was half a post short and had had no administrative support for the previous six months. The health part of the integrated service comprised four community psychiatric nurses ( CPNs). The voluntary organisation, Moray Council on Addictions ( MCA), with two paid counsellors and 25-30 voluntary counsellors, was located in the same building.

Referrals came directly to the individual services, and "ambiguous" referrals were discussed at a weekly meeting of the three services. Eligibility criteria to the three services was not co-ordinated. One concern was that individuals who requested voluntary sector provision received this without an assessment as to whether or not this was appropriate. A senior manager described "varying degrees of integration in the way each team works and accepts referrals" but said that protocols and ways of working together were being developed.

Neither social work nor health staff operated waiting lists for their services. However, social work staff indicated that the policy of allocating all referrals had resulted in high caseloads and that they needed to consider creating a waiting list. CPNs also told us that they had worked hard to get the waiting list down but that they now took on too much. They thought that if they only provided services in line with the protocols on priority, then young males would not get a service. One young man had been seventeenth on the waiting list for 18 months. They therefore operated a separate waiting system for these service users. MCA did not have a waiting list for assessment, but service users might have to wait for a volunteer counsellor to start work with them.

In recognition of the importance of alcohol misuse among young people in Moray, the local hospital automatically referred young people admitted due to excessive alcohol misuse to the social work team. Parents were sent a letter telling them that a social worker would visit. If there was no response after two or three attempts at contact, then no further action was taken. This is an interesting initiative, but it was unclear how effective it was at responding to the problems of these young people.

Separate files were kept by social work, health, and voluntary sector staff. We read 66 social work and 30 MCA files. NHS Grampian conducted an internal audit of 88 of its SMS files, but sample size was not sufficient to allow analysis at Action Team level. The results from the health file reading are discussed in Chapter 7.

We found that only 32% of the 97 social work and voluntary sector files contained an assessment, although the voluntary sector performed significantly better than social work in this regard. Of the 32 files which contained an assessment, over half were rated as weak or inadequate. Only 3% of these 32 files contained a single shared assessment although in all eight of the relevant files, a specialist assessment had been completed if this was appropriate. Only just over a third of the 97 files read in Moray contained a care and treatment plan or equivalent. The care plans that we read had very few clear targets or objectives of intervention. Only 28% of social work and voluntary sector files contained evidence of regular review of the care plan. Links to other services, especially Criminal Justice, were not always recorded. We found some cases with children involved which were closed because of failure by parents to keep appointments, but there was no clear recording about discussion with childcare workers about this or about any continuing monitoring of the parents' misuse of substances and any risk to children. This was confirmed by an observed practice. It was evident from these files that while social workers and nurses had a positive working relationship, their roles were very separate.

There was no evidence of risk to or from service users being routinely recorded, although one worker in an observed practice interview described a good induction about risk assessment. Only 2% of the 44 relevant social work and voluntary sector files where risk to the service user or others in the household was identified contained an up to date risk assessment and risk management plan. NHS Grampian had a Primary Care Trust Care Plan and a Home Visit Risk Assessment, and we had sight of an Alcohol Detoxification Care Plan, but they did not seem to be integrated with other care plans. Health staff had had basic awareness training about child protection, and MCA staff supervising volunteers would ask questions about, and record numbers and ages of children in the family.

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

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

The health staff in the integrated service dealt mainly with detoxification and methadone, the social work team prioritised families, particularly if there was risk to children, and the MCA worked mostly with individuals and significant others.

Staff spoke of good informal information sharing, weekly meetings, co-location, and the recent appointment of a single manager for health and social work staff as positives. We recognised that the team had only recently been set up and so it might be unrealistic to expect it to be functioning as a fully-integrated team. However, we found little written evidence of joint working to ensure effective referral mechanisms, effective shared assessment of needs and risk, or integrated care planning and review.

