Accountability and governance
Rights, Respect and Recovery was supported by the publication in 2019 of a new partnership delivery framework for ADPs (44).
The framework sets out the expectations of how an ADP should operate. ADP responsibilities include:
- devising strategic plans;
- promoting quality improvement;
- involving people with lived, living and family experience in activities;
- providing clear governance and oversight; and
- reaching out to the third sector.
Audit Scotland (45) identified six areas in which progress will support successful implementation of Rights, Respect and Recovery. These remain as relevant today as they were when written in 2019 and are:
- effective performance monitoring;
- clear actions and timescales;
- clear costings;
- linking of spending and outcomes;
- public performance reporting; and
- evaluating harm-reduction programmes.
We believe the drug and alcohol sector should have comprehensive standards and guidance and be inspected against them. This will help to ensure that continuous improvement reduces harm and prevents deaths.
The sector should have clearly defined lines of accountability that ensure services are provided to meet the needs of individuals. Strategic plans should be in place to deliver on evidence-based objectives. Partners should work effectively together to deliver the best service possible.
We have continued to receive feedback about the confused landscape in the alcohol and drugs sector. Approaches to delivery are inconsistent; monitoring, performance management and transparency are lacking; and accountability lines are ineffective.
The new framework for ADPs noted changes to the delivery landscape, including the introduction of Community Justice Partnerships and Integration Authorities. Many in services in the sector and in ADPs see the landscape as being cluttered and confused.
If the people who operate within the system find it challenging to navigate, consider how much more difficult it must be for those who access these services.
The framework established that all ADPs should:
- develop a publicly available local delivery framework setting out the membership and accountable officers for all partner organisations;
- produce locally agreed strategic plans underpinned by detailed needs assessments;
- ensure effective oversight and accountability arrangements are in place;
- have information-sharing agreements between partners and services; and
- establish local monitoring and evaluation against agreed indicators.
What needs to change
Our view is that the key components of ADP governance outlined in the framework are being implemented inconsistently.
The main problem areas are in delivery and local areas’ accountability to the Scottish Government to facilitate good governance. This may reflect issues with leadership and accountability at local level, the level of priority historically given to this agenda or confused messaging nationally. Whatever the cause, change is needed now to make a difference.
The Scottish Government has committed to introducing a National Care Service (NCS). Following consultation on its proposals, it has signalled an intention to look at incorporating alcohol and drug services into the NCS.
This change would need to be informed by the most up-to-date information on how an effective governance structure could operate. It would also need to be developed in collaboration with ADPs, Health and Social Care Partnerships, Integration Authorities, services, and people with lived and living experience and their families.
Action 99. The Scottish Government should undertake a transparent and externally validated benchmarking exercise to ensure that every ADP is implementing the partnership delivery framework.
Action 100. The Scottish Government should publish a statement setting out how governance of alcohol and drug services will be improved by the introduction of the NCS. The statement should clearly articulate how the service will establish the most effective governance structure for managing drug-related deaths and harms.
Following the release of the 2019 statistics on drug-related deaths, the First Minister recognised that the Scottish Government had “taken its eye off the ball” in this area.
She appointed a Minister for Drugs Policy to respond quickly and decisively to reduce drug-related deaths and harms, launching a National Mission to improve and save lives.
It is right that ultimate responsibility should sit with the First Minister and Minister for Drugs Policy, with scrutiny provided by the Scottish Parliament. The ministerial appointment is a positive shift. It has been received well by the sector and sends a powerful message that the issue is now being prioritised by the Government.
It is not possible, however, for this role to act in isolation. Layers of accountability are needed at local level to deliver meaningful change.
What needs to change
Appropriate local accountability is critical to delivering the paradigm shift that is needed to save lives.
Integration Authorities are responsible for the delivery of drug and alcohol services, which they provide through ADPs. ADPs must include people at a sufficiently senior level to make decisions for their organisation and facilitate quick action. Ultimate responsibility for ADPs’ responses to drug-related deaths and harms, however, should sit with the chief officer.
Each partner in an ADP must take responsibility for their own part in the local response, but a single central accountability line is needed. This will provide oversight and drive for change in local areas and create direct links to the national accountability structure.
