Prepared for the Auditor General for Scotland and the Accounts Commission March 2009

Drug and alcohol services in Scotland

Auditor General for Scotland The Auditor General for Scotland is the Parliament’s watchdog for ensuring propriety and value for money in the spending of public funds.

He is responsible for investigating whether public spending bodies achieve the best possible value for money and adhere to the highest standards of financial management.

He is independent and not subject to the control of any member of the Scottish Government or the Parliament.

The Auditor General is responsible for securing the audit of the Scottish Government and most other public sector bodies except local authorities and fire and police boards.

The following bodies fall within the remit of the Auditor General:

• directorates of the Scottish Government • government agencies, eg the Prison Service, Historic Scotland • NHS bodies • further education colleges • Scottish Water • NDPBs and others, eg Scottish Enterprise.

Note: Prior to September 2007, the Scottish Administration was generally referred to as the Scottish Executive. It is now called the Scottish Government. When dealing with the earlier period, this report refers to the Scottish Executive. Recommendations for the future refer to the Scottish Government.

The Accounts Commission The Accounts Commission is a statutory, independent body which, through the audit process, assists local authorities in Scotland to achieve the highest standards of financial stewardship and the economic, efficient and effective use of their resources. The Commission has four main responsibilities:

• securing the external audit, including the audit of Best Value and Community Planning

• following up issues of concern identified through the audit, to ensure satisfactory resolutions

• carrying out national performance studies to improve economy, efficiency and effectiveness in local government

• issuing an annual direction to local authorities which sets out the range of performance information they are required to publish.

The Commission secures the audit of 32 councils and 41 joint boards (including police and fire and rescue services). Local authorities spend over £19 billion of public funds a year.

Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. It provides services to the Auditor General for Scotland and the Accounts Commission. Together they ensure that the Scottish Government and public sector bodies in Scotland are held to account for the proper, efficient and effective use of public funds.

Acknowledgements:

Audit Scotland would like to thank the members of the project advisory group for their input and advice throughout the study (Appendix 2). We are also grateful to everyone who provided information and assisted us with this study.

Sally Thompson managed the project, with support from Mike McCarron (consultant), under the general direction of Claire Sweeney.

DrugandalcoholservicesinScotland1

Contents Summary page 2

Background

Aboutthestudy

Keymessages page 3

Keyrecommendations page 4

Part 1. The scale of drug and alcohol misuse page 5

Keymessages

Scotlandhasasignificantproblem withdrugsandalcoholcomparedto therestoftheUKandEurope page 6

Drugandalcoholmisuseaffectsall communitiesinScotlandbuthasa biggerimpactindeprivedareas page 8

Manypublicsectorbodies commissionorprovidedrugand alcoholservices page 9

Part 2. Direct expenditure on drug and alcohol services page 11

Keymessages

Thewidercostsofdrugandalcohol misuseareanestimated£5billion peryear

Thepublicsectorspent£173million ondrugandalcoholservicesin 2007/08 page 12

Spendingondrugandalcoholservices doesnotreflectlevelsofneed page 15

Fundingarrangementsfordrugand alcoholservicesarecomplexand makestrategicplanningdifficult page 16

Recommendations page 20

Part 3. Effectiveness of drug and alcohol services page 21

Keymessages

Drugandalcoholservicesvaryacross Scotland page 22

Nationalinformationonneedsandthe impactofservicesispoor page 24

Theimpactofdrugandalcohol servicesisnotknownatanational level page 25

Recommendations page 26

Part 4. Drug and alcohol partnerships page 27

Keymessages

Alackofcentralguidancehasledto variationinhowlocalpartnerships operate

Notalldrugandalcoholpartnerships haveachievedtheobjectivesset forthem

Therolesandresponsibilitiesofdrug andalcoholpartnershipsarestill unclear page 28

Recommendations page 30

Appendix 1. Notes to the text page 32

Appendix 2. Project advisory group membership page 34

Appendix 3. Drug and alcohol policy and guidance summary page 35

Appendix 4. Self-assessment checklist for partners page 37

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Summary

Drugandalcoholmisusearemajorproblemsin Scotlandbutresourcestoaddressthemarenotalways usedeffectively.

Summary3

Background

1.Theimpactofdrugandalcohol misuseinScotlandiswidespread.Both individualsandsocietymorewidely areaffectedintermsofhealth,child protection,crime,communitysafety, housing,employmentandsocial exclusion.Drugandalcoholmisuseare problemsacrossthewholeofScotland butparticularlyaffectpeoplelivingin deprivedareas.1,2

2.Thelinksbetweendrugandalcohol misuseandeffortstoaddressthem arecomplexandinter-related,and manyservicesareaimedatbothdrug andalcoholmisuse.Numerouspublic sectororganisationsareinvolvedin providingservices,includingtheNHS, councils,thepoliceandtheprison service.Thevoluntarysectorisakey partnerindeliveringservicesfordrug andalcoholmisuse.

3.TheScottishGovernmenthas launchednewstrategiesfordrugs andalcoholinthelast12months:The Road to Recovery: A new approach for tackling Scotland’s drug problem inMay2008andChanging Scotland’s Relationship with Alcohol: A framework for actioninMarch2009.Themaindrug andalcoholpolicydocumentsissuedby theScottishExecutiveandtheScottish Governmentoverthelastdecadeare summarisedinAppendix3.3

4.Multi-agencypartnershipworking fordrugandalcoholproblemshas beeninplaceforaround20years. Partnershipworkingisacoreelement intherecentScottishGovernment strategiesfordrugsandalcohol.4,5

5.TheScottishGovernmentandother keypublicbodiesinvolvedinproviding servicesdonotholdcomparabledata onthecosts,activityorimpactof drugandalcoholservicesinScotland. Inthisreportwehaveusedavailable nationaldatasupplementedwithlocal informationwherenecessary.

About the study

6.Theaimofourstudywasto identifyhowmuchthepublicsector

spendson‘labelled’drugandalcohol services.6Wealsoassessedwhether evidenceofneedorwhatworks determineshowthismoneyisused andwhatimpactthemoneyhashad.

7.Inthisstudy,we:

• analysedpublishedinformation onservicesandreviewednational documents

• collectedandanalysedexpenditure datafromallNHSboardsand councils.Intheabsenceofcost informationfrompoliceservices, wecollectedactivitydatafromall policeforcesinScotlandtogivean indicationofexpenditure

• carriedoutfocusgroupswithpeople whohaveproblemswithdrugsand alcohol,familiesdirectlyaffectedby drugandalcoholmisuse,localdrug andalcoholpartnershipsupportstaff andvoluntaryandprivatesector serviceproviders

• interviewedstaffandreviewed documentsfromagencies commissioningorprovidingdrug andalcoholservices.

8.Wedidnotcollectinformation onthewidercostsassociatedwith drugandalcoholmisuseasexisting researchisavailableandreferred toinPart2.Thisresearchcovers costsrelatingtogenericservices suchasaccidentandemergency (A&E)departments,andwider economicandhumancostssuchas theestimatedcostoflostearnings anddeathsduetodrugandalcohol misuse.

9.Thisreportisinfourmainparts:

• Thescaleofdrugandalcohol misuse(Part1).

• Directexpenditureondrugand alcoholservices(Part2).

• Effectivenessofdrugandalcohol services(Part3).

• Drugandalcoholpartnerships(Part4).

Key messages

Scotlandhashighlevelsofdrug andalcoholmisusecompared totherestoftheUK.Drugand alcohol-relateddeathratesare amongthehighestinEurope andhavedoubledinthelast 15years.Drugandalcohol misusearefoundacrosssociety butpeoplewhoarelikelyto beexcludedfromsocietyand thoselivingindeprivedareas aremostaffected.

In2007/08,thepublicsector spent£173millionondrugand alcoholservicesinScotland, £84millionspecificallyondrug servicesand£30millionon alcoholservices.Theremainder wasspentonjointdrugand alcoholservices.Funding arrangementsarecomplexand projectscanhaveanumber ofseparatefundingstreams, eachwithdifferenttimescales andreportingcriteria.Thisis anaddeddifficultyforthose planningandprovidingservices.

Thereisvariationacross Scotlandintherangeand accessibilityofdrugand alcoholservices.TheScottish Governmenthasnotsetout minimumstandardsintermsof range,choiceandaccessibility thatserviceusersandtheir familiescanexpecttoreceive. Spendingdecisionsarenot alwaysbasedonevidence ofwhatworksoronafull assessmentoflocalneed.

Giventhescaleofdrugand alcoholproblemsinScotland andtherangeofagencies involved,clarityofrolesand accountabilityisessential.It isimportantfortheScottish Governmenttosetoutthe directionandtherolesand responsibilitiesofpartner agenciesandhowperformance willbeassessed.

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Key recommendations

TheScottishGovernmentshould:

setclearnationalminimum standardsfordrugandalcohol servicesincludingtheirrange, qualityandaccessibility; receiveassurancethatthese standardsareimplementedin linewithsettimescales;and ensureperformanceisregularly monitoredandpubliclyreported

clarifyaccountabilityand governancearrangementsfor thedeliveryofdrugandalcohol servicesinScotlandandsetout clearlytheresponsibilitiesofall organisationsandpartnerships involvedinplanningordelivering theseservices.

Publicsectorbodiesshould:

ensurethatalldrugandalcohol servicesarebasedonan assessmentoflocalneedand thattheyareregularlyevaluated toensurevalueformoney.This informationshouldthenbe usedtoinformdecision-making inthelocalarea

ensurethatservice specificationsareinplaceforall drugandalcoholservicesand setoutrequirementsrelating toserviceactivityandquality. Whereservicesarecontracted, thisspecificationshouldbepart oftheformalcontract

setclearcriteriaofeffectiveness andexpectedoutcomesfor thedifferentservicesthatthey provideandundertakeregular auditstoensureservices adheretoexpectedstandards

usetheAuditScotlandchecklist detailedinAppendix4tohelp improvethedeliveryandimpact ofdrugandalcoholservices throughajoined-up,consistent approach.

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Part 1. The scale of drug and alcohol misuse

Scotlandhasagreaterproblemwithdrugsand alcoholthantherestoftheUKandmostofEurope, withdeprivedcommunitiesmostaffected.

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Key messages

Scotlandhashighlevelsofdrug andalcoholmisusecompared totherestoftheUK.The levelsofproblematicdrug misuseinScotlandaredouble thatofEnglandandthelevels ofalcoholdependencyarea thirdhigher.Alcoholmisuse isabiggerproblemthandrug misuse.

Drugandalcohol-relateddeath ratesareamongthehighest inEuropeandhavedoubledin thelast15years.Thisisata timewhenindicatorsofdrug andalcohol-relatedharmare reducinginothercountriesin Europe.

Drugandalcoholmisuseare foundacrosssocietybutpeople whoarelikelytobeexcluded fromsocietyandthoseliving indeprivedareasaremost affected.Peoplelivingin deprivedareasaremorelikelyto sufferserioushealthproblems asaresultoftheirdrugoralcohol misuse.

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Scotland has a significant problem with drugs and alcohol compared to the rest of the UK and Europe

10.In1982,theMinisterialAdvisory CouncilontheMisuseofDrugs definedsomeonewithproblematic druguseas“any person who experiences social, psychological, physical or legal problems related to intoxication and/or regular excessive consumption and/or dependence as a consequence of his/her own use of drugs or chemical substances.” 7

11.TheWorldHealthOrganisation definesalcoholdependencyas“a cluster of psychological, behavioural and cognitive phenomena. A central characteristic is the desire (often strong, sometimes perceived as overpowering) to drink alcohol.” 8

Ourreportreferstoalcoholmisuse andincludesalcoholdependency, hazardous,harmfulandbinge

drinking,allofwhichhaveharmful consequencesintermsofhealth, violenceandcommunitysafety.

12.Thelinksbetweendrugand alcoholmisuseandeffortstoaddress themarecomplexandinter-related. Manyproblematicdruguserswilluse morethanonedrugandmayalso misusealcohol.

Therearehighandincreasinglevelsof drug-relatedharminScotland 13.Thereisahigherprevalence ofdrugmisuseinScotlandthan elsewhereintheUK.Theestimated numberofpeopleaged15to54 misusingopiates,suchasheroin, decreasedfrom55,800in2000to 51,582in2003.Thisequatesto 1.8percentofthepopulation.9This isdoublethelevelinEngland,where approximately0.9percentofthe populationaged15to64misuse opiates.10

14.Theuseofcocaineisincreasingin Scotland.Thenumberofnewpeople contactingservicesandlistingcocaine astheirmaindrugproblemdoubled from284in2003/04to625in 2007/08.11Thenumberofdrug-related deathsinvolvingcocainehasalso doubledoverthepastfiveyears.12

15.Scotlandalsohasthehighest rateofinjectingdrugusersinthe UKwitharateof5.6per1,000 populationcomparedto4.2forthe UKasawhole.13Scotlandhashigh levelsofdruguserssharinginjecting equipment.Thereareanestimated 50,000peopleinScotlandwith hepatitisCanddruguserswhoinject andshareinjectingequipmentarethe largestgroupofpeopleaffected.14,15 16.Thereisalackofnationaldataon thelevelsofdrugmisuserelatingto ethnicity.In2007/08,justover 99percentofnewpeoplecontacting servicesfordrugproblemsdescribed theirethnicityaswhiteandalmost 96percentaswhiteScottish.16

17.Drugsareusedbypeopleofall agesbutin2007/08themedianage ofnewpeoplecontactingservices

fordrugproblemswas30years.17 Sixteenpercentofnewcontacts wereover40yearsofageandeight percentwere19yearsoryounger.18

18.Therearelimiteddataonthe numberofchildrenaffectedby parentalsubstancemisusebutthere isinformationonpregnantwomen collectedinhospitals.In2006/07, 566pregnantwomeninhospitalwere recordedashavingdrugproblems inScotland,arateof10.4per1,000 maternities.Thisratehasincreased from6.7per1,000in2002/03.19

Youngpeopleanddrugs 19.Thelevelofdrugmisuseamong 13and15-year-oldshasreduced acrosstheUK,primarilyasaresultof adeclineintheuseofcannabis:20

• Nearlyaquarter(23percent)of 15-year-oldsinScotlandreported usingdrugsin2006,comparedto 31percentin2004.