The social work team did not use the integrated assessment form, but nurses did. The tool was not available electronically and as there was no possibility of a shared health and social work IT system, it was not possible to share information in this way. There was some confusion in Moray as to whether a final draft of the form had been agreed. Documentation was therefore not harmonised and there seemed to be no systems for shared assessment of needs, which could lead to duplication. There was no standardised care plan. None of the voluntary sector files we read contained care plans which showed evidence of integrated care around the individual's needs and in 80% of the care plans in social work files this was either only partially evident or not evident at all. While service users had regular contact with specialised staff there was no evidence of this being co-ordinated.

Staff felt that appropriate information was shared between social work, health and MCA staff and that service users were clear about this. For instance, issues in relation to possible child protection concerns could be raised at the weekly meeting and these cases could be referred to the social work children and families team, with the addiction team retaining work with parents on their substance misuse. However we did not find consistent evidence of this from our reading of the case files. Only MCA had a written consent form to share information once a person started to attend their service and this information was evident in 90% of the case files we read. Only 41% of the social work files contained evidence of consent to share information. We found that half of the six relevant social work files and none of the five relevant voluntary sector files where there were children in the household contained an initial assessment of the impact of parental substance misuse on the children. Furthermore only one of the six relevant social work files and none of the five relevant voluntary sector files where there were children in the household contained a parenting assessment.

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.

The recently appointed manager of the integrated team was responsible to the Mental Health Joint Manager, but governance arrangements for health staff were less clear. We were told that they were line managed by the integrated team manager, a social worker, but received professional support from the clinical nurse manager. Staff felt that currently these arrangements lacked clarity.

In 80% of social work and voluntary sector files it was clear which agencies and professionals were involved. However, in only 35% of files was there evidence of multi-agency working with clearly stated roles and responsibilities, although the figure rose to 51% for the social work files alone.Only 3% of the 31 voluntary sector files contained evidence of multi-agency working with clearly stated roles and responsibilities.

There seemed to be a good relationship between GPs and specialist services in Moray, but some GPs had a limited view of their role, that of issuing methadone prescriptions. We were told by front line workers that only two GPs were signed up for enhanced methadone prescribing, and the rest would continue with existing patients but not take any new ones.

In response to enquiries, the Studio 8 direct access service was about to start offering sessions to carers. We were unclear if they had liaised with MCA, who saw significant others, about this initiative.

Elected members we met were positive about the provision of multi-agency work, underpinned by the strength of their Community Planning Partnership ( CPP), but accepted that difficulties in IT systems and confidentiality were hampering progress.

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

The Drug, Alcohol and BBV Forum had very little representation from service users, though some individuals did attend occasionally. Alcoholics Anonymous, Alanon and the Princess Royal Trust were regular attendees. A development day run by the Forum came to the conclusion that "user involvement requires further work". They were conducting a survey.

The integrated assessment form had been designed to support the participation of the service users in their assessments, with care plans signed by the user, and the one observed practice we undertook supported the view that this was in place in part.

Seventy nine percent of the social work and voluntary sector files we read contained evidence that the views of the service user were taken into account in this process but only 43% contained evidence that they were invited to attend decision making and review meetings. Performance in the latter was significantly better in the social work files. None of the 30 voluntary sector files read contained evidence individuals were invited to attend these meetings. However this may be due to a lack of any explicit reference to such meetings in MCA's cases recording materials. In just under half of the relevant 17 cases in Moray, there was evidence the needs of the carer had been identified. However, in only two of these cases was there evidence that the carer been offered a carers assessment, and in six cases was there evidence that the needs of the carers were being addressed. Overall, we think that there was scope for improvement in this area. More consistent use of the integrated assessment form would offer a framework for ensuring service users were fully involved in their own assessment and care planning.

Inclusion, equality and fairness in service access and delivery

The directory of services was to be reformatted in other languages, but there were no formal plans to engage people from different ethnic groups. There were, however, interpreter services available.

It was clear that Moray was in the process of trying to make the service more accessible through the Studio 8 project, and that because of the rural nature of the area, staff in service were prepared to do home visits where appropriate. The GP counselling service delivered by MCA was also available in various GP surgeries. The involvement of GPs varied however, and addiction services were still focused primarily on Elgin. The office of the Drug and Alcohol Team was not accessible for disabled people.

