guidance on good practice for the provision of services ...€¦ · this guidance addresses and...

CMK-22-04-045 (082)

D1430809

Guidance on Good Practice for the provision of services for Children and, Younger People who Use or Misuse

Substances in Wales

CMK-22-04-045 (082)

D1430809

Contents

PagePurposeofdocument 3

SectionA-examplesofgoodpractice1 Overview 5 1.1 Practicepoint1-deliveringeffectiveuniversaleducation 5 1.2 Practicepoint2-prescribing 6 1.3 Practicepoint3-needleexchange 7 1.4 Practicepoint4-conductingassessments 8 1.5 Practicepoint5-transitionplanning 9

SectionB-context2 Overview 11 2.1 ChildrenAct2004 13 2.2 Safeguardingchildren(section28) 13 2.3 Planning 14 2.4 TheNationalServiceFrameworkforChildrenYoungPeople andMaternityServicesinWales(NSF) 14 2.5 Childandadolescentmentalhealthservices 14 2.6 MentalCapacityAct 15 2.7 Serviceuserinvolvement 15 2.8 Childreninneedandtheirfamilies 15 2.9 Referralsandsharingofinformation 15 2.10 Assessmentframework 17 2.11 LookedAfterChildren 17 2.12 Suicide,attemptedsuicideandsubstancemisuse 17 2.13 Keycomponents 19

3 Scopeofdocument 20 3.1 Theclientgroup 20 3.2 Substancecoveredbytheframework 20

4 Patternsofsubstanceuseandmisuse 21

4.1 Pathways 21

4.2 Atriskgroups 21

5 Thefour-tierstrategicframework 23

SectionC-programmesandinterventions6 Universaleducationservices 25 6.1 Context 25 6.2 Accessandobjectives 25 6.3 Contentcharacteristics 25 6.4 Deliveryandstyle 26 6.5 Agencies,personnelandvenues 26

7 Selectiveortargetedprogrammes 28 7.1 Definition 28 7.2 Servicesthatprovidemoredetailedinformationandadvice ondrugsandservices 28 7.3 Preventionservices 28

8 Indicatedprogrammes(includingtreatment) 30 8.1 Assessment 30 8.1.1Definition 30 8.2 Definition 30 8.3 Specialistinterventions 31 8.3.1Pre-treatmentservices 31 8.3.2Communitybasedspecialistinterventions andtreatmentservices 32 8.3.3Inpatientservices 32 8.3.4Residentialservices 33 8.4 Organisationofcomprehensivespecialisedinterventionservices 34 8.5 Keyissuesforservicedelivery 34 8.5.1Leadagencyandleadprofessional 34 8.5.2Integratingservices 35 8.5.3Substancemisuseliaisonfunction(linkworkers) 35 8.5.4Involvingparentsandcarers 36 8.5.5Handlingtransitions 36 8.5.6Actualandvirtualteams 37 8.5.7Childprotection 37

SectionD-planning

9 Purposeofsection 39

10 Background 40

11 Thesuggestedplanningmodel 41 11.1 PlanningTier1 42 11.2 PlanningTiers2and3 42 11.3 PlanningTier4 42

12 Goodpracticeinplanning 43 12.1 Strategy 43 12.2 Developingtheknowledge-base 43 12.3 Responsivenesstothelocalpopulation 44 12.4 Partnershipswithprovidersofservices 45 12.5 Effectivecollaboration 45 12.6 Effectivenessthroughcontractingorservicelevelagreements 46 12.7 Organisationalfitness/commissionerselfassessment 46 12.8 Performancemanagement 47 12.9 Animprovementcycleforservicesforyoungpeoplewhouse ormisusesubstances 47 12.10 Standardsandstandardsetting 47

Purposeofdocument

Substancemisuseinchildrenandyoungpeoplepresentsamajorpublichealthchallenge.TheUKhassomeofthehighestratesofyoungpeopleaged15-16usingormisusingsubstancesinEurope.Currentlytherearerisingtrendsintheuseofalcohol(particularlybyyoungwomen)andbingedrinkinghasincreaseddramatically.

Thisdocumentaimstoassistplannersandserviceprovidersinestablishingeffectiveservicesforyoungpeopleinrelationtosubstancemisuse.Althoughevidencefortheeffectivenessofinterventionsinthisareaislimitedthereareemergingthemesofgoodpracticethatcanhaveapositiveimpact.Thisguidanceaddressesandhighlightstheseandpresentsaframeworkfororganisationsandagenciesthathaveresponsibilitiesandaninterestinthisarea.

