Partnership Working

Neil Hunter has spent thirteen years working in addictions services, initially running a young person’s alcohol and drugs service in north Glasgow before moving on to spend seven years working for social work services in the management and coordination of addiction services in Glasgow City Council. He’s spent the last and the last two and half years working with what is known as the Glasgow Addictions Partnership, first of all as Community Services Manager when the partnership was formed in 2003, and, more recently, as Joint General Manager.

Care Appointments caught up with Neil and asked him, first of all, what the motivation and impetus had been behind the creation of the Addictions Partnership?

‘By the turn of 2000 a lot of work had been done separately by the NHS and the Council looking at reviewing all of our services and the whole improvement/best value agenda for addictions services. Glasgow is fairly unique in that the local authority and the NHS provide significant amounts of their frontline core services around alcohol and drugs – most of the other areas in Scotland have a much more mixed economy of frontline services but such is the scale of Glasgow’s problem with alcohol and drugs that the local authority and the NHS have always felt the need to look at delivery of core services being aligned to their own statutory responsibilities.’

In 2000 the local authority and the NHS in Glasgow came to the conclusion that trying to deal with the city’s alcohol and drugs problems across two different organisational entities was not delivering, as Neil Hunter explains:

‘What we had at that time was a social work service which had addictions services within it. We spent about two years reviewing these comprehensively, aligning them into arrangements with our local area services in social work, and through 2001 – 2002 we had a massive improvement agenda on the social work side. At the same time we were reviewing what we were doing in Glasgow around the methodone programme – that was a joint review between the health board and the council and we concluded what we needed to do was to join up our services far more comprehensively than they had been up to that point. A that time in Glasgow we had a situation were there were three specific organisations providing addictions services: there was one within the local authority and there were two directorates within the NHS, one of which was for drugs only and the other was for alcohol and drugs but didn’t prescribe for opiate users. At the time we had an estimated population of 15,500 people with serious drugs problems, of whom, city-wide, we were in contact with somewhere around one in four or one in three. What we were doing at that time was not sufficiently joined-up or of a scale and quality that the city required to make an impact on its drugs problem.

‘As a result of all that activity we took a decision to develop a piece of work that would see the NHS and council services come together as one partnership. That was formed from our experience in other areas, especially learning disabilities where we had a partnership between the NHS and local authority for some time and had shown considerable scope for development.

‘The formation of the Addictions Partnership in 2003 gave us much more focus on improving the scale and nature of our services. We co-located our addictions services under the line-management of a service manager and asked NHS staff, who were working in two separate directorates, to join our local authority teams in nine areas. These became Community Addiction Teams which are joint teams of NHS and social work staff.

‘Within each Addiction Team you have nursing staff, social care staff, psychology staff, medical staff and increasingly we are deploying occupational therapists across the teams. The unique thing about the Teams is that they are co-located together under single management – each of our Community Addiction Managers has joint authority over both organisations and has overall responsibility for the delivery and service governance across the NHS and council social work.

‘Bringing the different functions together has meant that the whole service has become much more localised – our nine Community Addiction Teams operate out of a range of locality premises, for example in the East End of Glasgow the Community Addiction Team is based in the heart of the area at Parkhead Cross. The office there is part of a bigger Community Health and Social Care Partnership and the front end of the operation offers a whole range of group work, individual counselling, individual treatment facilities. Critically, what we did with all the Community Addiction Teams was to install facilities that enabled all types of professionals could practice there, including clinical staff. So all nine teams can provide individuals with immediate access to a whole range of professionals who might have an input in meeting their overall needs, or indeed to one particular professional who will then act as their key worker throughout the course of their journey. This is a critical part of our work – what we saw in the past was services that were fairly remote from the host communities that would offer their services on very much an ‘out-patient’ basis, which meant that local stakeholders like GPs and social work staff couldn’t influence the priorities of that particular organisation or directorate.’

So, is this ‘partnership working’ a unique set-up in terms of addictions services in Scotland?

‘I wouldn’t say it’s unique, but we took an early decision in Glasgow that the scale of our problems was such that it required an integrated approach – Glasgow has 23% of Scotland’s serious problem drug using population and around 24% of the injecting population. What we’ve done has been fairly radical in that we’ve moved people out of their previous organisational arrangements into a new one and we’ve supported that change by creating a partnership ethos, by developing people’s working arrangements around single shared assessment, around joint care planning, single management. I’m not aware of any one doing it on this scale or to this depth in Scotland.’ {mospagebreak}

The Community Addiction Teams provide immediate access to a wide range of services and professionals as Hunter explains.

‘All of the Community Addiction Teams have specialist sub-teams for young people, they have specialist posts in some teams for working with families and at least two of our teams have specialist BME services. The key feature of the Teams has been the ability to front-load in our operation the right person to meet an individual’s needs at the right time – for example, quite often people will walk in to our services with abscesses or perhaps injection site wounds and infections and we can deploy some of our RGN nurses to deal with that situation and to help bring the individual into more regular contact with our service, which will be very much focused on their treatment and rehabilitative needs.

‘We have a good mix of RMN and RGN nursing staff to reflect the fact that people present at out services with various concerns and problems ranging from the purely physical to pretty complex issues around their mental health, problems with families, problems with the community, problems with the criminal justice system – we need to be able to respond to that with the right person on a daily basis.’