5.4 Strategic Management and Leadership

The restructuring of the DAAT, with an Implementation Group emphasising the need to deliver change, and the leadership provided by the chair and vice chair of the DAAT, had resulted in greater drive and momentum. The improvements from this were beginning to be seen, though there was still some way to go. We therefore found performance in this area to be ADEQUATE.

Vision

Moray had recently re-structured its Action Team in response to an extensive consultation with stakeholders. There was a Strategic Drug and Alcohol Action Team and an Implementation Group. The former comprised chief officers from the partner agencies and six local authority elected members, and set the strategic agenda, while the latter comprised heads of service and was responsible for translating the strategic priorities into actions. Neither body had representation from people using services although this had been discussed. It was too early to judge how successful the restructuring would prove. However, most of the staff and other stakeholders we spoke to during the inspection felt that there was a clearer direction for substance misuse services and greater drive from the current DAAT Chair. The vision, aims and values for the DAAT had recently been revised at the time of our inspection, to enable a more comprehensive review of joint policies, procedures, protocols and guidance.

There were plans to base the DAAT Drug and Alcohol Development Officer and the Community Safety Drug and Alcohol Information and Prevention Officer with the integrated health and social work team with the intention of helping bridge planning and operational issues.

Moray DAAT had a strategy which set out its mission statement and its five key aims and objectives which were:

• Prevention through education;
• Equity of access to and provision of services across Moray;
• Promoting consultation, involvement, advocacy and public information;
• Combating alcohol and drug related crime; and
• Developing clear strategies through good information and effective communication.

Joint planning and development of services

The DAAT was linked to the community planning structure through the Community Health and Social Care Partnership, covering adult services, primary and acute care. There was one Community Health Partnership committee which was also the theme group for health and community care for the community planning structure. There were clear strategic links between the DAAT's Corporate Action Plan and Moray's Community Plan. Although there were no explicit links between the CAP and the Service Development Plans of individual agencies, the Community Service Department of Moray Council had the integration of substance misuse services as a key priority for 2006-07 in its Service Improvement Plan. Senior representatives of partner agencies were members of the DAAT's strategic or implementation group. For example, the General Manager of Moray's Community Health and Social Care Partnership and the Integrated Manager for Mental Health and Substance Misuse (with overall responsibility for drug and alcohol services in Moray) sat on the Strategic Group, while the planning lead in the Community Health and Social Care Partnership sat on the Implementation Group. Six Moray elected members, chosen for their strategic responsibilities for social work, education and health for example, sat on the Strategic Group.

Given the size of the population of Moray, links among the various strategic planning mechanisms in Moray appeared to be largely through cross-representation of individuals. These arrangements seemed to have been deliberately constructed and were largely felt to be effective by those involved.

Moray's second Community Plan (2006-10) had seven key themed areas. Alcohol and drug misuse was mentioned as a key health improvement area in 'Achieving a Healthy and Caring Community' but drug and alcohol misuse mainly featured under 'Achieving a Safer Community', as the responsibility of the Community Safety Partnership. The DAAT and its strategy were referred to, and the priorities were identified as reducing under-age drinking, and driving under the influence of drink or drugs. The objectives for reducing substance misuse for the next five years related to young people, their families, and wilful fire-raising resulting from substance misuse. These same issues were largely the focus of the substance misuse project which was part of Moray's Community Safety Strategy 2005-08. This Strategy stated that tackling substance misuse was one of its four main aims.

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

The DAAT Development Officer was a member of the Community Safety Steering Group, the Community Safety Co-ordinator was a member of the DAAT Implementation Group and there was a Substance Misuse Task Group. However, the Moray Service Improvement Priorities for Children, Families and Criminal Justice (March 2006) taken from the Community Services Improvement Plan contained nothing in relation to substance misuse. This was surprising given the high profile of GOPR and Hidden Harm.