• Sevenpercentof13-year-oldsin Scotlandreportedusingdrugsin 2006,comparedto11percent in2004.21

However,reporteduseofillegaldrugs amongschoolchildreninScotlandis stillhigh.

Drug-relatedhealthharmanddeaths 20.In2007/08,therewere 5,363dischargesfromacute generalhospitalswithadrug-related diagnosis,arateof108per100,000 population.Overthelastsixyears, therehasbeenlittlechangeintherate ofdrug-relateddischarges.22Ninety-five percentofpeopledischargedwitha drug-relateddiagnosiswereinitially admittedasanemergency.23 In2006/07,itisestimatedthat 148,050consultationswithGPs relatedtodrugmisuse.24

21.Drug-relateddeathsinScotland arethehighestrecordedintheUK andamongthehighestinEurope.In EnglandandWales,therateofdrug­relateddeathswas2.7per100,000 populationin2005comparedto 7.3per100,000inScotland.25

Part1.Thescaleofdrugandalcoholmisuse7

22.Drug-relateddeathsinScotland areattheirhighesteverlevelandare increasing.In2007,therewere455 drug-relateddeaths,a103percent increaseovertenyears.26,27Insome localareas,therehasbeenareduction inthenumberofdrug-relateddeaths inrecentyearsandsignificantvariation year-on-year.Forexample,inGlasgow therewere106drug-relateddeathsin 2004,thisfellto75in2005andthen increasedto113in2006.In2007, therewere90drug-relateddeathsin Glasgow.Mostdrug-relateddeathsin Scotlandinvolvemorethanonedrug andalcohol.28

Drugsandcrime 23.Seizuresofillegaldrugsby Scottishpoliceforcesincreasedby 27percent,from16,425in 1999/2000to20,938in2006/07.29 Seizuresofcocainehaveincreased atatimewhenfiguressuggest greatercocaineuseinsociety. Between2002/03and2006/07, cocaineseizuresbyScottishpolice forcesincreasedfrom17percent ofallseizuresofClassAdrugsto30 percent.Heroinaccountedforthe majorityofClassAseizures.30,31

24.Drugmisuseanddrugdealingin localcommunitiesleadstoincreases inboththefearofcrimeandactual crime.Seventy-sixpercentofpeople surveyedbytheScottishExecutivein 2006believedthatdrugmisusewasa ‘bigproblem’intheircommunity.32 25.In2007/08,theaveragespend onaheroinaddictionwas£245a weekand£624aweekonacocaine addiction.33Drugusersreportthata mixtureofsocialsecuritybenefitsand crimearemostcommonlyusedto fundtheirhabits.34Thishasobvious implicationsforcrimeratesandthe widercostsofdrugmisuse.

Therearehighandincreasinglevelsof alcohol-relatedharminScotland 26.Alcoholmisuseisabigger problemthandrugmisuseintermsof thenumberofpeoplemisusingand theharmcausedtohealth.Estimating

thesizeofScotland’salcohol problemisnoteasyduetoalackof nationaldataandunder-reportingof consumption.

27.InEngland,thefirstnational alcoholneedsassessmentwas carriedoutin2004.Itestimated that3.6percentofthepopulation agedbetween16and64was dependentonalcohol.35InScotland, itisestimatedthat4.9percentof thepopulationaged16andoverare dependentonalcohol.Thehigher prevalenceofalcoholdependency inScotlandwasfoundtobelargely duetothehigherratesofalcohol dependencyinScottishwomen.36

28.Overthelast45years,alcohol salesintheUKhavedoubled,rising from5.7litresofpurealcoholper personaged16andoverin1960to 11.3litresin2005.37

29.Therehavealsobeenchangesin thetypesofalcoholpurchasedover time.Salesofbeerhaveremained steadysince1980,buttherehave beenincreasesinthesaleofwine, cideranddrinkssuchasalcopops.38

30.MorealcoholissoldinScotland thaninEnglandandWalesperhead ofpopulation.In2007,anaverage of12.2litresofpurealcoholwas soldperpersonaged18andoverin Scotland,comparedto10.3litresin EnglandandWales.Thisdifference ispartlyduetopeopleinScotland buyingmorespiritscomparedtothe restoftheUK,anaverageof3.6 litresperpersonaged18andover inScotland,comparedto1.8litresin Englandin2007.39

31.Thenumberoffemalesreporting drinkingabovetherecommended weeklylimit(14unitsofalcohol)is increasing.40In1995,13percentof womenaged16to64yearsdrank morethan14unitsperweek,rising to17percentin2003.Thisislikelyto beanunder-estimate.40

Youngpeopleandalcohol 32.Levelsofunder-agedrinking arehigh.In2006,overathird (36percent)of15-year-oldsreported thattheyhadconsumedalcoholin thepreviousweek.Therehasbeena reductioninreporteddrinkingamong boys.Reporteddrinkingamong 15-year-oldgirlsincreasedfrom tenpercentin1990to23percentin 2002.Thishassincefallento 15percentof15-year-oldgirlsreporting theydrinkalcoholin2006,thisis 50percenthigherthanin1990.41

33.FiguresforhospitalA&E departmentshighlightthe consequencesofyoungpeople drinking.Overafive-weekperiodin 2006,nearly650childrenranging fromeightto15-years-oldwere treatedforalcohol-relatedproblemsin ScottishA&Edepartments.42

Alcohol-relatedhealthharmand deaths 34.In2007/08,therewere 42,430dischargesfromacutegeneral hospitalswithanalcohol-related diagnosis.Overthelastfiveyears, thedischargeratehasincreasedby ninepercent,from710per100,000 populationin2002/03to777per 100,000population.43

35.Alcoholisconsideredtobea contributoryfactorin11percentof allattendancesatA&E.Thebusiest timeforalcohol-relatedattendances isFridaynight/Saturdaymorning, betweenmidnightandfourinthe morning.44

36.In2006/07,itisestimatedthat around111,200consultationsfor alcoholmisusetookplacewithGPs andpracticenurses.45Theroleof GPsandpracticestaffinrelationto alcoholmisuseislikelytogrow,with specificfundingfromtheScottish Governmenttosupportscreeningand briefinterventionsinprimarycare.46

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Exhibit 1 Deaths from chronic liver disease and liver cirrhosis, 1950 to 2006

DeathsinScotlandareincreasingatagreaterratethaninEnglandandWales.

Source: Changing Scotland’s relationship with alcohol: a discussion paper on our strategic approach, Scottish Government, 2008

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Other European countries

Scotland England and Wales

37.Scotlandhasthehighestalcohol-relateddeathrateintheUKand thenumberofdeathsinScotlandis increasing.In2007,therewere 1,399alcohol-relateddeaths,a 75percentincreaseovertenyears, andover100percentincreaseover 15years.47Theincreaseinalcohol­relateddeathsinthelast15yearshas variedacrossthecountry.48Alcohol­relateddeathratesinScottishmen aredoublethatoftherestoftheUK.49

38.Scotlandhasoneofthehighest ratesoflivercirrhosisinWestern Europeandoneofthefastest growingratesofdeathsdueto liverdiseaseintheworld.Ratesof alcoholicliverdiseaseinScotland increasedby52percentbetween

1998and2002.50,51Theincreasein chronicliverdiseaseandlivercirrhosis inScotlandisatatimewhenratesare decreasingacrossEurope(Exhibit1).52

Alcoholandcrime 39.Alcoholmisuseislinkedto violentcrime:

• Asurveyofthreepolicestations inGlasgowshowedthatbetween April2006andMarch2007,two­thirdsofthoseincustodyfora violentoffencewereunderthe influenceofalcohol.53

• In2003,62percentofdomestic abusecasesinvolvedalcohol.54

• Forty-fivepercentofpeople accusedinhomicidecasesare reportedtohavebeenunderthe influenceofalcoholand/ordrugs.55

Drug and alcohol misuse affects all communities in Scotland but has a bigger impact in deprived areas

40.Drugandalcoholproblemsaremore acuteindeprivedcommunities.56While thereisnorelationshipbetweenpoverty andwhetherpeoplehavetriedillegal drugs,thereisaclearlinkbetween povertyandproblematicdruguse, particularlyheroinandcrackcocaine.57

41.Therelationshipbetweenalcohol anddeprivationismorecomplex.People inprofessionalhouseholdsaremore likelytoexceedtherecommended weeklylimits,butthoselivinginthe mostdeprivedcommunitiesexperience morehealthproblemsbecauseoftheir drinking.58Peoplelivinginthe20percent mostdeprivedcommunitiesinScotland arearoundsixtimesmorelikelytobe admittedtohospitalandtodiedueto

Part1.Thescaleofdrugandalcoholmisuse9

alcoholmisusethanthosefromthemost affluentareas.59

Peoplewhoarelikelytobeexcluded fromsocietyhaveparticularproblems withdrugsandalcohol 42.Drugandalcoholmisuseare greaterproblemsforpeoplewho aresociallyexcluded,comparedto therestofsociety.Uptothreein fourpeopleusingdrugshavemental healthproblems,anduptooneintwo peoplewithalcoholproblemsmay haveamentalhealthproblem.60Audit Scotlandispublishinganoverview reportofmentalhealthservicesin ScotlandinMay2009.

43.Thereisalsoevidenceofhigh levelsofdrugmisuseamonghomeless people.Asampleof225homeless peopleinGlasgowshowedthat 56percentofthoseunder35years oldwereaddictedtodrugs,withheroin beingthemostcommon.Thesame sampleshowedthat54percentof homelesspeoplereportedhazardous drinkingbehaviour.61

44.Over40percentofprisoners arelikelytohaveanalcoholproblem, fourtimeshigherthanthegeneral population.62Two-thirdsofprisoners testpositiveforillegaldruguseon admissiontoprison.63

45.Drugandalcoholmisusedoes notjustaffecttheusersthemselves. Childrenofparentswhomisusedrugs andalcoholareoftenatincreasedrisk ofemotionalandphysicalabuse.In thelongterm,theymayexperience pooreducationalattainmentand limitedlifechoicesandaretherefore atriskofdevelopingsubstance problemsthemselves.64

46.Nationalinformationonchildren affectedbyparentalsubstancemisuse inScotlandispoor,butitisestimated thataquarterofchildrenontheChild ProtectionRegisteraretheredueto parentalalcoholordrugmisuse.65 Thereareanestimated60,000children affectedbyparentaldrugmisuse andapproximately65,000children affectedbyparentalalcoholmisuse inScotland.66,67

Many public sector bodies commission or provide drug and alcohol services

47.Drugandalcoholservicesare generallyclassedas:

• preventionservices,suchas educationinformalorinformal settings

• treatmentandcareservices, suchascounselling,needle exchange,detoxification,relapse prevention,prescribingofchemical substitutessuchasmethadone, residentialrehabilitation,trainingor employmentservices

• enforcementandregulation activities,suchastestpurchasing operationstorestrictthesaleof alcoholtounder-agepeople,arrests fordrugdealingorinternational policeeffortstotackledrug traffickingandseizeillegaldrugs.

48.Prevention,treatmentandcare servicestoaddressdrugandalcohol misuseareoftenjointandmanystaff addressbothdrugandalcoholproblems. Moredetailsaboutwiderpartnership workingaresetoutinPart4.

49.Arangeofdrugandalcohol servicesareprovidedeitherdirectlyby councils,theNHS,policeandprisons orcommissionedfromthevoluntary andprivatesectors(Exhibit2,overleaf). Thevoluntaryandprivatesectors alsoprovideavarietyofprevention, treatmentandrehabilitationservices thatarenotfundeddirectlybythe publicsector.

50.Therearemanygenericservices thattargetpeoplewhoaresocially excludedinsocietythatalsohelp peoplewhomisusedrugsandalcohol suchasservicesforhomelesspeople. TheScottishGovernment’snew initiativetoincreasetheroleofGPs, practicenursesandhospitalA&E departmentsinscreeningandbrief interventionsforalcoholproblemsis anotherexampleofageneralservice providingsomespecialistsupport.

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Exhibit 2 Examples of drug and alcohol services provided by the public sector

Publicsectorbodiesprovidearangeofdrugandalcoholservices.

Source: Audit Scotland, 2008

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Prevention Treatment and care Enforcement

Councils

Educationinschoolsand communities,lifeskillsand leisureactivitiesforat risk groups,parentingskills

Backtoworksupport,socialworker support,education,counselling,residential rehabilitation,supportedaccommodation andhousing

DrugTreatment andTestingOrders (DTTOs),arrestreferral programmes,Drug Courts1

NHS Healthpromotion,brief interventions,suchas consultationswithaGP

Detoxificationinhospital,treatingeffectsof alcoholordrugmisuse,relapseprevention, GPandpracticenursecontact,methadone andothersubstituteprescribing,harm reductionsuchasneedleexchanges

Controlmisuseof prescribeddrugsand prescriptions

Police andthe SCDEA2

ChoicesforLife3,school educationandprevention visits,communitypoliceofficer engagement

Arrestreferral,servicesprovidedbypolice doctorsandnurses,chaplains

Intelligence-led operations,drugs seizures,arrestsfor drugandalcohol- relatedoffences, testpurchasing4, enforcementof licensinglaws

Prisons Awarenessraisingprogrammes onaddictions

Counselling,one-to-onesupportand groupworkprogrammes,detoxification, methadoneandothersubstituteprescribing, addictionnursesupport,chaplainsand wider‘communityintegrationplanning’with essentialservices5

Testingforillegal druguse,detection activities,egsniffer dogsandsurveillance atvisits

Notes: 1. DTTO – Community sentence alternative for serious drug misusing offenders. Arrest referral – aim to divert less serious offenders into treatment at point of arrest. Drug court – specialised courts where convicted offenders agree to take part in treatment and report regularly to the sheriff. 2. The Scottish Drug Enforcement Agency (SDEA) was formally established in 2001. In 2006, the agency adopted the Scottish Crime and Drug Enforcement Agency (SCDEA) title to reflect a commitment to prevent and detect serious and organised crime and target those criminals who have the capacity and resources to cause the most damage to Scotland’s communities. 3. Choices for Life is a multi-media concert delivered to all primary seven children in Scotland to raise knowledge about drugs, alcohol and smoking and to encourage positive lifestyles. It is organised by the SCDEA in partnership with the Scottish Government, NHS Health Scotland and others. 4. Test purchasing – police operation where under-18s attempt to buy alcohol to test enforcement of licensing laws. 5. Essential services – services to address financial, housing, employment and other barriers to people recovering from problematic drug and/or alcohol use.