The Addictions Partnership is funded by Greater Glasgow and Clyde NHS and Glasgow City Council and has an operating budget of around £37 million. One of the key features in Glasgow has been the commitment from the NHS board and the council to fund its own services so the Addictions Partnership has been able to go beyond relying on Scottish Executive allocations. Neil Hunter gave us an insight the kinds of service provision that their funding pays for:

‘Such is the priority of the addiction agenda in Glasgow that the NHS and the city council have invested in it from their own core resources. Of course that’s been difficult for them as they obviously face a whole range of stark choices in relation to health improvement planning and budget allocation. On top of that core platform we’ve been able to use funding from the Scottish Executive to specifically target those areas of national priority such as access to treatment waiting times, young people and children. More recently we’ve brought into all our teams a focus on community justice, particularly around arrest referral and throughcare addictions services – bringing offenders into treatment services of the first time, which is one of our big areas of development this year. 

‘The other proportion of our non-Community Addiction Team budget goes in purchasing and providing secondary services – from this partnership we have one 16-bed inpatient unit based at Stobhill Hospital called Eriskay House. We have two partial hospitalisation services which focus on daily, intensive clinical support for people whose needs cannot safely be met in the community but who don’t require inpatient admission. We also commission seven community rehabilitation services from three or four different voluntary sector providers, so in every area of the city there is a core, structured day care service focusing on rehabilitation for people with alcohol and drug problems.

‘We’ve just this year completed the commissioning of a brand new service, modelled for us, on working with people beyond core alcohol treatment, focusing on independent living, relapse prevention and getting people out of ‘service land’ and into something which is much more focused on promoting independence. At any one time we commission 133 residential beds and are the biggest sole commissioner of residential rehabilitation in Scotland, as you would expect.

‘This year has seen a massive expansion in our Alcohol Related Brain Damage (ARBD) services – Glasgow has a huge concentration of ARBD and to date we haven’t done anywhere near as much as we need to do around assessment, diagnosis, rehabilitation, so this year sees, for the first time, the formation of our city-wide assessment and rehabilitation team. We have just completed a commissioning programme for 40 care beds and 56 accommodation beds form people with ARBD which has been a massive expansion. We also commission two specialist young people’s accommodation projects, one is focused on young people with very severe needs which is delivered for us by the Mungo Foundation and the other which is delivered by Quarriers.’ {mospagebreak}

With major changes in organisational structures and systems can come uncertainty and a degree of anxiety among staff members. Hunter points out that while there were concerns amongst partnership staff early on, significant progress has been made.

‘We did a 12-month evaluation process of our first two pilot teams and this resulted in a fairly weighty report, the author of which was employed by the NHS board and consequently was at arms-length from the service. The report showed that the staff within the service said that the work had been the most challenging they’d ever been involved in but for significant periods of the pilot they were uncertain about their role and responsibilities because these were fluctuating. They were also quite often unclear as to where their governance, line management and accountability was, as the partnership started to form.

‘However, when staff were asked if they would prefer to return to their previous organisational arrangements they almost universally said no because they could see the tangible benefits for service users and they could see that the previous organisational arrangements were unsustainable and weren’t fully meeting the needs of the service user.

‘Meanwhile, stakeholders said that it made considerable sense to them that there was a rational point of access for addictions services: GPs for instance appreciated having local access to a whole range of services that would fit a patient’s needs.

‘It is a hugely challenging change – this is maybe why in other parts of Scotland similar services are till in the planning stages. However, two and half years later, I think we could say with a degree of pride that in a lot of the areas that we found most challenging we have now made progress. In terms of tangible benefits and results since the formation of the partnership, we can look at the statistic from 2003 where 1 in 3 or 1 in 4 of Glasgow’s drug using population were in touch with services, that has, in 2006, increased to 1 in 2. Obviously we still have a lot of work to, in that 50% of people are still not in touch with treatment services, but three years ago that figure was 75%. Just by bringing services together we have increased our capacity to receive people, to asses their needs and to engage them in treatment and care.’

Professionally there are bound to be inherent benefits for staff working within this partnership type environment as they are exposed to skillsets that vary greatly from their own. Hunter develops this theme:

‘One of the things that inevitably happens when you are working in an integrated service is that you learn much more about the role of other professionals about which, perhaps, you had previously not been too clear. We’ve done a lot of organisational development work within our teams on understanding each others’ roles and understanding how they can benefit service users. What we are absolutely clear about is that integrated services bring together people with specialist skills and those specialist skills come together in the blend and the mix of the overall team and make that team stronger, more effective and more efficient.

‘At the beginning of our project towards integration, people were concerned about accountability and governance but what we’ve found is that by bringing people together one can see a great deal of evidence-based practice around safe and effective service delivery. We now have one joint care governance committee which looks at nursing, social care, medical governance as well as governance across the allied health professions. We’ve started bringing people into a common CPD framework, while recognising that social care, nursing etc each have their own unique CPD requirements. However, having a joint learning plan allows us as an organisation to provide high quality training and learning opportunities for people across the board, linked into their own CPD.’

Hunter has no doubts as to the benefits of the partnership set-up and the very positive outcomes that it can help deliver.

‘At the root of the system we have people who are in secondary specialist services who will all have a named care manager from the Community Addiction Team working across the whole system – if people fall out of service or relapse there will be one person whose job it is to track them down and bring them back into contact with the service. 

‘This partnership has allowed us to focus on outcomes around social renewal and employment and training – as an NHS system or a council system we would deal with these things in isolation but bringing it together allows the whole treatment system to focus around service users being able to become independent and to participate again in the social and economic life of the city.’