Thedocumentisinfoursections:

SectionA-SummariesofGoodPractice

SectionB-Context

SectionC-Programmesandinterventions

SectionD-Planning

ThedocumenthastobereadinthecontextofpreviousgoodpracticeframeworksforsubstanceissuedbytheWelshAssemblyGovernmentparticularlythoseforneedleexchange,inpatientcareandresidentialrehabilitation.

SimilarlytheframeworkneedstobeconsideredinthecontextofstrategiesaimedatthehealthandwelfareofchildreninWalesandrelevantlegislationsomeofwhicharehighlightedbelow.ThisincludestheMentalCapacityAct2005.

TheFrameworkhasbeenproducedbyasubgroupoftheWelshAssemblySubstanceMisuseProjectBoardandisbasedonworkcommissionedfromtheWelshInstituteofHealthandSocialCarein2006.

SectionA-Summariesofgoodpractice

1 Overview

SectionAhighlightsspecificexamplesofgoodpracticeforprovidersinthefiveareasof:

Deliveringuniversaleducation•

Prescribing•

NeedleExchange•

ConductingAssessments•

TransitionPlanning.•

Thesearekeyareasforserviceprovidersandtheinformationbelowsummariseswhatiscurrentlyconsideredtobegoodpractice.

1.1 Practicepoint1-DeliveringEffectiveuniversaleducationTheprovisionofhighqualityuniversaleducationisakeyrequisiteofanysystematicapproachtothedeliveryofastrategyforsubstancemisuse.

Deliveringeffectiveuniversaleducationprogrammesrequires:

implementationofastandardnationally-agreedapproachthatretains•theflexibilitytorespondtodiverselocalconditionsandtochangingpatternsofuseandmisuse;

long-term,intensiveprogrammesdevelopedthatofferintegrationbetween•primaryandsecondaryschools;

programmesthataredevelopmentallyappropriate,sequentialand•contextuallyappropriate;

teachingtakesplacewithinastandardisedmodelofPSEasopposedto•asituationinwhichPSEissubjecttowidevariationindeliveryandoftenutilisesnon-specialisedteachingstaff;

programmesemployawhole-schoolapproachthatincorporatesmessages•onsmoking,alcoholanddrugeducation;

healthpromotionisdeliveredinthecontextoftherebeingactiveschool•policiesonsubstances;

localdeliveryislinkedwithstrategiessuchasthenationalhealthyschools•programme;and

informationisavailableaboutservicestowhichtheymightturnformore•detailedinformationandadviceandwithwhichtheycandiscussanyconcernsthattheymighthave.

1.2 Practicepoint2-PrescribingWewouldadviseclinicianstorefertotheappropriatesectionsintheDrugMisuseanddependenceUKguidelines2007onclinicalmanagementforspecificpointsofpractice.

Pharmacotherapiesareavailabletotreatavarietyofsubstancemisuse-relatedproblemsincluding:

emergencies(e.g.afteroverdoses,fits,dehydration,hypothermia);•

detoxificationandwithdrawalsyndromes(e.g.buprenorphine,•benzodiazepines,chlormethiazole,lofexidine,methadone,);

substitution(e.g.,buprenorphine,bupropion,methadone,•nicotinereplacement);

relapseprevention(e.g.acamprosate,naltrexone,pseudoephedrine;•

comorbidpsychiatricdisorders(e.g.anxiety,depression,ADHD);•

comorbidphysicaldisorders(e.g.HIV,HepatitisC,diabetes);and•

vitaminreplacement.•

Pharmacologicaltreatmentsareusuallyreservedforpatientswhoaredependent.Theyareavailabletotreatwithdrawalsyndromes,tomaintainabstinence,topreventcomplications,andtotreatpsychologicalandphysicaldisorders.Onlybuprenorphineislicensedforusebyunder18yearolds,butnicotinereplacementtherapycanbeprescribedforunder18yearoldsifamedicalpractitionerdeemsitappropriate.Thishasveryimportantimplicationsforpractitionerswhoaretreatingadolescentswithsubstancemisuseproblemsbecausemostoftheirpatientswhorequireaprescribingservicedosobecausetheyaredependentandthisrequiresspecialistintervention.

Thereisgeneralconsensusthattreatingadolescentsbyprescribingshouldbeinitiatedbyaspecialistserviceandtheirtreatmentshouldusuallybesupervisedandmonitoredbythatservice.Whileitisimperativethatpharmacologicaltreatmentisadministeredsafely,itisequallyimportanttoseeitasonepartofaphasedtreatmentandmanagementprocess.