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Part 2. Direct expenditure on drug and alcohol services

Spendingpatternsdonotreflectnationalprioritiesanddonot alwaysreflectindicatorsofneed.Fundingarrangementsare oftencomplexandfragmented.

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Key messages

In2007/08,thepublicsector spent£173millionondrugand alcoholservicesinScotland, £84millionspecificallyondrugs servicesand£30millionon alcoholservices.Theremainder wasspentonjointdrugand alcoholservices.

Sixty-eightpercentofdrug andalcoholmoneyisspenton treatmentandcareservices. TheScottishGovernment’s recentstrategiesfordrugs andalcoholhaveafocuson preventionbutcurrentlyonly aroundsixpercentofdirect spendisonpreventative activities,includingservicesfor childrenaffectedbyparental substancemisuse.

TheamountthatNHSboards andcouncilsspendondrugand alcoholservicesvariesacross thecountry,fromalmost £14perheadofpopulationin theBorderstojustover £53inGreaterGlasgowand Clyde.Whilesomevariation wouldbeexpected,current patternsofspenddonotmatch nationalindicatorsofneedsuch aslevelsofmisuse.

Fundingarrangementsare complexandservicescanhave anumberofseparatefunding streams,eachwithdifferent timescalesandreportingcriteria. Thisisanaddeddifficultyfor thoseplanningandproviding services.

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The wider costs of drug and alcohol misuse are an estimated £5 billion per year

51.Itisestimatedthatthewider economicandsocialcostsofdrugand alcoholmisuseinScotlandarealmost £5billionperyear,£2.6billionfordrug misuseand£2.25billionforalcohol misuse.68,69Wehaveestimatedthe widereconomicandsocialcostsof drugmisusebasedonaHomeOffice

Exhibit 3 The estimated wider economic and social costs of drug and alcohol misuse

Thewidereconomicandsocialcostsofdrugandalcoholmisuseareestimated atalmost£5billionperyear.

Criminal justice costs (£2,734m)

Economic costs (£820m)

NHS costs (£488m)

Social/human costs (£626m)

Social work costs (£182m)

56%

17%

13%

10%

4%

Note: In the absence of alternative data we have calculated the economic and social costs of drug misuse by using the Home Office methodology and applying Scottish prevalence figures of problematic drug misusers in 2003. Source: Costs of alcohol use and misuse in Scotland, Scottish Government, May 2008. Social and economic costs of Class A drugs in England and Wales 2003/04, Home Office, 2006

estimateforEnglandandWalesin 2004.Scottishfigureswereexpected inMay2008buthavenotyetbeen published.

52. Thecurrentestimatesofthe widereconomicandsocialcostsof bothdrugandalcoholmisuseare believedtobeunder-estimates. Theseestimatesincludewiderhealth economiccostsandthecosttothe Scottisheconomy.Forexample, criminaljusticecostsof£2.7billion includeestimatesofpolicetime dealingwithalcoholmisuse(£288 million)andthecostsofdealingwith drug-relatedcrime(£684million). HealthcostsincludeA&Eattendances (£46million)andhospitalinpatient care(£273million).Thehealthcosts duetoalcoholmisusearegreaterthan thosefordrugmisuse.Coststothe economyincludepeoplebeingabsent fromwork(£286million)(Exhibit3).

53.Inadditiontoservicesspecifically fordrugsandalcohol,therearemany widerservicesthathelppeoplewith drugandalcoholproblemsorthatdeal withtheimpactofdrugandalcohol misuse(Casestudy1).

The public sector spent £173 million on drug and alcohol services in 2007/08

54.Informationonhowmuchthe publicsectorspendseachyearon drugandalcoholservicesisnot readilyavailable.Therearenational dataonprevalenceandsomedata onactivitybutthereisnonational informationonthespendondrugand alcoholservicesatalocallevel.

55.Aspartofthisreview,we collectedinformationfromallNHS boardsandcouncilsonhowmuch theyspentdirectlyondrugandalcohol servicesin2007/08.Wealsocollected informationfromtheeightpolice forcesonthenumberandsizeof dedicateddrugsquadsandlicensing departmentsandonthenumberof dedicatedcampusandschoolliaison officers.70,71Weusedthisinformation toestimatethecostofdrugand alcohollabelledpolicework.

56.Usingtheselocallyprovided data,plusnationallabelledspend, weestimatethatthepublicsector inScotlandspent£173millionon drugandalcoholservicesin2007/08 (Exhibit4).

Part2.Directexpenditureondrugandalcoholservices13

Case study 1 Examples of wider services for drugs and alcohol

Housingsupport–FabPadsupportsrecentlyhomelesspeopleandthose atriskoflosingtheirtenanciesinGlasgow.Itsupportspeopletodesignand decoratetheirhomestogivethemasenseofachievement,commitment totheirtenancyandultimatelycommitmenttomoveonintheirlives.Many oftheclientshaveproblemswithdrugsandalcoholandtheserviceoffers additionalsupporttothesepeople.In2007/08,approximately60percent ofpeopleattheservicehadaddictionproblems.Theannualcostofthe projectin2007/08inGlasgowwas£379,333.TheFabPadprojectisalso beingdeliveredinEdinburgh,Borders,NorthAyrshire,EastAyrshire,East Dunbartonshire,WestDunbartonshire,StirlingandSouthLanarkshire.

Antisocialpolicing–TheCommunityPreventionTrialinGlasgowCityCentre hasbeenrunningsince2003andaimstoreduceviolenceanddisorderinthe citycentre.Asitisestimatedthatapproximately70percentofviolentassaults inthecityarealcohol-related,thefocusoftheinitiativeisafter10pm.The projectcostsapproximately£80,000peryearandinvolvesStrathclydePolice, GlasgowCityCouncilandNHSGreaterGlasgowandClyde.

Source: Audit Scotland, 2008

Exhibit 4 Public sector spend on drug and alcohol services

Thepublicsectorspent£173millionondirectdrugandalcoholservices in2007/08.

Source: Audit Scotland, 2008

£ million

NHSboards 90

Councils 66

Policeforces 10

ScottishPrisonService 3

ScottishGovernmentdirectspend(eg,research) 4

Total 173

57.Thereare,however,differencesin thewaybudgetsarerecordedineach localareaandthewaythatservices areprovided.Manyservicesfor peoplemisusingdrugsandalcoholare deliveredaspartofgeneralservices

NHSboards 58.In2007/08,theScottish Governmentallocated£34million toNHSboardsfordrugandalcohol treatmentservices.Theseallocations haveincreasedinrecentyears:

andsofundingwillnotbelabelled asspecificallyfordrugoralcohol • Drugfundingincreasedfrom services.Thismakesitdifficulttogive almost£9millionin1998/99to comprehensivefiguresforwhatis around£24millionin2007/08. spentondrugsandalcohol.

• Alcoholfundingincreasedfrom £3millionin2004/05tojustover £10millionin2007/08.72

59.NHSboardsgenerallyaddto thismoneytoprovideservices,and in2007/08theyspentanadditional £56million(62percentoftheir totaldirectspendondrugand alcoholservices).

60.Theamountspentonalcoholand drugservicesshouldincreaseasthe ScottishGovernmenthasallocated anadditional£85.3millionforalcohol misuseoverthethreeyearsfrom 2008/09to2010/11;mostofthis moneywillgotoNHSboards (£24.8millionin2008/09).The ScottishGovernmentalsoplansto increaseallocationstoNHSboards fordrugservicesfrom£24.7millionin 2008/09to£28millionin2009/10.

Councils 61.TheScottishGovernment,in agreementwithCOSLA,allocates fundstocouncilsusinganagreed formulaknownastheGrantAided Expenditure(GAE).73TheGAEis notanallocationbutamethodfor calculatingeachcouncil’sindicative spendoneachofitsservices basedonitspopulation’sneeds.74In 2006/07,£42millionoftheGAEwas identifiedforservicesfor‘adultswith addictionandsubstancemisuse’, althoughitisacouncil’sdecisionhow tospenditsGAE.75,76

62.In2007/08,councilsspent £66millionondrugandalcohol services.Thisincludes£7.5million transferredtothemfromNHSboards.

NHSandcouncilspend 63.NHSboardsandcouncilsspent justunderonepercentoftheirtotal combinedrevenuebudgetsonlabelled drugandalcoholservicesin2007/08.

ComparisonswithEngland 64.In2005/06,governmentlabelled drug-relatedexpenditurewas estimatedat£2,695perproblematic druguserinEngland,comparedto £1,293perproblematicdruguserin Scotland.77InEngland,thereisno

14

ring-fencedfundingforalcoholservices, comparedtojustover£10millionto NHSboardsinScotlandin2007/08.

65.InEngland,significantresources havebeenallocatedtodrugservices overthelasttenyearsbyboththe DepartmentofHealthandtheHome Office.Someofthismoneywasused toestablishtheNationalTreatment Agency,aspecialhealthauthority createdtoincreasetheavailability, capacityandeffectivenessofdrug treatmentservices,andseveral intensivecriminaljusticeinterventions.

Voluntaryandprivatesectors 66.Thevoluntaryandprivate sectorsprovidemanydrugand alcoholservices.Threeofthemain independentfundersofthevoluntary sectoraretheBigLottery,LloydsTSB FoundationforScotland,Partnership DrugsInitiativeandtheRobertson Trust.TheBigLottery’sBetterOff Fundprovided£10millionover fiveyearsbetween2003and2007 tofundcommunityrehabilitation projectsforpeoplewhomisuse drugs.LloydsTSBFoundationfor Scotland,inpartnershipwiththe ScottishGovernment,provided approximately£1.2millionfordrug andalcoholservicesin2007/08and theRobertsonTrustcontributedan additional£730,000.

Mostdirectspendondrugandalcohol servicesisfortreatmentandcare 67.Sixty-eightpercentofdirect expenditureondrugandalcohol servicesisspentontreatmentand care,includingresidentialtreatment andcommunitytreatmentsuchas methadone(Exhibit5).78Different treatmenttypesarediscussedin moredetailinPart3.

Prevention 68.TherecentScottishGovernment strategiesfordrugsandalcohol emphasisetheimportanceof prevention.79However,in2007/08, onlysixpercentofdirectspendwas onpreventativeactivities.Thisincludes interventionsforchildrenaffectedby parentalsubstancemisuse.79

Exhibit 5 Breakdown of direct spend on drug and alcohol services, 2007/08

MostdirectexpenditureondrugandalcoholservicesinScotlandisspenton treatmentandcareservices.

Treatment and care (£115.8m)

68%

6%

9%

5%

3%

9%

Prevention (£10.6m)

Enforcement and regulation (£8.9m)

Criminal justice services (£16.2m)

Other (£16.4m)

Essential services (£4.9m)

Notes: 1. Essential services are services to address financial, housing, employment and other barriers to people recovering from problematic drug and alcohol use. 2. Criminal justice services are services aimed at diverting drug and alcohol misusing offenders from crime and into treatment. Source: Audit Scotland, 2008

69.Scottishpoliceforcesspent almost£3millionondedicated campusandliaisonofficersin 2007/08.Theseofficersworkinsome schools,collegesanduniversitiesand aimtopreventthemisuseofdrugs andalcohol.

70.Othergeneralpreventionwork thathelpsvulnerableyoungpeople andthoseconsideredtobeatriskis notlabelledasdrugoralcohol-related butwillhelppeopleaffectedbydrug andalcoholmisuse.The Road to Recovery,theScottishGovernment’s newdrugsstrategy,detailswider workbeingundertakentoaddress theunderlyingfactorsassociatedwith drugmisusesuchasaneconomic strategyandearlyyearsframework.

71.Thereisresearchonhowto improvetheeffectivenessofdifferent treatmentservicesbutthereisnot thislevelofevidenceforprevention services.If,inlinewithgoodpractice, agenciesusetheevidenceto influencespendthenthismayaffect howmuchtheyspendonprevention activities.

Enforcementandregulation 72.Enforcementandregulation activitiesaccountforfivepercentof thedirectspendondrugsandalcohol.80

73.Basedondatacollectedonthe numberandsizeofdedicateddrug squadsandlicensingdepartmentsfrom allforces,weestimatethatexpenditure ondrugandalcohollabelledpolice workwas£7.1millionin2007/08.81 TheeightpoliceforcesinScotland recordinformationaboutdrugand alcoholoperationsdifferently,therefore itisnotpossibletocompareactivityor costbetweenpoliceforceareas.

74.Thisestimatedoesnotincludethe costoftheScottishCrimeandDrug EnforcementAgency(SCDEA).The SCDEAcosts£23.3millionayearand aimstopreventanddisruptseriousand organisedcrime.Asignificantamount ofitsworkisdrug-related.