The Moray DAAT had recently conducted an extensive consultation involving a wide range of stakeholders including service users. This had influenced recent changes. Staff told us that their involvement in strategic planning and development came through the Forum. The DAAT Chair admitted that it had been difficult to secure the involvement of service users and carers in the Forum and their views had instead been sought through consultation exercises. In the past these had not been acted on but the most recent one resulted in the setting up of the new direct access service.

Commissioning arrangements

NHS Grampian funding for the commissioned substance misuse services in Moray came centrally from the Board and they were still in the process of discussing disaggregating funding to Moray. Moray Council was about to undertake a review of the commissioning of services through the voluntary sector. The DAAT had been developing commissioning processes, and thought that the effectiveness of the process was evidenced in the commissioning of the direct access service, with clear expectations in relation to performance and outcomes.

The inspection team had difficulty in accessing the records of one of the main voluntary sector service providers in Moray. Although this issue was resolved, we think that both health and the local authority should review their service level agreements with this organisation to make sure it is contractually obliged to allow access to their records for the purpose of contract monitoring and external inspection. The main barrier appeared to have been their policy on and guarantees of confidentiality to their service users. The organisation will require the support of the local authority to review this policy to make sure that it protects service users while still facilitating external scrutiny of the organisation.

Recommendation 14
Health and social work commissioners should examine contractual arrangements with providers to ensure that contracts include clear statements that they have appropriate access to their files.

Range and quality of services

Moray faced significant challenges in providing the range of services required because of the extensive and rural nature of the area. Substance misuse services were concentrated in Elgin, although we did hear from service providers that the DAAT was flexible about providing funding for services to go to the service user.

Studio 8 was funded for one year from £182,000 received from the Scottish Executive after the Drug Treatment and Rehabilitation Review. The service aimed to "offer easy initial access, assessment and onward referral for members of the public who were experiencing difficulties with their own or someone else's alcohol use".

The GP Counselling Service, delivered by the Moray Council on Addictions since 2003 in GP practices throughout Moray, and jointly funded by the local authority, provided an important local service to people with drug and alcohol problems.

Moray had two voluntary sector initiatives to support people back into employment: Moray New Futures was a partnership initiative which was not confined to people misusing substances, although the majority of those referred had drug or alcohol problems; and Progress 2 Work was specifically for former users or those on a treatment programme and extended into Aberdeenshire. It always exceeded minimum targets set by funding bodies, 40% of people in the project last year being placed in employment or training and 60% of those sustaining the placement for more than 13 weeks.

Example of Good Practice
Progress 2 Work was specifically for people recovering from drug and alcohol problems. New Futures (not specific to substance misuse although former service users made up a significant number of their clients) offered packages of support to help people move on, including counselling, activities, career advice, educational opportunities and chances to gain qualifications in for instance computers, food hygiene, fork lift truck driving. This approach seemed very positive and was spoken highly of by service users we met who were in touch with this project. It was also a partnership initiative and staff worked across the two projects. The integrated team manager hoped to create a full-time throughcare post within the team.

There were no specialist GP posts in Moray. However, the head of SMS informed us that there had been recent progress. Following a meeting, Moray GPs had agreed to prescribe if the consultant (shared with Aberdeenshire but based at the Fulton Clinic) visited regularly and a specialist GP was employed. There was no proper inpatient unit for treating people with drug or alcohol problems in Moray. There was also very little affordable housing, which was an important issue for people misusing substances.

There was no residential provision in Moray and no resources allocated to it in the most recent Corporate Action Plan. Staff were of the view that resources were better concentrated on developing the spread and intensity of community support available within the area.

Services in Moray had developed opportunistically. As a result some felt there was a proliferation of some services, gaps in others, and a lack of co-ordinated service development. Following on from the reorganisation at strategic level, the task for Moray was to identify the need for services, critically examine the range and roles of existing service provision across the agencies in order to identify gaps and duplication, and build a range of services which would operate in a way which met current and future anticipated needs. This may identify a need for new services but it may be that there is a need for current services to deliver in different ways to respond to identified need.

Recommendation 15
Moray should follow up its review of strategic and operational structures with a fundamental review of need and develop services and staff accordingly.