Somespecialistservicesprescribeforstabilisation,reductionanddetoxificationandtrytoavoidmaintenancetreatments.Titrationanddetoxificationmayalsobeprovidedforover16yearoldsbysubstancemisuseservicesthatareprimarilyintendedforadults.Thereshouldbeeasyaccesstobedsforthemostcomplexcases;ifnot,crisesmaydevelop.

Pharmacotherapyforunder16yearoldsrequiresconsiderableskillandthepractitionerswhosupervisesitmustbewelltrainedinaddictionpsychiatry.Plannersandserviceprovidersshouldalsorecognisethatthesearehighriskgroupsofyoungpeoplewhorequireverycarefulmonitoring.

Supervisedconsumption

Supervisedconsumptionofsubstancesthatareprescribedforyoungpeopleisessential.Pharmacistsshouldinformthespecialistserviceinvolvedifayoungpersondoesnotpickuptheirmedicationevenonce.Thereshouldbeaprotocol

fortheclinicifclientsdonotpickuptheirscriptsdaily(i.e.forhowmanydayscanthey‘gowithout’)beforethescriptisstopped.TheDrugMisuseandDependencyUKGuidelinessuggestnomorethan3daysbutchildrenandyoungpeoplemayhavelowertolerancesoservicesshouldtakethisintoaccountandmakeappropriateclinicaldecisions.

1.3 Practicepoint3-NeedleExchangeWhenworkingwithinaharmminimisationframework,easyaccesstoneedlesandsyringesmightberegardedasgoodpracticeinservicesforadults.Thesameisnotnecessarilysoforyoungpeopleowingtothedifferentstatutoryandlegalrequirementsforminors.Therefore:

Full assessment and informed consent are essential• and,whereyoungpeopleunder16areinvolved,needleexchangeshouldonlybeprovidedinthecontextofacareandtreatmentplanthatisregularlyreviewed.

Injectingillicitsubstancesisdangerousandeveryeffortshouldbemade•toencourageclientstochangetheirrouteofadministrationtoasaferone,toengagewithservicesaseffectivelyaspossibleandtoreduceorstoptakingdrugs.

Theprinciplesofharmreductionshouldnotbelostwhendealingwith•youngerdrugusers.However,additionalharmfulfactorsandtheirdifferinglegalstatusmustalsobecarefullyconsidered.

Themajorityofyoungerpeoplewhouse‘harder’drugsareagedover16.However,thereisarequirementtoprovidealimitedvolumeofneedleorsyringeexchangeservicesforunder16s.Insuchcases,servicesmustensurethatstaffarecompetenttodealwiththefollowingmatters:

recognisethatthechild’swelfareisparamountineveryactivity;•

gainvalidconsentfortheintervention;•

involveparentsandcarers;•

ensuretheneedleorsyringesupplyispartofawidercareplan;•

assesseachyoungperson’sawarenessoftherisksofinjectingandtheir•abilitytounderstandtheserisks;

ensureeachyoungperson,familyandcarerisawareoftheboundaries•imposedbyconfidentialityandtheservice’sdutyinrelationtochildprotection;and

employchildprotectionprocedurestoensurethatchildrenandyoung•peoplearesafeguardedwhennecessary.

Inaddition,servicesshouldensurethatneedleexchangeprotocolsareacceptedbythelocalareachildprotectioncommittee(ACPC)andlocalchildrensafeguardingboards,whenestablished.

Specialconsiderations:

needleexchangeforyoungpeoplemustbedeliveredaspartofaplanned•packageoftreatment;

independent,anonymousprovisionisnotgoodpracticeduetothelegal•statusofyoungpeople;

servicesmustensurethattheyareworkingwithinthefactandspiritof•theChildrenAct1989;thisincludespromotingchildprotection,takinganholisticapproachtoworkingwithchildrenandyoungpeople,andinvolvingparents/carers,ifpossible;

assessmentforneedleexchangemustbecomprehensiveandholisticwith•thebestinterestsofeachyoungpersonbeingparamount;also,children’sdevelopmentalneeds,parentalinvolvementandotherenvironmentalfactorsneedtobetakenintoaccount;

allneedleexchangeshouldbeprovidedwithinaharmminimisation•approach(i.e.advisingonalternativeroutesofdruguse,encouragingreductioninfrequencyofdruguse,providinginformationonpersonalsafety[forexamplenotinjectingalone,unsuitabilityofcertainsubstancesforinjection]);and

thestaffmemberhastodemonstratethateachyoungpersonhassufficient•knowledgeandunderstandingtoinjectdrugsassafelyaspossibleanditalsoneedstobeestablishedthatprovidingcleaninjectingequipmentlessensthepotentialriskstotheyoungperson.