75.Thereisalsoasignificantamount ofgeneralpolice,prisonandcourt timespentondrugandalcoholissues butthisisnotcosted.Thewidercosts ofdrugandalcohol-relatedcrimein

Part2.Directexpenditureondrugandalcoholservices15

Exhibit 6 NHS board and council spend on drug and alcohol services, 2007/08

NHSboardsandcouncilsspendmoreondrugservicesthanonalcoholservices.

Notes: 1. Figures in the bars show how much is spent in each NHS board area, by councils and NHS boards (£ million). 2. Combined spend is spend on joint services for drug and alcohol that cannot be differentiated. Source: Audit Scotland, 2008

Perc

enta

ge o

f tot

al e

xpen

ditu

reon

dru

g a

nd a

lcoh

ol s

ervi

ces

NHS board area Combined spend Drugs Alcohol

0

10

20

30

40

50

60

70

80

90

100

Ayrsh

irean

d Arran

Borde

rs

Dumfri

esan

d Gallow

ay

Fife

Forth

Valle

y

Gram

pian

Greate

r Glasgo

w

and Clyd

e

Highlan

d

Lana

rkshir

e

Loth

ian

Orkney

Shetla

nd

Tays

ide

Wes

tern Isl

es

Scotti

shto

tal

1.4

5.0

0.2

0.7

0.1

1.9

1.6

1.4

0.8

2.8

2.6

4.9

12.6

4.9

0.7

5.6

0.9

6.1

2.4

2.2

0.1

0.4

0.2

0.2

2.2

4.6

0.1

0.3

25.9

52.9

4.4 0.6

0.5

4.6

2.3

6.8 34

0.9

3.2

13.9

0.05

0.3

5.5

0.03

77

Scotland,includingpolice,prison andcourttime,areestimatedat £2.7billionayear.82,83 Spending on drug and alcohol services does not reflect levels of need

Publicbodiesspendsignificantlymore ondrugservicesthanalcoholservices 76.Inthissection,wefocusonNHS boardsandcouncilsastheyspend themajorityofmoneyondrugand alcoholservices.Weshowdatabased onNHSboardareasalthoughfigures shownincludeNHSandcouncil spendforthatarea.

77.In2007/08,almosthalfofthe moneyspentbyNHSboardsand councilswasondedicateddrug services(£77million)andasixth ondedicatedalcoholservices(£26 million).84Thisdoesnotreflectthe scaleoftherespectiveproblems,for examplethenumberofalcohol-related deathsinScotlandin2007(1,399)was

threetimeshigherthanthenumberof drug-relateddeaths(455).

78.WeaskedNHSboardsand councilshowmuchtheyspentin 2007/08oneitherdrugoralcohol servicesorcombinedserviceswhere itwasnotpossibletodifferentiatethe spend(Exhibit6).Theamountspent ondrugandalcoholservicesbyNHS boardsandcouncilsvariesacrossthe country.Thecombinedspendineach areamakesitdifficulttogivedefinite figuresforthetotalamountspenton drugoralcoholservices.

79.ThepercentageoftotalNHSand councildrugandalcoholspendthat isdrugsspecificvariesfrom75per cent(£13.9million)inLothiantosix percent(£0.03million)intheWestern Isles.ThepercentageoftotalNHSand councildrugandalcoholspendthat isalcoholspecificvariesfrom29per cent(£0.2million)inShetlandtofour percent(£0.1million)inDumfriesand Galloway.

80.However,someareas,particularly ruralareas,havehighlevelsof combinedspend.Thisisusedtofund jointservicesratherthanservices specificallyfordrugoralcohol problems.Highlevelsofcombined spendinruralareasarepossiblya reflectionoftheneedtobemore flexibleindeliveringservicesinmore sparselypopulatedareas.

Variationinspendacrossthecountry doesnotreflectindicatorsofneed 81.Theamountspentondrugand alcoholservicesvariesacrossthe country,fromalmost£14perheadof populationintheBorderstojustover £53inGreaterGlasgowandClyde (Exhibit7,overleaf).

16

Exhibit 7 NHS and council spend on drug and alcohol services per head of population, 2007/08

SpendperheadofpopulationvariesacrossScotland.

Spe

nd p

er h

ead

of p

opul

atio

n (£

)

NHS board area

53.1

31.9 31.7 31.3 29.5 26.8

23.4 22.8 20.9 20.7 18.2 17 16.3 13.5

30

0

10

20

30

40

50

60

70

80

90

100

Greate

r Glasgo

w

and Clyd

e

Shetla

nd

Orkney

Tays

ide

Ayrsh

irean

d Arran

Gram

pian

Highlan

d

Loth

ian

Fife

Forth

Valle

y

Lana

rkshir

e

Wes

tern Isl

es

Dumfri

esan

d

Gallow

ayBor

ders

Scotti

shav

erag

e

Source: Audit Scotland, 2008

82.Thescaleofthisvariationinspend isnotexplainedbydifferencesinthe levelsofdrugandalcoholmisusein alocalareaorbythelevelsofharm causedasaresultofthemisuse (Exhibits8and9).

Funding arrangements for drug and alcohol services are complex and make strategic planning difficult

83.Fundingfordrugandalcohol servicescomesfromarangeof sourcesincludingNHSring-fenced allocations,NHSunifiedbudgets, councilgeneralallocations,specific grantfunding,thevoluntarysector,the policeandtheScottishPrisonService. Fundingforaprojectmaybedirected throughseveraldifferentagencies beforeitreachestheactualservice (Exhibit10,overleaf).Thiscanmake transparencyoffunding,planningand long-termstabilityforservicesdifficult andcreatesasignificantadministrative burdenonservicemanagers.

84.Thevoluntarysectorprovides manydrugandalcoholservices. In2007/08,aroundathirdof directexpenditureontreatment andcarewasspentonservices providedbythevoluntarysector.In ourfocusgroup,voluntarysector representativesreportedthatthe fundingarrangementsareparticularly challengingforthem,asprojectsare oftensupportedbynumerousfunding streamswithdifferenttimescales andreportingmechanisms.The fundingarrangementsofthevoluntary sectorGreaterEasterhouseAlcohol AwarenessProject(GEAAP)in Glasgowhighlightthecomplexityof thesearrangements.Thisisdespite theAddictionsPartnershipinGlasgow coordinatingfundingonbehalfof arangeofstatutoryagenciesinan attempttostreamlinearrangements (Exhibit11,overleaf). 85.Short-termandtemporaryfunding ofprojectsdoesnotalwaysallow forsufficienttimetoevaluatethe

effectivenessoftheseservices.Itcan alsohaveanegativeeffectonpeople usingtheserviceastherelationship andtrustdevelopedwithaworker overtimeisvulnerableiffundingis shortterm.

86.Multiplefundingstreamswith differentcriteriaandshort-termfunding makeitverydifficulttoplananddeliver servicesandcanputprojectsatrisk. Providingservicesthiswaydoesnot offervalueformoneyandislikelyto haveanimpactonvulnerableclients (Casestudy2,page20).

87.AllocationsfromtheScottish Governmentcanbeannouncedat shortnotice,whichgiveslocalareas ashortlead-intimetoplanand deliverdrugandalcoholservices.For example,detailsofa150percent increaseinNHSboardallocationsfor alcoholservicesfor2008/09were issuedon20March2008.

Part2.Directexpenditureondrugandalcoholservices17

Exhibit 8 NHS and council spend on drug and combined drug and alcohol services per 1,000 population, 2007/08

Spendondrugspecificandcombineddrugandalcoholservicesdoesnotreflectdrugmisuseprevalencerates.

Drug spend Combined drug and alcohol spend

Drug prevalance

45,000

40,000

35,000

30,000

25,000

20,000

15,000

10,000

5,000

0

30

25

20

15

10

5

0

Dru

g a

nd c

ombi

ned

dru

g a

nd a

lcoh

olla

belle

d s

pend

per

1,0

00 p

opul

atio

n (£

)

NHS board area

Drug

misuse prevalence per 1,000

population aged

15-54 years

Greate

rGlas

gow

andClyd

e

Ayrsh

irean

dArran

Tays

ide

Orkney

Shetla

nd

Gram

pian

Highlan

d

Loth

ian

Forth

Valle

y

Lana

rkshir

e

Fife

Dumfri

esan

d

Gallow

ay

Wes

tern Isl

es

Borde

rs

Note: Combined drug and alcohol spend is spend on joint services that cannot be differentiated. Source: Audit Scotland, 2008

Exhibit 9 NHS and council spend on alcohol and combined drug and alcohol services per 1,000 population, 2007/08

Spendonalcoholspecificandcombineddrugandalcoholservicesdoesnotreflectalcohol-relateddischargerates.

Alcohol spend Combined drug and alcohol spend

Alcohol-related hospital discharge rates

35,000

30,000

25,000

20,000

15,000

10,000

5,000

0

20 18 16 14 12 10 8 6 4 2 0A

lcoh

ol a

nd c

ombi

ned

dru

gs a

ndal

coho

l lab

elle

d s

pend

07/

08 p

er1,

000

popu

latio

n (£

)

NHS board area

Alcohol-related

hospital discharges 2006/07 per

1,000 population

Orkney

Greate

rGlas

gow

andClyd

e

Highlan

d

Shetla

nd

Ayrsh

irean

dArran

Tays

ide

Wes

tern Isl

es

Gram

pian

Dumfri

esan

d

Gallow

ay

Forth

Valle

y

Lana

rkshir

e Fif

e

Borde

rs

Loth

ian

Note 1. Combined drug and alcohol spend is spend on joint services that cannot be differentiated. Note 2. We have used alcohol-related hospital discharge rates as the prevalence of alcohol dependency is not available at NHS board level. Source: Audit Scotland, 2008

18

Exhibit 10 Main funding streams for drug and alcohol services, 2007/08

Fundingstreamsfordrugandalcoholservicesarecomplex.

Scottish Government

Drug and alcohol services

Unified budget

£6,870m

Resource transfer £7.5m

Alcohol treatment £10.7m

Drug treatment £23.7m

Drug treatment £23.7m

Scottish Prison Service £3m

Police forces £60m1

£1.2m

Grants, eg Fairer Scotland

Fund £435m over three years

Lloyds TSB Foundation for

Scotland

Big Lottery Fund

Robertson Trust

£10m over three years

£0.7m £66m £90m

Local councils

NHS boards

Grants to voluntary

sector £1.1m

Grants to voluntary

sector £0.5m

Drug Treatment and Testing

Orders £6.6m

Scottish Crime and Drug Enforcement

Agency £23.3m

Grant Aided Expediture (GAE)

identified for substance misuse £42m

(2006/07)

Finance and sustainable growth portfolio

Health and wellbeing portfolio

Drugs courts £1.9m

Justice portfolio

Note 1. Scottish Government estimate of police spend on drug-related crime. Source: Audit Scotland, 2008

Part2.Directexpenditureondrugandalcoholservices19

Exhibit 11 Funding for the Greater Easterhouse Alcohol Awareness Project in Glasgow, 2008/09

Localprojectsoftenreceivefundingfromnumerousdifferentsources,andfordifferenttimeperiods.

Greater Easterhouse Alcohol Awareness Project 2008/09

Total = £506,737

Services delivered to over 6,000 individuals per year

North East Community

Alcohol Support Service

One year (rolling funding)

£172,942

NHS Greater Glasgow and

Clyde

Running costs

One year

Glasgow City Council social

inclusion budget

Core service salaries

One year (rolling funding)

£151,288 £30,000

Glasgow Addiction Partnership (coordinates public sector funding)

£84,977 (per year)

Five years

Big Lottery

Befriending service

£33,530 (per year)

Three years

Comic Relief

Young person’s service

£14,000 (per year)

Three years

Tudor Trust

Alternative therapies

£20,000

One year

Mentor UK

Young Booze

Busters

Glasgow Homelessness

Network

Source: Audit Scotland, 2008

TheconcordatandSingleOutcome Agreements 88.InApril2008,followingagreement ofaconcordatbetweentheScottish GovernmentandCOSLA,Single OutcomeAgreements(SOAs)were introducedacrossScotland.SOAsset outhoweachcouncilanditspartners, includingtheirlocalNHSboard,will addresstheirprioritiesandimprove servicesforthelocalpopulation. SOAsareintendedtoencourage

councilsandtheirpartnerstofocuson outcomesratherthanonmeasuring process.

89.Aspartoftheconcordat,certain councilfundsarenolongerring­fenced.Thismeansthatcouncilscan nowusemoneypreviouslybadged foruseforspecificpurposesaspart oftheirgeneralallocations.Specific grantssuchastheSupportingPeople Grant,YouthJusticemoniesandthe

ChangingChildrenServicesFund, whichhelpedtosupportpeoplewith drugandalcoholproblems,arenow partofacouncil’sgeneralallocation.

90.Thereductioninring-fencing allowsgreaterdiscretionforcouncils, withtheirpartners,toallocate resourcesaccordingtoperceivedlocal needsandpriorities.However,unless therearegoodinformationsystems inplaceitmaybedifficulttoknow

20

Case study 2 Short-term funding can have an impact on services

Aberlourisachildren’scharityprovidingservicesandadvicetovulnerable children,youngpeopleandfamiliesinScotland.

In1999,ScottishEnterprisegrantfunding(theNewFuturesFund)paid Aberlourtoprovideanemploymentandtrainingservicetosubstance­misusingmotherswithdependentchildreninGlasgow.Themajorityofthese serviceusershavenotbeeninpaidemploymentandhavenotcompleted basiceducation.Inasix-monthperiod,theserviceworkedwitharound 25clients,helpingthemtoengageinfurthereducation,trainingand/or employment.