Quality assurance and continuous improvement

Developing a robust system of data collection and analysis was identified as a key priority in the DAATCAP. However, this was still at an early stage and performance indicators through which services would report to the DAAT were being worked on by a task group of the Implementation Group. There were no internal quality assurance procedures for the team and these needed to be put in place. This issue required to be clarified quickly. Moray Council on Addiction kept an electronic record of referrals and standard letters were sent out. A paper file was set up only if someone using the service was seen by a counsellor.

Management information

Moray's SEQ identified that "Health and local authority computer systems were unable to communicate with each other, therefore having a negative effect on the sharing of information". Historically, different members of the DAAT gave separate reports on levels of activity and trends. A single reporting mechanism for health and social work was planned, and it was hoped that the new integrated service would help in the development of this single data collection system. Statistics were gathered from the police, health, etc. but were not sufficiently analysed to feed into and plan future activity.

Recommendation 8
A recommendation on management information applicable to all three Action Teams is made in Chapter 6.

5.5 Partnership Working

Partnership working in Moray varied. We found evidence that health integration at strategic level could be improved, and housing could play a stronger role, but there was positive support for the DAAT from the council, and a senior council official chaired the DAAT. Work was beginning to strengthen the links between strategic and operational levels. The development of the integrated team and its relationship with the local voluntary providers will be an important factor in the future of partnership working. Joint budgeting was an area for improvement. We found performance in this area to be ADEQUATE, with strengths just outweighing weaknesses.

Partnership arrangements

Many people we spoke to were positive about the recent change in the leadership of Moray DAAT and saw an improvement in partnership working as a result. Health did not seem to be as fully engaged as other partners in community planning and DAAT meetings. However, there were good relations with the police, and elected members in Moray were positive about partnership working in the area. Education seemed well integrated with the Implementation Group which was chaired by the Community Learning and Development Manager and we found good links between the DAAT and the integrated children's service partnership. Housing were not engaged in the Moray DAAT. According to the chief housing officer, the Council were finding it difficult to engage on the overlapping issues when there were large parts of the agenda which did not overlap, but she suggested themed groups could feed into the implementation group and DAAT. A recent consultancy report had highlighted that substance misuse issues were not being sufficiently addressed at a strategic level within the homelessness strategy.

AA and Al anon were members of the Moray drug and Alcohol and BBV Forum and we attended a meeting where there was good representation from a range of agencies.

The chair of the Moray DAAT saw the priority as strengthening the links between strategic and operational levels. This was being taken forward in a number of ways including co-location of strategic and operational staff. The example quoted was the Moray Drug and Alcohol Team which was co-located with a recently appointed manager for both health and social work staff. However, as set out earlier in the report, this team was not yet operating in a fully integrated way.

Development and review of joint policies, procedures and protocols

We saw a review undertaken by Moray DAAT of the policies and procedures of local voluntary sector, NHS and social work service providers, although this was undated. There was an action plan to address gaps, which encouraged organisations to share good practice.

As yet there appeared to be no joint working policies and procedures in relation to the new integrated team. This should be addressed as a matter of urgency. There was a policy on automatic referral to social work and the police of any drug-related incidents in schools and to social work of any under-age drinking incidents.

Recruitment, deployment and development of staff

The integrated drug and alcohol service in Moray had three drug and alcohol social workers, one of whom was senior and had responsibility for the other two and therefore a reduced caseload. There were four CPNs and a nursing assistant. It was intended that the team would also include the DAAT development officer, a post which was currently vacant, the drug prevention officer, and an administrative post, also unfilled at the time of the inspection. It was intended to review the structure in 18 months. The criminal justice addictions worker was part of the Criminal Justice Team but line managed through Aberdeenshire. This was part of the Grampian-wide service set up to respond to a Scottish Executive initiative to give priority to substance misuse services for those who became involved in crime. There was also a part-time criminal justice social work post linked to Inverness prison, which was lottery funded until April 2007, and an exit strategy was currently being examined. The integrated team manager planned to create a permanent throughcare post.