1.4 Practicepoint4-ConductingAssessmentsAssessmentiscrucialinallsubstancemisusescenariosbuttheprocesshasaparticularimportanceinthecontextofyoungpeople.Goodpracticesuggeststhat:

Eachyoungerpersonshouldbemadeawarethat,iftheywouldprefer,•theymayseeadifferentpersonthantheonewhoisallocatedtothembytheservice(e.g.somefemaleclientsmayprefertoseeafemalememberofstaff).

Asinformationofasensitivenatureisoftendisclosedduringassessment,•itshouldtakeplaceinaprivateroom.

Itisgoodpracticetoreadandexplainastatementaboutconfidentiality,•anypointsnotunderstoodmustbeclarifiedandeachyoungerpersonshouldbeassistedtoaskquestions.Staffmustnotassumethatayoungerpersonisliterate.

Usually,assessmentsmustprovideanopportunityforeachyoungperson•totalkopenlyandwithoutanyadditionalpressures.Ifayoungerpersoncomesforanassessmentwithafriendorrelative,theusefulnessoftheotherpersonbeingpresentmustbecarefullyconsidered.

Wheneverpossibleandinordertopromotecontinuityofservice,•eachassessmentbythemorespecialisedservicesforyoungerpeopleshouldbecompletedbytheworkerwhoislikelytobecomethecasemanagerorleadprofessionalforthatyoungerperson.

Ifayoungerpersonappearstobeintoxicatedornotcoherentenoughto•proceed,heorsheshouldbeaskedtoattendatalaterdate.Iftheyoungerpersonseemstobeatriskoflossofconsciousness,orhasanyothersignsofoverdose(includingthatderivedfromself-disclosure),theassessmentmustbestoppedimmediatelyandanambulancecalled.

Ifatanypoint,astaffmemberhasseriousconcernsaboutthesafetyof•ayoungerpersonoranotherperson,fromtheinformationdisclosed,theyshouldsharetheirconcernswiththeyoungerpersonandstateclearlythereasonsfortheirconcern.Itmaybenecessarytoseekguidancefromacolleagueormanager.Ifthissituationarisestheyoungpersonshouldbemadetofeelascomfortableaspossibleandnotmadeundulyanxious.

Allstaffmemberswhohaveormaybecomeawareofconcernsaboutthewelfareorsafetyofachildorchildrenshouldknow:

whenandhowtomakeareferraltolocalauthoritychildren’ssocialservices;•

whatservicesareavailablelocally;•

howtogainaccesstothem;•

whatsourcesoffurtheradviceandexpertiseareavailable;and•

whotocontactinwhatcircumstances,andhow.•

(NB At an early stage, substance misuse staff should determine whether they need to involve Social Services. Staff should have received training to assist them to identify indicators that a child may be ‘in need’ or where there are child protection concerns and how to refer appropriately)

1.5 Practicepoint5-TransitionPlanningTheinterventionelementoftheyoungpeople’sstrandofthisguidanceisfoundedonthehopethatearlyinterventionwillreducetheneedforyoungpeopletouseserviceswhentheyareadults.Goodpracticeinrelationtotransitionplanningsuggests:

allyoungpeoplereceivingassessmentcare,and/orinterventionsfor•potentialoractualsubstancemisuseshouldhaveatransitioncareplanthatisdevisedpriortotheireighteenthbirthday.Thisshouldidentifyanycontinuingneedsandtheorganisationsthatarebestabletomeetthoseneeds;

inordertoplantransitionarrangements,providersofservicesforadults•andforyoungpeoplewhoaremisusingsubstancesshouldworktogether;

transitionworkerscouldbebasedinservicesforadults,butalsoholdsome•sessionsinsubstancemisuseservicesforyoungpeople;

acareco-ordinator,whowecalltheleadprofessional,shouldbeidentified•inthecareplanfromwithintheleadagencyandensuretherearerobustlinkswithallotherappropriateprofessionals.Inmanycases,youngpeopleof18whorequireservicesinrespectoftheirmisuseofsubstancesmayalsorequireinterventionsfromothermainstreamservices,suchashousing,educationandprimarycare;and

transitionsofyoungpeopletoservicesforadultsmaytakeplaceatdifferent•agesordevelopmentalstagesdependingontheagenciesinvolvedandtheexpectationsthatfallonthem(e.g.YOTs,SpecialistCAMHSandservicesforchildrenwhoarelookedaftermayhavedifferentarrangements).Transitionarrangementsshouldensurethatthesedifferentarrangementsareincludedintheclientscareplan,whererelevant.