In2006,fundingforAberlourmovedtoCommunityPlanningPartnerships (CPPs).Theservicereceivedayear’sfundingfromtheCPPsin2007/08 andafterthistimealternativefundinghadtobesought.Inanyoneyear, theremaynotbeserviceusersfromeveryCPPandthisthereforemade negotiationsdifficult.Theprojectdidnotsecurefundingandhadtoclose.

Source: Audit Scotland, 2008

whetherdrugandalcoholprojects securethenecessaryfunding.

91.Drugsandalcoholarenot includedintheconcordatasaspecific commitmentandalthoughseveralof the15nationaloutcomescouldrelate todrugandalcoholmisuse,thereis nodirectlink.Allofthe32firstSOAs domentiondrugandalcoholmisuse. However,somereferencestodrugs andalcoholareverybriefandthe expectedimpactondrugandalcohol servicesisoftenunclear.

Recommendations

Thepublicsectorshould:

regularlyreviewfunding arrangementsfordrugand alcoholservicestoensurethat theymaximisevalueformoney andreflectlevelsoflocalneed

workwithprovider organisationstoreducethe impactofcomplexandshort­termfundingonprojects.

•

•

21 21

Part 3. Effectiveness of drug and alcohol services

Thereisnoconsistencyintheservicesavailable andinformationtoassesscost-effectiveness nationallyislimited.

22

Key messages

Thereisvariationacross Scotlandintherangeand accessibilityofdrugand alcoholservices.TheScottish Governmenthasnotsetout minimumstandardsinterms ofrange,choiceoraccessibility thatserviceusersandtheir familiescanexpecttoreceive.

Spendingdecisionsarenot alwaysbasedonevidence ofwhatworksoronafull assessmentoflocalneed.The majorityofdrugandalcohol servicesdonothaveclear aimsandthereisverylittle informationonwhethertheyare achievingspecificoutcomesor measuresofsuccess.

Somelocalareashave informationontheactivity,cost andimpactofdrugandalcohol servicesbutthisisnotavailable nationally.Itisnotpossibleto comparethecost-effectiveness ofdifferentservices.

•

•

•

Drug and alcohol services vary across Scotland

92.Thedrugandalcoholservicesthat peoplereceivevarydependingon wheretheylive(Casestudy3).

93.CurrentScottishGovernment policyhighlightstheneedtohavea rangeofservicesinplacetomeet individualneedsbutthereissome evidenceofalackofchoice.Drug serviceuserswhoparticipatedinour focusgrouphighlightedthattheyfeel theyhavelittlechoice:“one size fits all – you have to fit with the service, not it with you.” 85

94.Thereisnodirectionfromthe ScottishGovernmentonwhatmoney fordrugtreatmentandcareservices shoulddeliver.AlthoughtheScottish ExecutivedevelopedNational Quality Standards for Substance Misuse Servicesin2006thereisnonational monitoringofwhethertheyhave beenimplemented.86Adifferent

Case study 3 Examples of alcohol services in Tayside and Forth Valley

NHSTaysiderunstheTaysideAlcoholProblemService(TAPS).Peoplecan contacttheservicedirectlyorthroughaGPorsocialworker.

Theserviceoffersassessmentandtreatmentoptionsinsatelliteclinics acrosstheregionandhasawell-establishedresidentialfacilityinalocal hospital,whichpeoplecanalsoaccess.

NHSForthValleyrunstheCommunityAlcoholService.Peoplecancontact theservicethroughaGPorthroughSignpostForthValley,whichisadirect accessserviceforpeoplewithsubstancemisuseproblemsacrosstheForth Valleyarea.

Theserviceoffersarangeofcommunity-basedtreatmentincludinghome detoxificationthatprovidespeoplewithtreatmentintheirhomeratherthan inahospitalorotherresidentialsetting.

Source: Audit Scotland, 2008

approachistakeninEnglandwhere thegovernmenthassetoutand monitorsarequiredrangeofdrug serviceswhichshouldbeinplaceand minimumstandardsofaccess.

95.ThereisdirectionfromtheScottish Governmentonwhatadditionalmoney foralcoholservicesshoulddeliver.The ScottishGovernment’sadditional allocationof£24.8milliononalcohol servicestotheNHSin2008/09has comewithaclearinstructionto usesomeofthemoneytoprovide screeningsandbriefinterventions topreventpeoplefromdeveloping seriousproblemswithalcoholandthe remainderonsupportingadditional treatmentandpreventionservices. TheScottishGovernmenthasasked everyNHSboardtocompletea progressreportsettingouthowmuch oftheadditionalmoneytheyhave spentin2008/09andwhatservicesit hasfunded.

96.Inaddition,aspartofthenew alcoholstrategy,aMonitoringand EvaluationReferenceGroupfor Alcoholhasbeenestablishedtotrack implementationofthealcoholstrategy andrelatedoutcomes.Thisgroupis chairedbyNHSHealthScotlandand aimstoidentifytheimpactofthe additional£85.3millionoverthree yearsforalcoholmisuse.

97.Despitetheincreasedpresence ofcocaineinScotland,drugservices remainfocusedonheroinmisuse andmaynotbesetuptosufficiently meettheneedsofpeoplewho misusecocaine.TheScottishAdvisory CommitteeonDrugMisuseestimated thatonlyninepercentofdrug treatmentservicesprovidetreatment specificallyforpeoplewhomisuse drugsthathaveanti-depressantor moodelevatingproperties,suchas cocaine.Thefewspecialistservicesfor cocainemisuseareallinurbanareas, suchasAberdeenandEdinburgh.87

Prevention 98.Therearenationalinitiativesaimed atpreventingdrugandalcoholmisuse. Forexample,theKnowtheScore campaignaimstoincreaseknowledge andpromoteavoidanceofdrug misuseandhasabudgetof£580,000 for2008/09.Therearealsonational preventioninitiativesforalcohol,for exampleAlcoholAwarenessWeeks, thataimtoraiseawarenessabout alcoholconsumptionandhavea budgetof£190,000for2008/09.There isnonationalinformationcollectedon preventionactivityatalocalleveland thereisnoevaluationoftheimpactof thispreventionwork.

99.Oftenpreventionformspartof theworkoftreatmentandcare

Case study 3Examples of alcohol services in Tayside and Forth Valley

NHSTaysiderunstheTaysideAlcoholProblemService(TAPS).PeoplecancontacttheservicedirectlyorthroughaGPorsocialworker.

Theserviceoffersassessmentandtreatmentoptionsinsatelliteclinicsacrosstheregionandhasawell-establishedresidentialfacilityinalocalhospital,whichpeoplecanalsoaccess.

NHSForthValleyrunstheCommunityAlcoholService.PeoplecancontacttheservicethroughaGPorthroughSignpostForthValley,whichisadirectaccessserviceforpeoplewithsubstancemisuseproblemsacrosstheForthValleyarea.

Theserviceoffersarangeofcommunity-basedtreatmentincludinghomedetoxificationthatprovidespeoplewithtreatmentintheirhomeratherthaninahospitalorotherresidentialsetting.

Source: Audit Scotland, 2008

Part3.Effectivenessofdrugandalcoholservices23

Exhibit 12 NHS board and council spend on community and residential treatment, by NHS board area, 2007/08

ThespendoncommunitytreatmentcomparedtoresidentialtreatmentvariesacrossScotland.

Perc

enta

ge o

f tre

atm

ent s

pend

(res

iden

tial a

nd c

omm

unity

trea

tmen

t)

NHS board area Community treatment

Residential treatment

0

10

20

30

40

50

60

70

80

90

100

Ayrsh

irean

d Arran

Borde

rs

Dumfri

esan

d Gallow

ay

Fife

Forth

Valle

y

Gram

pian

Greate

r Glasgo

w

and Clyd

e

Highlan

d

Lana

rkshir

e

Loth

ian

Orkney

Shetla

nd

Tays

ide

Wes

tern Isl

es

Scotti

shav

erag

e

9% 11% 7% 10% 2% 25% 23% 18% 11% 15% 1% 14% 22% 18%

Source: Audit Scotland, 2008

91% 89% 93% 90% 98%

75% 77% 82% 89% 85%

99% 86%

78%

100% 82%

servicesandcanbedifficultto separateout.Forexample,inGreater GlasgowandClydeitisestimated thatathirdofthe£47million treatmentandcarespendwillhave animpactonchildrenaffectedby substancemisusethroughsupporting parentingandtreatingparents.

Residentialandcommunitytreatment 100.Itisimportantthatarangeof servicesisavailabletomeettheneeds ofpeoplewhomisusedrugsand alcohol,asitisunlikelythatasingle serviceortypeoftreatmentwillsuit everyone.Serviceusersshouldbe activelyinvolvedinthesedecisions.

101.Residentialtreatment, prescribingofsubstitutes(suchas methadone)andothercommunity treatment(forexamplecounselling) haveaplaceinhelpingtotreatpeople whomisusedrugsandalcohol.88

102.Theuseofresidentialdrugand alcoholservicesvariesacrossthecountry andhighlightstheissueofchoiceand accessibility.Theamountspenton communitytreatmentcomparedto residentialtreatmentvaries(Exhibit12). InsomeareasofScotland,peoplewho

misusedrugsandalcoholcanbereferred toresidentialtreatment,whileinother areasthisserviceisrarelyoffered.89 Supportinthecommunityaftera residentialplacementisimportanttolong­termpositiveoutcomesfortheindividual.

103.Thereisnocentralmonitoring ofthenumberofpeopleinresidential treatmentbuttherearesome limiteddatafrom2005/06onservice activityandentrycriteria.AScottish Governmentreportestimatedthatin 2005/06therewere352bedsavailable forresidentialtreatmentfordrugand alcoholmisuse,providedby22separate servicesacrossScotland.Thenumber ofbedsperservicerangedfromtwo to104andthecapacityofresidential servicesinScotlandwasestimated as1,670peopleperyear.In2005/06, residentialtreatmentoccupancyrates inthese22servicesvariedfrom 36percentto96percent.90Almost athirdofthebedsandserviceswere locatedinGlasgow.Thereportnoted thatareaofresidenceandagewere themainlimitingfactorsinaccessing residentialservices.Onlyoneservice acceptedpeopleunder16andathird ofthebedswereonlyavailableto Glasgowresidents.91

104.Residentialtreatmentis moreexpensiveperserviceuser thanotherformsoftreatment.In 2007/08,£19.4millionwasspent onresidentialtreatmentbyNHS boardsandlocalcouncils.In2006 inAberdeenCity,itwasestimated thattheaveragepackageofcarefor residentialrehabilitationperperson cost£20,000peryearcomparedto £3,000forcommunityrehabilitation.92 Oftenapersonaccessingresidential treatmentwillhavealreadytriedother programmestohelpthemmanage orrecoverfromtheiruseofdrugsor alcohol.

105.Methadoneprescribingisa commontreatmentinScotland,with around20,000peopleestimatedto bereceivingthesubstitutedrugin 2004.93Methadoneonitsownisa lessexpensiveoptionthanresidential treatmentandcanbeusedtohelp manageaddictiontoopiates.In 2007/08,£24.9millionwasspenton methadonetreatmentinScotland.94 Thereisnonationalestimateofthe unitcostsofmethadonetreatment butinEnglandtheaveragecostper personforayearhasbeenestimated at£1,970.95

24

106.Formethadoneprogrammesto beeffective,cliniciansneedtoregularly reviewmethadoneprescriptions withtheserviceuserandensure otherservicesareinplacetosupport them.However,theScottishAdvisory CommitteeonDrugMisusepublished areviewofmethadoneprescribingin 2007whichhighlightedthatalthough methadonewasthedrugtreatment withthemosteffectivetrackrecord, informationontheperformance ofserviceswassparseandthere wereconcernsaboutmethadone prescribinginScotland.Thereview notedproblemsrelatingto“prescribing philosophy; limited availability of treatment options in some areas; inconsistency in practice and quality of service across Scotland; effectiveness of services – in particular relating to the delivery of acceptable harm reduction and recovery outcomes, crime reduction and the safety of children.” 96

107.DrugTreatmentandTesting Orders(DTTOs)arealternativesto custodyandofferprescribedsubstitute drugtreatment,suchasmethadone, foroffendersinthecommunitywith compulsorydrugtesting.Peoplewho havemisuseddrugswhoattendedour focusgroupfeltthatakeybenefitof DTTOsisthattheyareabletokeepthe samekeyworkerandbuildtrust.The averagecostofaDTTOisestimated atjustover£18,000perserviceuser

97peryear.

108.Itisdifficulttoofferarangeof servicesforaddictioninruraland remoteareas.Theseareasoften needtotakeadifferentapproachto deliveringservicesthanmoreurban areas.Forexample,inLochaberin Highlandtherewerelimitedsocial workorsupportworkerservicesfor peoplemisusingdrugsandalcohol. StafffromNHSHighlandandHighland Councilworkasoneserviceoffering integratedsubstancemisuseservices aspartofthewidercommunity mentalhealthservice.Thisapproach hasassistedcommunicationacross theserviceandhasenabledaccess toawiderrangeofprofessional andsupportstaffforserviceusers, includingthosewithdualdiagnoses.

Servicesforfamilies 109.TheScottishGovernment highlightstheimportantrolefamilies affectedbydrugandalcoholmisuse playinhelpingpeopletorecoverin theirrecentdrugsandalcoholpolicies. TheScottishExecutiveestablished theScottishNetworkforFamilies AffectedbyDrugs(SNFAD)in2003, andtheScottishGovernmentprovided £70,000toSNFADin2007/08.SNFAD isanumbrellagroupthatsupports localfamilygroupsacrossScotland. However,ourfocusgrouphighlighted thatfamiliesinneedareoftennot awareofthesupportavailable.Thereis noequivalentorganisationforfamilies affectedbyalcoholmisuse.