Staff in the drug and alcohol team appeared to have a high degree of autonomy. While this might be expected with experienced staff, the findings of our case file audit suggested that there were deficiencies in practice which needed to be urgently addressed. Supervision would be one way of ensuring this.

The Drug and Alcohol Team in Moray carried out a high number of home visits. While this was important to ensure the service was accessible in a rural area, it may not always be the best use of resources. Moreover, the lack of a patch-based system for staff meant that much time was taken up in travel. The team recognised this.

Recommendation 16
Roles, responsibilities, and accountability in the integrated team should be clarified and joint working policies and procedures put in place.

Moray's specialist cover for drugs was provided from Aberdeen and we saw little evidence of good working links between this and the GPs in Moray, who perceived it as remote.

Moray DAAT produced a training issues paper in September 2006 following an inter-agency development day. This recognised the need for a training needs analysis, training plan and identified budget. Staff in Moray spoke positively about training opportunities. Child protection training was mandatory and STRADA courses were available, although some staff felt these were quite basic. More staff would like the opportunity to undertake a 12-week accredited course at Robert Gordon's University. There were time and travel constraints to attendance at conferences. The integrated team manager acknowledged the need for a staff training plan for the team and that training may have been neglected due to cost and time issues. Housing staff could access drug and alcohol training through the DAAT. STRADA had undertaken a review of training in early 2006 and a number of courses had been planned as a result of this.

Joint budgeting and use of financial resources

The Moray SEQ stated that "the Moray DAAT has found this area problematic and has only recently been able to access many of the budget figures and resources which underpin this area of work". Moray DAAT had an aligned rather than a pooled budget for substance misuse services. Moray was to conduct a corporate review of voluntary and private sector funding through the appointment of a project co-ordinator for a 12-month period. Moray felt that they did not get a fair financial settlement from NHS Grampian, although there were additional contributions on the ground in staff and kind.

The Moray Drug and Alcohol Action Team ( DAAT) submitted its Corporate Action Plan ( CAP) for 2006-07 to the Scottish Executive in May 2006 and received feedback on the CAP in October 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 £108,000 of Scottish Executive funding made available to the DAAT for use in 2005-06. In addition, a further £184,000 of funding was available from partner organisations of the DAAT for 2005-06, £65,000 from NHS Grampian and £119,000 from the local council.
• Alcohol Specific Spend - there was £123,000 of Scottish Executive funding made available to the DAAT for use in 2005-06. In addition, a further £31,000 of funding was available from partner organisations of the DAAT for 2005-06, all of this from NHS Grampian.
• Combined Drug and Alcohol Specific Spend - there was £190,000 of Scottish Executive funding made available to the ADAT for use in 2005-06. In addition, a further £245,000 of funding was available to partner organisations of the DAAT for 2005-06, £127,000 from the local authority and £118,000 from other sources.

In 2005-06 the total expenditure incurred was £672,000 against the total funding available above of £881,000, resulting in an underspend to 31 March 2006 of £209,000. The main reasons given for the some of the underspend related to the late award of contracts, recruitment difficulties and sickness absence. Of the actual spend, £257,000 was from Scottish Executive resources and the remainder contributed by health and the council. In addition, the total projected spend for 2006-07 was estimated at £1,133,000.

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

5.6 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.

Moray should develop their performance management to enable them to measure progress. Despite the appointment of a single manager for the integrated service, Moray has some way to go to deliver a service that is truly integrated, as at present, the links are informal and a quality assurance and governance process is needed. The recently opened direct access service, Studio 8, had the potential to offer easier access for service users. The restructuring of the DAAT, the commitment of the chair and vice chair, and the enthusiasm of local councillors gave optimism for clearer direction for substance misuse services, but it was too early to be clear about the impact these changes might have. We found the capacity for improvement to be ADEQUATE.

Factors which will underpin and support positive change were identified. They included the restructuring of the DAAT, with clear leadership, the involvement of local councillors, the beginnings of joint commissioning, and the introduction of the collection of some performance management information, as well as the development of services such as Studio 8, the GP counselling service and the employment and training initiatives.