The Scottish Government has mandated the establishment of Chief Officers’ Groups through other public protection initiatives. Chief Officers’ Groups oversee multi-agency public protection arrangements (MAPPA) and adult protection for vulnerable individuals. They should also be responsible for action on drug-related deaths in their areas.
The Dundee Drugs Commission highlighted that it was “necessary to level the playing field, ensuring that all partners including statutory and third sector partners are held equally accountable“. This is needed to “enhance patient safety and quality of provision”.
We support this recommendation. It is critical that all partners are treated equally – accepting accountability is no exception.
ADPs are required to have a clear strategic plan. The plans should incorporate measurable outcomes and priority actions that are aligned with national outcomes and priorities.
Currently, however, there is no requirement for the plans to be signed off or performance managed at any defined level. Nor are they scrutinised as part of performance management at national level.
The Chief Officers’ Group must have oversight of the strategic plans and proposed spending within ADPs. This is necessary to ensure that spending aligns to local and national priorities but also, more importantly, that it meets the needs of the local population.
Action 101. Chief officers ultimately should be accountable for the response to drug-related deaths in their area, coordinated through the Chief Officers’ Group. Chief officers should take responsibility for delivering strategic outcomes against national targets and for improving the system to prevent deaths wherever possible.
As part of the push for greater accountability and broader culture change in the way people who use drugs are seen, there should be a greater shift towards reviewing every death for learning and for change.
Currently, all ADPs should have a drug-death review group. The effectiveness of some of the reviews conducted by these groups has been questioned, however.
Some ADPs review only the deaths of those who were already engaged in services. Learning from deaths of individuals who were not engaged in services must also be captured to help determine how services can better support individuals into treatment.
We are clear that a formal review process should be undertaken for every suspected drug-related death. These should start from the principle that every drug-related death is preventable.
Reviews should capture the lessons learned and facilitate meaningful improvement. Outcomes should be reported to the Chief Officers’ Group, with recommendations for change.
The Chief Officers’ Group may require more in-depth reviews (such as significant adverse event reviews or critical incident reviews), through which more significant failings can be identified. People with lived and living experience and families must be included in the review process.
There are many examples of reviews in other areas from which a standardised approach to reviewing drug-related deaths could be developed. These include reviews of child deaths, adult support and protection, and suicides.
Action 102. The Scottish Government should develop a national framework for the operation of drug-death review groups across Scotland. It should set the expectation that every death is reviewed to learn lessons, with these being reported directly to the Chief Officers’ Group to facilitate change and prevent further deaths.
Standards and inspection
As we have emphasised throughout this report, our expectation is that the rhetoric of treating drug dependency as a health condition must be transformed into action. Treatment for dependency must have parity with the treatment of other health conditions if this is to be achieved.
An issue raised repeatedly with us is that unlike other health and social care settings, alcohol and drug treatment is not appropriately regulated with standards, guidance and pathways.
A national set of guidelines and standards is needed to ensure consistency of practice, and the safety of people who use drugs and workers supporting them. As we outlined in Chapter 3, we are calling for the MAT standards to be expanded and for standards and guidance to be developed for the whole system of treatment and recovery.
It is vital that these standards are monitored and services are held to account for delivering against them.
What needs to change
Currently, the sector has no inspections or systems of validated self-evaluation to ensure the quality and safety of treatment and services.
Inspection is instrumental to delivering an effective system of care. Inspectors must be given appropriate powers to ensure that lessons learned are adopted. Where they are not taken into account, measures should be taken to ensure patient safety and the effective delivery of services.
An avenue should be developed as part of this inspection process to allow people with lived and living experience and their families to raise concerns and make complaints. They should be able to do this anonymously to ensure that no individual fears consequences for their loved one’s treatment as a result of a complaint.
Action 103. The Scottish Government should ensure that all services in the alcohol and drugs sector are inspected by either Healthcare Improvement Scotland or the Care Inspectorate. Avenues for individuals to anonymously raise concerns or complaints for investigation should be provided.
The current practice is for ADPs and services in the drugs sector to be monitored and evaluated at national level through self-assessment. These self-assessments have been criticised for being incomplete, inconsistent and inaccurate.
Self-assessments need to be externally validated. The Scottish Government should hold chief officers to account where these are found to be of an inadequate quality, as would be expected for any other monitoring information.
Action 104. The Scottish Government should ensure that all self-assessments used are externally validated and chief officers are held to account for their quality.
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