Joined-upservices 110.TheScottishExecutiveprovided aseriesofoperationalguidance onintegratingtreatmentandcare services.98Despitethis,therearestill problemsinthewaythatsomeservices worktogether.Thislackofjoined-up workingaffectsspecificgroupsof peopleincludingthosewithadiagnosis ofaddictionandmentalillnessand recentlyreleasedprisoners.99

111.Generalservices,suchas housingsupportandemployment andtrainingservices,alsohave animportantroletoplaybutthe availabilityoftheseservicesfordrug andalcoholmisusersvariesacross Scotland.100

National information on needs and the impact of services is poor

112.Nationaldrugandalcohol informationexistsonprevalence, indicatorsofharmsuchashospital dischargesanddeathsandpolice informationonarrests,seizuresofillegal drugsandalcohol-relatedoffences.

113.TheScottishGovernmentfunds anationaldatabaseofdrugtreatment servicesthatrecordspeopleentering specialistdrugservices.Thisdatabase isbeingdevelopedtoprovidefollow­upinformationonindividualsafter asettimeintreatment.Thereis noequivalentdatabaseforalcohol servicesandnationalinformationon

alcoholservicesisweak.However, theScottishGovernmenthasfunded researchtoestimatethecapacityof alcoholservicesinScotland.Thisisdue tobepublishedinApril2009. 114.Informationontheactivity,cost orimpactofservicesdesignedto reducedrugandalcoholproblems existsinsomelocalareasbutthe typeandqualityofdatacollectedvary acrossScotland.Nationalinformation onthecost,activityandqualityof servicesisnotavailable.

115.Thelackofconsistent, comparableandsharedinformation makesitdifficulttoplanand commissionprevention,treatmentand careservicesandtoinfluencehow servicesdevelopbasedonevidence.

116.Serviceplannersandproviders assesslocaldrugandalcoholservice needs,buttheseassessmentsareoften notdoneinanycoordinatedwayacross alocalarea.Whereneedsassessments areundertakentoinformthe developmentofservices,thisisusually onlyinrelationtoadditionalresources andoftendoneasaone-offexercise.

117.Currently,localmonitoring ofservicesgenerallyfocuseson numbersofpeopleinaserviceand activityratherthanonthequalityof theservicedeliveredortheoutcomes achieved.

118.Publicbodiesdonotroutinely evaluatetheeffectivenessofdrug andalcoholservices.Lessthan onepercentoftotalspendbyNHS boardsandcouncilsondrugand alcoholservicesisusedforresearch andevaluationpurposes.Thereare, however,someexamplesofgood practicewheretherehasbeena comprehensivereviewofalldrug andalcoholservicesinanarea (Casestudy4).Agenciesplanning andprovidingservicesinGlasgow, Edinburgh,AberdeenandAyrshire establishedaworkinggroupin2008 tobenchmarkdrugandalcohol servicesinScotland.Thisworkisstill atanearlystage.

Part3.Effectivenessofdrugandalcoholservices25

Localcost-effectiveness 119.Therearenocomparableunit costsfordrugandalcoholservices inScotland(withtheexception ofcriminaljusticeinterventions) tohelplocalareasevaluatecost- effectivenessofservices.InEngland, thegovernmentisconsultingon guidancesettingoutunitcostsfor varioustreatments.

The impact of drug and alcohol services is not known at a national level

120.Thereisnoconsistent understandingofwhatthemoney spentondrugandalcoholservices hasbought.TheScottishGovernment hasnotdefinedwhatconstitutesa ‘service’,an‘intervention’,orany measuresofsuccessforservices.

121.Fundingfordrugandalcohol servicesgenerallydoesnothaveclear aimsorexplicitoutcomesattached. Aspartofourfieldwork,wefound thatmanyservicesdidnothavea servicelevelagreement,contract orservicespecificationthatstated theexpectedactivityoroutcomeof thefunding.Theuseofservicelevel agreementsandcontractsvaried acrossthecountry.

Outcomes 122.Althoughdemonstratingbenefits fromthespendingondrugand alcoholservicesiscomplex,there aresomeexamplesofgoodpractice wherepublicsectorbodieshave changedthewayinwhichtheywork tofocusonoutcomes(Casestudy5).

123.TheScottishGovernmentchairs theDeliveryReformGroup,which itestablishedin2008toadvise ministersonhowtoimprovedelivery arrangementsfordrugandalcohol servicesandensurebetteroutcomes forserviceusers.Asubgroupofthe DeliveryReformGroupdeveloped anoutcomestoolkitfordrugand alcoholservicesinJanuary2009 (Exhibit13,overleaf).Basedonthe proposalsoftheDeliveryReform Grouptheseoutcomemeasureswill notbemandatorybutmaybeusedby

Case study 4 Comprehensive review of addiction services in Greater Glasgow

Before the review:In2003,addictionservicesinGreaterGlasgowwererun acrossthreeagencies:NHSDrugProblemService,NHSAlcoholandDrug DirectorateandSocialWorkAddictionservices.Theservicepeoplereceived dependedonwheretheylived.

The review:Aseriesofstrategicreviewsfocusedondifferentservicessuch ascouncilservices,homelessservicesandservicespaidforbytheNHS andcouncilbutdeliveredbyothers(eg,residentialservices).Eachstrategic reviewincludedneedsassessments,ananalysisoflevelsofcurrentuse andserviceuserviewsandaliteraturereviewofeffectiveness.Allthis informationwassharedacrossagencies.

After the review:Thereisnowasinglepartnershipwithresponsibilityfor theplanningandperformanceofdrugandalcoholservicesacrossGreater Glasgow.Thereare13CommunityAddictionTeamsacrossGreaterGlasgow withasinglemanagementstructure,forbothNHSandcouncil,andsingle accountability.Theservicehas580staffandabudgetof£42millionperyear, whichismanagedthroughajointfinancialframework.

Source: Audit Scotland, 2008

Case study 5 Outcome-based service development in West Lothian

WestLothianAlcoholandDrugActionTeam(ADAT)hasdevelopedaseries ofstagestohelptocommissionservicesbasedonoutcomemeasures.

Stage 1 analysis – building the evidence base.Regularneedsassessment andresearchintowhatworkstoprovideevidencetoinformfundingdecisions.

Stage 2 planning – specifying the outcomes.Alocaloutcomeframework isagreedbasedonneedsassessments.Thefocusisontheoutcomesthat providersmustachieveandhowtheywillachievetheseoutcomesisnotset outinadvance.Potentialserviceproviderssubmitanoutcomespecification andanoutcomedeliveryplanrecordshowtheproviderwillachievethe outcomesandwhatfundingisneededtodelivertheproject.Anoutcome milestonechartisusedtoidentifykeyclientstagesandcapacityinthe service.Alltendersareevaluatedagainstspecificcriteria.

Stage 3 doing – outcome contracting.Successfulproviderssubmit quarterlymonitoringtemplateswhicharefocusedonoutcomes.All successfulprovidersarealsorequiredtocompleteequalityimpact assessments,whicharereviewedonanongoingbasis. Source: Audit Scotland, 2008

servicesandrecordedthroughSOAs. 124.Giventhelackofconsistenthigh- Itwillbeimportantforlocalareasto qualityperformancemanagementdata havebaselineinformationagainst andthatnewoutcomemeasuresare whichtomeasuretheirperformance. proposedasoptional,comprehensive Theproposalsdonotincludeanyplans andcomparableoutcomeinformation tomonitorwhichareasimplement willnotbeavailableacrossScotland theseoutcomes. inthenearfuture.Thiscontrastswith

thedevelopmentinEnglandover

26

recentyearsofasystemfornational perfomancemanagementand accountability,whichcombinesservice datawithunitcosts. 125.Theimpactofenforcementactivity iscomplex.Arrestsanddrugseizures areincreasingovertimebuttheimpact thatthishasontheavailabilityofillegal drugsorScotland’sdrugproblemisnot known.RecentresearchbytheUnited KingdomDrugPolicyCommission highlightsthelackofevidenceof effectivenessofenforcementactivity.101

126.Whiletherearesomeexamples ofgoodpracticeintermsofreviewing servicesandprovidingintegrated services,thisisnotroutinelysharedto helpimproveservicesacrossScotland.

127.ThepublicsectorinScotland shoulduseaconsistentperformance frameworktohelpthemtobenchmark servicesandperformance.Aself­assessmentchecklistissetoutat Appendix4,whichaimstohelppartners improvethedeliveryandimpactofdrug andalcoholservicesintheirlocalareain aconsistentwayacrossScotland.

Recommendations

Exhibit 13 Scottish Government example outcomes for drug and alcohol services

Drug specific:

Reductionindrug-relatedmorbidity,mortalityanddeaths.

Lessdrug-relatedcrime–acquisitive,violent,organised.

Alcohol specific:

Reducealcohol-relatedinjuries,physicalandpsychological morbidityandmortality.

Lessalcohol-relatedviolence/abuse/offencesandantisocialbehaviour.

Drug and alcohol:

Saferandhappierfamiliesandcommunities.

Reducednumberofchildrenlookedafterandaccommodated/separated fromparents.

Increasesinyoungpeoplecompletingschool,collegeortraining.

Reductioninchildren’sexposuretosubstancemisuse.

Increasedproductivityintheworkplace.

Reductioninadultsonbenefitsduetodrug/alcohol-relatedincapacity.

Lessabsenteeism/lostproductivitycausedbydruguse/alcohol consumptionintheworkplaceandeducationalestablishments.

•

•

•

•

•

•

•

•

•

•

•

Source: Scottish Government, 2009

TheScottishGovernmentand publicsectorbodiesshould:

workcloselytogetherto developaperformance frameworkincorporating,but notlimitedto,existingtargets. Furtherworkisrequiredto identifyinformationonspend, activityandoutcomes

ensurethatthereisa comprehensiverangeofservices availableineachlocalarea

developunitcostinformation fordifferentdrugandalcohol servicestohelppublicbodies measureandcomparethecost- effectivenessofvariousservices.

•

•

•

TheScottishGovernmentshould:

setclearnationalminimum standardsfordrugandalcohol servicesincludingtheirrange, qualityandaccessibility; receiveassurancethatthese standardsareimplementedin linewithsettimescales;and ensureperformanceisregularly monitoredandpubliclyreported.

Publicsectorbodiesshould:

ensurethatalldrugandalcohol servicesarebasedonan assessmentoflocalneedand thattheyareregularlyevaluated toensurevalueformoney.This informationshouldthenbe usedtoinformdecision-making inthelocalarea

•

•

ensurethatservice specificationsareinplaceforall drugandalcoholservicesand setoutrequirementsrelating toserviceactivityandquality. Whereservicesarecontracted thisspecificationshouldbepart ofaformalcontract

setclearcriteriaofeffectiveness andexpectedoutcomesfor thedifferentservicesthatthey provide,andundertakeregular auditstoensureservices adheretoexpectedstandards

usetheAuditScotlandchecklist detailedinAppendix4tohelp improvethedeliveryandimpact ofdrugandalcoholservices throughajoined-up,consistent approach.

•

•

•

27

Part 4. Drug and alcohol partnerships

Drugandalcoholpartnershipshavebeeninplace sincethelate1980sbuttheyhavenotallachievedthe objectivessetforthem.

28

Key messages

Partnershipsfordrugsand alcoholhavebeeninplacesince thelate1980s.Limitednational guidancehasbeenissuedto partners,despitethecreation ofnewpartnershipbodiesand advancesinunderstandingthe problemsofdrugandalcohol misuse.

Giventhelimitedguidance,drug andalcoholpartnershipshave evolvedtoworkindifferent waysacrossScotland.Some partnershipshaveoperated strategicallywhileothershavehad amoredetailedfocusonspecific services.Notalldrugandalcohol partnershipshaveachievedthe objectivessetforthem.

Therearemanypublicsector bodiesinvolvedindelivering drugandalcoholservices,each withdifferentaccountabilityand governancearrangements.A clearerstructurefororganising resourcesfordrugandalcohol servicesinScotlandisneeded, alongsideclarityabouttheroles ofservicesandpartnersand howtheyshouldlinktogether.

•

•

•

A lack of central guidance has led to variation in how local partnerships operate

128.Manypublicsectorbodies contributetoaddressingdrugand alcoholproblemsinsomeway.NHS boards,councils,thepoliceandthe prisonserviceallplayapart.Although theseagenciesaddressdrugandalcohol problemsthroughtheroutinework theydo,suchascitycentrepolicingat weekends,thesepartnersshouldalso cometogethertojointlyplanservices andshareresourcestotackledrugand alcoholproblemswithinalocalarea.

129.Sincethelate1980s,partnership bodieshavebeentaskedwith developingcross-cuttinglocal responsestonationalgovernment strategiesfordrugsandalcohol.These partnershipbodieshavebeenknown

asAlcoholMisuseCoordinating Committees,DrugActionTeams, AlcoholActionTeamsandAlcoholand DrugActionTeams(ADATs).

130.TheScottishExecutivepublished adetailedremitforDrugAction Teamsin1995.Thisguidancewas updatedin2002whenAlcohol ActionTeamsandjointAlcoholand DrugActionTeamswerebeing formedlocally.Theaimsforthese partnershipssetin1995wereto:

• collectandshareinformationto assessthelocaldrugproblem

• ensureeffectiveprevention measuresaredeveloped

• assessiftherangeandqualityof servicesmeetsneeds,andplanand initiateimprovementswhereneeded

• ensurecommunityviewsare takenonboard

• ensureregularevaluationand reviewsareundertakenofservices andactivitieswithaviewto improvingefficiency.

131.Eachlocalpartnershiphas developedadifferentfocus: performancemonitoringhasbeen poorinsomeareas,involvementof localcommunitieshasbeenvariable andpartnershipswereoftenable toinfluenceonlyasmallproportion ofmoneyspentinanareaondrug andalcoholservices.Insomeareas, ADATshaveactedascommissioning bodies,whileinotherstheyhavehad astrategicplanningrole.

132.Despitesignificantchanges inthewaydrugandalcohol servicesoperateandadvancesin understandingtheproblemsofdrug andalcoholmisuse(includingthe impactonchildprotection),theremit ofdrugandalcoholpartnershipshas notbeenrevisedsince2002.The ScottishGovernmentplanstoissue revisedguidanceondrugandalcohol partnershipsinspring2009,based onproposalsmadetheDelivery ReformGroup.

Not all drug and alcohol partnerships have achieved the objectives set for them

133.Althoughitisnotpossibleto assesstheperformanceofdrug andalcoholpartnershipsagainstthe revisedguidance,itispossibletolook atwhetherpreviousexpectations havebeenmet,andtocompare theoriginalexpectationswiththe proposedexpectations(Exhibit14).

134.Ingeneral,ADATshavenot achievedwhatwasexpectedof thembutthereareexamplesofgood practice.Forexample,inMoray, OperationAvonaimstoreducethe amountofstreetdrinkingamong underageyouthsandofferssupport andadviceatanearlystagetothose whomayalreadybesufferingthe adverseaffectsofalcoholmisuse. ThisinitiativeinvolvesGrampian Police,NHSGrampian,Moray Council,MoraySocialandHealth CarePartnerships,MorayDrug andAlcoholService,MorayYouth JusticeandCommunityLearningand Development.

The roles and responsibilities of drug and alcohol partnerships are still unclear

135.TheScottishGovernmentplans toissuerevisedguidanceondrugand alcoholpartnershipsinspring2009. Theguidancewasoriginallyplanned tobepublishedinNovember2008.

136.Thisrevisedguidancewillbethe resultoffouryears’workatanational leveltoreviewlocalAlcoholandDrug ActionTeams.In2005,thethen JusticeMinisteraskedforareview oftheeffectivenessandperformance ofADATsinrelationtodrugservices. Thiswasfollowedin2007withthe ScottishExecutive’sReport of the Stocktake of Alcohol and Drug Action Teams.

Part4.Drugandalcoholpartnerships29

Exhibit 14 Drug and alcohol partnerships have not met initial objectives published in 1995

1995 guidance Performance to date note that there is no central monitoring of these objectives

2009 proposals based on Delivery Reform Group proposals

Collect andshare informationto assessthelocal drugproblem

Inmostareas,localdatacollectionandanalysisareundertaken byoneormorepartner.However,itisrareforpartnerstopool thisinformationortrytobuildalocalpicture.

Improvementsarerequiredtoensurethathealthandsocial workcollectappropriatedata,andshareit.

Identificationandassessmentoffamilieswhereparents misusesubstancesneedstobeimproved.

Provideaclearassessmentoflocal needsandcircumstances,including bothmetandunmetneeds.

Setoutclearlyandopenlythe totalityofresourcesthateach partnerisdirectingtothepursuitof alcoholanddrugsoutcomes.

Ensureeffective prevention measuresare developed

Thereisnonationalinformationcollectedonpreventionactivity andlimitedresearchoneffectivepreventionmeasures.

Nationalfocusandfundinghasbeenontreatmentandthis hasbeenreflectedatalocallevel,whereonlysixpercentof identifieddirectspendin2007/08wasonpreventionservices.

Setoutanapproachtothe commissioninganddeliveryof services,includingpreventive interventions,inpursuitofthe outcomesidentified.

Assessifquality andrangeof servicesmeets needs,and planandinitiate improvements whereneeded

Needsassessmentsarenotalwayscarriedoutroutinelyfor allservicesorusedtoinformspendingdecisions.Theytend tobeadhocandratherthananequalpartnershipapproach onepartnermayhaveagreaterinfluence.

Thelackofinformationsharingbetweenpartnerslimitsthe usefulnessofanyneedsassessmentundertaken.

ADATsgenerallyonlyinfluencethefundingofsomeofthe drugandalcoholservicesintheirarea.Theycannottherefore changeserviceswhereneeded.

Provideaclearassessmentoflocal needsandcircumstances,including bothmetandunmetneeds.

Setoutabroadoutlineofthe servicestobeprovidedand/or commissioned,reflectingthelocal assessmentofneed.

Ensure community viewsaretaken onboard

Thereislittleevidenceofroutineinputfromserviceusers, theirfamiliesorwidercommunities.

Theinvolvementofserviceusers,theircarersandfamilesin thedevelopmentofservicesneedstobeimproved.

CommunityforumsnolongerexistinallADATareasand thereisnouniformityofapproachinconsultingthewider community.

Providelocalvisibility,advocacyand leadershipforalcoholanddrugs issuesforservices,serviceusers, familiesandcommunities.

Ensureregular evaluationand reviewsare undertaken ofservices andactivities withaview toimproving efficiency

Publicbodiesdonotroutinelyevaluatetheeffectivenessof drugandalcoholservices.Insomeareas,servicesreceive continuationoftheirfundingwithnoevidencebase.

Therearelocalexamplesofserviceevaluationbutno coordinatedapproachorScotland-wideinformation. Lessthanonepercentofdirectspendondrugsandalcohol isspentonresearchandevaluation.

Therearesomegoodpracticeexamplesofreviewing servicesinScotlandbutthepublicsectordoesnotroutinely sharethisinformationinordertoimproveservices.

Identifykeyoutcomesrelating todrugsandalcohol,theirplace withinthewiderframeworkof priorityoutcomescontainedwithin SingleOutcomeAgreements,and howtheirachievementwillbe measured.

Source: Audit Scotland, 2009

30

137.TheDeliveryReformGroup’s proposalshavesetoutgeneral principlesforpartnersand partnerships,whichareinlinewith previousguidance(Exhibit14).These havestilltobeapprovedbyministers. Ifapproved,furtherworkisneeded toclarifyhowtheseproposalswill beimplementedconsistentlyacross Scotlandandwhatrolevoluntary sectorpartnerswillplay.

138.Underthenewproposals,drug andalcoholpartnershipswillsitwithin CommunityPlanningPartnerships (CPPs).Ifthereismorethanone drugandalcoholpartnershipina NHSboardareathepartnershipswill beexpectedtocoordinateactivity. Thelocalpartnershipswillbeheld accountableforSingleOutcome Agreementcommitmentsthrough CPPsandforhealthtargetsthrough NHSpartners.Ahealthtargetfor alcoholwasintroducedin2008to provideanagreednumberofbrief interventionsthataimtoprevent peopledevelopingalcohol-related problems.Ahealthtargetfordrug misusewillbeintroducedin2009/10 andwillfocusonwaitingtimesfor services.Thedetailsofthistargetare stillunclear.

139.Thereare32councils,14NHS boards,eightpoliceforcesandeight CommunityJusticeAuthorities,each withdifferentboundaries.102The 22ADATsinScotlandhavetowork witheachofthesebodies.Todate, theyhavefounditdifficulttoensure thatdrugsandalcoholarepriorities ineachlocalarea,notleastbecause ofthevarietyofagenciestheymust workwith(Exhibit15).Newguidance needstohelptoclarifyaccountability andgovernancearrangementsand prioritysetting.

140.IntheGreaterGlasgowand Clydearea,localNHSboardand councilpartnershaveworkedto streamlinetheirapproachtothe planning,deliveryandperformance managementofdrugandalcohol services.Thishasfocusedonthe creationofasingleAddictions Partnershipprovidingasingleplanning

structureacrossallareasandincludes CPPsandCommunityHealthand CarePartnerships(CHCPs).

141.Thenewproposalsforlocal drugandalcoholpartnershipsinclude thedevelopmentofanational supportfunctionwithintheScottish Governmenttohelplocalpartnerships achieveimprovementsforpeople whomisusedrugsandalcohol.Itis envisagedthatsupportcoordinators willworkinlocalareastosupport amovetoanoutcomes-based approach,tocaptureandsharebest practiceandtofacilitatediscussions betweenpartners.Therewouldbeno scrutinyroleforsupport coordinatorsbuttheywillworkin areasthataskfortheirhelp.The ScottishGovernmenthopesthat theoutcomestoolkitfordrugand alcoholserviceswillalsohelplocal areasmovetoanoutcomes-based approach.

Recommendations

TheScottishGovernmentshould:

clarifyaccountabilityand governancearrangementsfor thedeliveryofdrugandalcohol servicesinScotlandandsetout clearlytheresponsibilitiesofall organisationsandpartnerships involvedinplanningordelivering theseservices

systematicallyidentifyand disseminategoodpractice –includingthedetailsof localdrugandalcohol-related interventionsandtreatments.

Publicsectorbodiesshould:

ensurethatdrugandalcohol partnersareclearabouttheir roleindeliveringeffectiveand joined-updrugandalcohol servicesinScotland

•

•

•

putsystemsinplaceto routinelyengagewithservice usersandtheirfamiliesto ensurethattheirviewsinform thedevelopmentofdrugand alcoholservicestoaddress localneeds.

•

Part4.Drugandalcoholpartnerships31

Exhibit 15 Public sector bodies and partnerships that relate to drug and alcohol services in a rural and urban area.

Community Health and Social Care Partnership (CHaSCP)

NHS Western

Isles

Western Isles

Greater Glasgow and Clyde

Alcohol & Drug Action

Team (ADAT)

Western Isles Community

Planning Partnership

(CPP)

Western Isles

Councils

Northern Community

Justice Authority

(CJA)

Northern Constabulary

East Glasgow

CHCP

North Glasgow

CHCP

South East

Glasgow CHCP

South West

Glasgow CHCP

West Glasgow

CHCP

East Dunbartonshire

CHP

East Dunbartonshire

CPP

West Dunbartonshire

CHP

East Renfrewshire

CHP

East Renfrewshire

CPP

Renfrewshire CHP

Renfrewshire CPP

Inverclyde CHP

NHS Greater Glasgow and Clyde

Alcohol and Drug Action Team (ADAT)

North area

South West area

South East area

Glasgow City Council

Glasgow Community Justice Authority

North Strathclyde Community Justice

Authority

Strathclyde Police

East Dunbartonshire

Council

West Dunbartonshire

Council

East Renfrewshire

Council

Renfrewshire Council

Inverclyde Council

Inverclyde CPP

West Dunbartonshire

CPP

East area

Glasgow Community Planning Partnership (CPP)

West area

Each area contains two local CPPs

Source: Audit Scotland, 2008

332 2

Appendix 1. Notes to the text

Notes to Summary

1 Drug misuse and the environment,TheAdvisoryCouncilfortheMisuse ofDrugs,1998.

2 Alcohol Statistics Scotland 2008,InformationServicesDivision(ISD) Scotland,2009.

3 PriortoSeptember2007,theScottishAdministrationwasgenerally referredtoastheScottishExecutive.Sincethechangeinadministration itisnowcalledtheScottishGovernment.Whendealingwiththeearlier periodthisdocumentreferstotheScottishExecutive.

4 The Road to Recovery: a new approach for tackling Scotland’s drug problem,ScottishGovernment,2008.

5 Changing Scotland’s Relationship with Alcohol: A framework for action, ScottishGovernment,2009.

6 Wehavedefinedlabelledexpenditureasdirectidentifiableexpenditure fordrugand/oralcoholspecificservicesorspecificdrugand/oralcohol- relatedcontributionsforuseinotherservices,forexample,adedicated addictionsworkerinahousingproject.

Notes to Part 1

7 MinisterialAdvisoryCouncilontheMisuseofDrugs,1982. 8 International statistical classification of diseases and related health

problems,10threvision,WorldHealthOrganisation,2007. 9 Estimating the National and Local Prevalence of Problem Drug Misuse

in Scotland,GordonHay,MariaGannon,NeilMcKeganey,Sharon HutchinsonandDavidGoldbery,2004.

10 Local and national estimates of the prevalence of opiate use and/or crack cocaine use (2004/05),GordonHay,MariaGannon,JaneMacDougall, TimMillar,CatherineEastwood,NeilMcKeganey,2006.

11 ScottishDrugMisuseDatabase,ISDScotland. 12 Psychostimulant Project Group Report,ScottishGovernment,2008. 13 2007 National Report to the EMCDDA,UKFocalPointonDrugs,

October2007. 14 HepatitisCisablood-borneinfection.Mostcasesoccurinpeoplewho

shareneedlescontaminatedwithtracesofbloodtoinjectillegaldrugs. Aftermanyyearsofinfectionsomepeopledevelopcirrhosis,andafew developlivercancer.

15 http://www.hps.scot.nhs.uk/bbvsti/Hepatitisc.aspx?subjectid=93 16 Drug Misuse Statistics Scotland 2008,ISDScotland,2008. 17 Themedianisthemiddlevalueofanorderedsetofdata. 18 Drug Misuse Statistics Scotland 2008,ISDScotland,2008. 19 Ibid. 20 2007 National Report to the EMCDDA,UKFocalPointonDrugs,

October2007. 21 Scottish Schools Adolescent Lifestyle and Substance Use Survey

(SALSUS),BMRBSocialResearch,2006. 22 Drug Misuse Statistics Scotland 2008,ISDScotland,2008. 23 Ibid. 24 Ibid. 25 2007 National Report to the EMCDDA,UKFocalPointonDrugs,

October2007. 26 Drug related deaths in Scotland in 2007,GeneralRegisterOfficefor

Scotland,2008. 27 Althoughnationallydrug-relateddeathsareincreasingthereislocalvariation. 28 Drug related deaths in Scotland in 2007,GeneralRegisterOfficefor

Scotland,2008. 29 Drug seizures by Scottish police forces,ScottishExecutive,2007. 30 Drug seizures by Scottish police forces 2005/06 and 2006/07,Scottish

Government,June2008. 31 Therearethreecategoriesofillegaldrugseachwithdifferentpenalties

forpossessingordealing.ClassA,BandCdrugsaredetailedunderthe MisuseofDrugsAct1971,withClassAconsideredthemostharmful.

32 Scottish Crime and Victimisation Survey,ScottishExecutive,2006. 33 ScottishDrugMisuseDatabase,ISDScotland. 34 The Road to Recovery: a new approach for tackling Scotland’s drug

problem,ScottishGovernment,2008. 35 Alcohol needs assessment research project (ANARP): the 2004

national alcohol needs assessment for England,DepartmentofHealth, November2005.

36 Psychiatric morbidity among adults living in private households 2000, OfficeofNationalStatistics,2002.

37 Alcohol: price, policy and public health,ScottishHealthActiononAlcohol Problems,2008.

38 Ibid. 39 NeilsenRetailTracking,2008. 40 ScottishHealthSurvey,ScottishExecutive,2003. 41 Scottish Schools Adolescent Lifestyle and Substance Use Survey

(SALSUS),BMRBSocialResearch,2006. 42 Harmful Drinking,NHSQualityImprovementScotland,2006. 43 Alcohol Statistics Scotland 2008,ISDScotland,2009. 44 Findingsfromrandomlyselectedtendayperiodin2005intenA&E

departmentsinHarmful drinking: The size of the problem,NHSQuality ImprovementScotland,2006.

45 Alcohol Statistics Scotland 2008,ISDScotland,2009. 46 Abriefinterventionisadiscussionaimedatmotivatingorsupporting

someonetotrytochangetheirbehaviour.Itisoftenadiscussion betweenaGPandtheirpatient.

47 http://www.gro-scotland.gov.uk/statistics/deaths 48 Ibid. 49 Health Statistics Quarterly,OfficeofNationalStatistics,spring2007. 50 Health in Scotland 2007, AnnualreporttotheChiefMedicalOfficer,2008. 51 Alcohol: price, policy and public health,ScottishHealthActiononAlcohol

Problems,2008. 52 Changing Scotland’s Relationship with Alcohol: a discussion paper on our

strategic approach,ScottishGovernment,2008. 53 UnpublisheddatasuppliedtotheScottishGovernmentbyStrathclyde

Police,2007. 54 Alcohol and intimate partner violence:keyfindingsfromtheresearch,

HomeOffice,2004. 55 Homicide in Scotland 2007-2008,ScottishGovernment,2007. 56 Deprivedcommunitiesareidentifiedbylookingatindicatorsthatshow

disadvantageinthepopulation,suchasincome,employment,education, housing,healthandgeographicalaccess.

57 Drug Misuse and the Environment,TheAdvisoryCouncilfortheMisuse ofDrugs,1998.

58 http://www.drugscope.org.uk/resources/faqs 59 Alcohol Statistics Scotland 2008,ISDScotland,2009. 60 Mind the Gaps: Meeting the needs of people with co-occurring

substance misuse and mental health problems,ScottishExecutive,2003. 61 Survey of the health and well-being of homeless people in Glasgow,A

Kershaw,NSingletonandHMeltzer,2000. 62 Prison Health in Scotland: A health care needs assessment,Scottish

PrisonService,2007. 63 Ibid. 64 Hidden Harm: Responding to the needs of children of problem drug

users,AdvisoryCouncilontheMisuseofDrugs,2003. 65 Ibid. 66 Have we got our priorities right?Aberlour,2007. 67 Changing Scotland’s Relationship with Alcohol: A discussion paper on

our strategic approach,ScottishGovernment,2008.

Appendix1.33

Notes to Part 2 68 DuetotheabsenceofScottishestimatesofthewidereconomicand

socialcostsofdrugmisusewehaveusedthemethodologyfromSocial and economic costs ofClass A drugs in England and Wales 2003/04, HomeOffice,2006,andappliedScottishprevalencefigures.

69 Costs of alcohol use and misuse in Scotland,ScottishGovernment, May2008.

70 TheAssociationofChiefPoliceOfficersinScotland(ACPOS)highlight thatthisislikelytobeasignificantunder-estimateasitdoesnotinclude workundertakenbyoperationaluniformedofficersorplainclothes divisionalunitswhowilldealwithdrugoffendersormakeroutine licensedpremisesvisitsaspartoftheirroutineactivities.

71 Campus/liaisonofficersandpoliceofficerswhoworkwithschools, collegesanduniversitiestoraiseawarenessofsubstancemisuseand preventproblematicbehaviour.

72 NationalNHSring-fencedallocationsfordrugsexistedfrom1998before dedicatedmoneyforalcoholwasintroducedin2004.

73 TheConventionofScottishLocalAuthorities(COSLA)isthe representativevoiceofScottishlocalgovernmentandalsoactsasthe employers’associationonbehalfofallScottishcouncils.

74 TheGAEformulaisbasedonfactorssuchasdemographics,deprivation andhealthindicators.Theactualfundingallocationismadethrougha blockrevenuesupportgrant.Councilshavethediscretiontosettheirlocal servicebudgetsatdifferentlevelstotheindicativelevelsintheGAE.

75 Scottish local government financial statistics,2006/07(webonly publication–http://www.scotland.gov.uk/publications)

76 Publisheddatacurrentlyonlyavailablefor2006/07. 77 2007 National Report to the EMCDDA,UKFocalPointonDrugs,2007. 78 FigureincludesNHS,councilandScottishPrisonServicelabelled

expenditure. 79 FigureincludesNHSandcouncilspend,thecostofpolicecampusand

liaisonofficersandScottishGovernmentlabelledexpenditure(eg,Know theScoreandChoicesforLife).

80 Figureincludespolice,ScottishPrisonServiceandsomeScottish Governmentlabelledexpenditure.

81 Thisispoliceenforcementandregulationworkanddoesnotincludethe preventionworkofcampusandliaisonofficers.

82 Costs of alcohol use and misuse in Scotland,ScottishGovernment,May 2008.

83 DuetodelaysinScottishGovernmentestimatesofthewidereconomic andsocialcostsofdrugmisusewehaveusedmethodologyfromSocial andeconomiccostsofClass A drugs in England and Wales 2003/04, HomeOffice,2006,andappliedScottishprevalencefigures.

84 Theremaining£53millionwasspentoncombineddrugandalcohol services.

Notes to Part 3

85 AuditScotlandfieldwork,2008. 86 National Quality Standards for Substance Misuse Services,Scottish

Executive,2006. 87 Psychostimulant Project Group Report,ScottishAdvisoryCommitteeon

DrugMisuse,2008. 88 The Road to Recovery: a new approach for tackling Scotland’s drug

problem,ScottishGovernment,2008. 89 Review of Residential Drug Detoxification and Rehabilitation Services in

Scotland,ScottishGovernment,2007. 90 Ibid. 91 Ibid. 92 Ibid. 93 Review of methadone in drug treatment: prescribing information and

practice,ScottishGovernment,2007.

94 Thisincludes£10.8milliononthecostsofthemethadoneand £14.1milliononpharmacydispensingcosts.

95 Unit Costs for Drug Misuse,NationalTreatmentAgency,2006. 96 Reducing harm and promoting recovery: a report on methadone

treatment for substance misuse in Scotland,ScottishAdvisory CommitteeonDrugMisuse,2007.

97 Costs and equalities and the Scottish criminal justice system 2005/06, ScottishGovernment,2008.

98 TheEffectiveInterventionsUnitoftheScottishExecutiveprovideda seriesofdocumentsonIntegratedCare.

99 Approaches to alcohol and drugs in Scotland,Scotland’sFuturesForum, 2008.

100 Essential Care,ScottishGovernment,2008. 101 Reducing drug use, reducing reoffending,UnitedKingdomDrugPolicy

Commission,2008.

Notes to Part 4 102 CommunityJusticeAuthorities(CJAs)wereestablishedbyThe

ManagementofOffenders,etc.(Scotland)Act2005.TheeightCJAsare: FifeandForthValley,Glasgow,Lanarkshire,LothianandBorders,North Strathclyde,Northern,SouthWestScotlandandTayside.

34

Appendix 2. Project advisory group membership

Member Organisation

AlisonDouglas HeadofAlcoholMisuseTeam,ScottishGovernment

JoeGriffin HeadofDrugsPolicyUnit,ScottishGovernment

NeilHunter JointGeneralManager,GlasgowAddictionServices (ApartnershipbetweenNHSGreaterGlasgowandClydeandGlasgowCityCouncil)

JackLaw ChiefExecutive,AlcoholFocusScotland

KenLawton ChairofScottishCouncil,RoyalCollegeofGeneralPractitioners

DaveLiddell ChiefExecutive,ScottishDrugsForum

WillieMacColl NationalDrugsCoordinator,ScottishCrimeandDrugEnforcementAgency

RonniePaul HeadofHousingandSocialWork,NorthLanarkshireCouncil

PeterRice ConsultantPsychiatrist,NHSTayside

MaggieWatts Chair,ScottishAssociationofAlcoholandDrugActionTeams

TomWood FormerChair,ScottishAssociationofAlcoholandDrugActionTeams

Note: Members of the project advisory group sat in an advisory capacity only. The content and conclusions of this report are the sole responsibility of Audit Scotland.

Appendix3.35

Appendix 3. Drug and alcohol policy and guidance summary

Drugs policy 1997 to 2008

Year Policy Main issues

1999 Tackling Drugs in Scotland: Action in Partnership

Scotland’snationaldrugsstrategyproducedinresponsetoUK’s WhitePaperTackling Drugs to Build a Better Britain.Itsetsout nationalobjectivestopreventuseandlimitharm.

2000 Drug Action Plan: Protecting our Future ScottishExecutiveactionplantotakeforwardthenationaldrugs strategy.

2002

2002

2003

2003

Know the Score Drugs Strategy

Integrated Care Pathways for Drug Misuse

Mind the Gaps

Getting our Priorities Right

Thelaunchofanationalcampaignprovidinginformationondrugs andmessagesaboutthedangersofdruguse.

Informationandsupportontheplanninganddeliveryofintegrated servicesfordrugmisusers.Detailstheprinciplesandelementsof effectivepractice.

Reportonmeetingtheneedsofpeoplewithco-occurringsubstance misuseandmentalhealthproblems.

Nationalguidancetoprotectchildrenfromthedamaging consequencesoftheirparents’substancemisuse.

2004 Review of Treatment and Rehabilitation Services

Summaryandactionplantoensureeffectiveprovisionofdrug treatmentandrehabilitationservices.

2006 Hidden Harm: Next Steps ScottishExecutiveactionplantoaddressissuesforchildrenand youngpeopleaffectedbyparentalsubstancemisuse.

2008 The Road to Recovery: A new approach to tackling Scotland’s drug problem

DrugsstrategyforScotlandstructuredaroundthemesofprevention, enforcement,childprotectionandrecovery.

36

Alcohol policy 2002 to 2009

Year Policy Mainissues

2002 Plan for Action on Alcohol Problems Nationalstrategyaimingtoreduceharmfulsocialandindividual consequencesofbingedrinkingandharmfuldrinking.

2003 Mind the Gaps Reportonmeetingtheneedsofpeoplewithco-occurringsubstance misuseandmentalhealthproblems.

2003 Getting our Priorities Right Nationalguidancetoprotectchildrenfromthedamaging consequencesoftheirparents’substancemisuse.

2004 Anti-social Behaviour Act Tacklingallformsofantisocialbehaviourincludingstreetdrinking, noisypubsandclubsanddrunkenbehaviour.

2005 Licensing Act AimstoaddressScotland’srecordonalcoholby:reformingoutdated licensinglaws;tacklingunderagedrinking;crackingdownonbinge drinking;andinvolvinglocalcommunities.

2006 Hidden Harm: Next Steps ScottishExecutiveactionplantoaddressissuesforchildrenand youngpeopleaffectedbyparentalsubstancemisuse.

2007 Plan for Action on Alcohol Problems Update

Buildsonprogressof2002plan.Setsoutacomprehensive programmeofactionforthenextthreeyearstochangedrinking culturesandreducealcohol-relatedharmthroughgovernment action,partnershipworkingandencouragingindividualresponsibility.

2007 Partnership Agreement: Scottish Executive and the Alcohol Industry

TheScottishExecutiveandthealcoholindustryagreedanumberof actionsinafirststepofalong-termcollaborativeapproachtoalcohol consumptioninScotland.

2008 Changing Scotland’s Relationship with Alcohol: A discussion paper on our strategic approach

Illustratesthescaleofalcohol-relatedharmandoutlinestheScottish Government’sstrategicapproachtotacklingalcoholmisuse. Proposes,forconsultation,apackageofmeasuresdesignedto reducealcoholconsumptionandrelatedharm.

2009 Changing Scotland’s Relationship with Alcohol: A framework for action

SetsouttheScottishGovernment’sapproachtotacklingalcohol misusearoundfourmainareas:reducedalcoholconsumption; supportingfamiliesandcommunities;positivepublicattitudes;and improvedtreatmentandsupport.

Appendix4.37

Appendix 4. Self-assessment checklist for partners

Thechecklistonthenextfewpagessetsoutsomeofthehigh-levelpractical issuesarounddrugandalcoholservicesraisedinthisreport.NHSboards, councils,policeforces,prisonsandthevoluntaryandprivatesectorsshoulduse thechecklisttoassessthemselvesagainsteachstatementasappropriateand assessthestrengthofallrelevantpartnershiparrangements.

Thischecklistisbasedonstatementsfromavarietyofsourcesincluding previousAuditScotlandreports,AuditCommissionreportsandNationalAudit Officereports.

38 A

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on

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ac

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ne

eded

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bu

t ac

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in

hand

Yes

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ell

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for

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40 A

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nt p

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on

Yes

in

Yes

in

No

N

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but

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d ?

Drug and alcohol services in Scotland If you require this publication in an alternative format and/or language, please contact us to discuss your needs.

You can also download this document at: www.audit scotland.gov.uk

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ISBN 978 1 906752 36 1 AGS/2009/3

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