SectionB-Context

2 Overview

Substancemisuseinchildrenandyoungpeoplepresentsamajorpublichealthchallenge.TheUKhassomeofthehighestratesofyoungpeopleaged15-16usingormisusingsubstancesinEurope.Currentlytherearerisingtrendsintheuseofalcohol(particularlybyyoungwomen)andbingedrinkinghasincreaseddramatically.

Improvedoutcomesforchildreninrelationtosubstancemisusecanonlybedeliveredandsustainedwhenkeypeopleandbodiesworktogethertodesignanddelivermoreintegratedservicesaroundtheneedsofchildrenandyoungpeople.

Providingtherangeofeducation,preventionandtreatmentservicesforchildrenandyoungpeoplewhomisusesubstancesisakeycomponentofsafeguardingandpromotingthehealthandwellbeingofchildren.Safeguardingchildrenshouldnotbeseenasaseparateactivityfrompromotingtheirwelfareandshouldbeplacedwithinthecontextofwiderservicesforchildreninneedthereforeitisimperativethatsubstancemisuseservicesmaintaingoodcontinuingcollaborationwithsocialservicestopromotethebestinterestofthechildren.

TheChildrenAct,2004,providesthelegislativecontextforthisframeworkestablishingstatutoryChildrenandYoungPeople’sPartnershipsandthatarerequiredtopublishaChildrenandYoungPeople’sPlan(CYPP),settingouthowtheywillworktogethertoimprovethewellbeingofchildrenandyoungpeople.Thisisthekeystatementofplanningintentforchildrenandyoungpeopletowhichallotherplans,includingthosecoveringsubstancemisuseservicesforchildrenandyoungpeople,musthaveregard.TheCYPPalsoprovidesabasisforthejointplanningofservices.

SafeguardingChildrenWorkingTogetherundertheChildrenAct2004StatutoryguidanceissuedbytheWelshAssemblyGovernmentin2006statesthat:Allthosewhohavecontactwithchildrenandyoungpeople,includingeverybodywhoworkswithorhascontactwithchildren,parents,andotheradultsincontactwith,orseekingcontactwith,children,shouldbeabletorecognise,andknowhowtoactupon,evidencethatachild’shealthordevelopmentisormaybebeingimpairedandespeciallywhentheyaresufferingoratriskofsufferingsignificantharm.Practitioners,fostercarers,andmanagersshouldbemindfulalwaysofthewelfareandsafetyofchildren-includingunbornchildrenandolderchildren-intheirwork.

UniversalEducationservicesthatinformandhelpyoungerpeoplewithhandlingthepressurestousesubstancesshouldbeavailabletoeverychildandyoungpersoninWalesandtheirplanninganddelivery(followingidentifiedgoodpractice)shouldbeco-ordinatedonalocalbasisatCSPlevelandincludedintheCYPP.Safeguarding Children: Working Together under the Children Act 2004Chapter5refers.

Universaleducationshouldbecomplementedbyselectiveortargetedprogrammesaimedatspecificatriskgroupsofchildren,youngpeopleoryoungadults.Theseshouldfocusonattendingtoriskfactorsandraisingresilienceandshouldbeco-ordinatedonalocalbasisatCSPlevel.

Trainingshouldbeavailableforallrelevantprofessionalsandadvancedtrainingisrequiredbydesignatedstaffsthathaveresponsibilityforeducatingyoungpeoplewhoattendtheirinstitutions/organisationsaboutsubstancesandsubstancemisuse.

Individualisedandplannedprogrammesofassessment,interventionandcareforcertainidentifiedchildrenoryoungpeoplewhoaremisusingsubstancesneedtobeavailablefromspecialistagencies.Theseprogrammesshouldincludeawiderangeofinterventionsor‘treatments’foryoungerpeople(andfortheirfamilies)includingpsychologicaltherapies,pharmacologicaltreatmentsandneedleexchange.

Comprehensivespecialisedinterventionservicesofthisbreadthshouldbedeliveredbycreatingsingleagenciesorbringingtogetherseparateagenciestoactasasingleentityorbycreatinganetworkofmorelooselyrelatedagencies.

Amuchsmallernumberofyoungerpeoplearelikelytorequireinpatientservicesorresidentialfacilitiessuchastherapeuticcommunitiesforpsychosocialrehabilitation,halfwayhouses,grouphomes,andspecialisedfostercare.Theseneedtohaveclearlydefinedoutcomesuccessfactors.

Assessmentisthekeyprocessthatinitiatesinterventionandthewayinwhichitishandledisoftenanimportantmatterindeterminingwhetheryoungerpeopleandtheirfamiliescontinuetousetheservicestheyareoffered.

Wherethereismorethanasingleagencyinvolved,theyshouldagreebetweenthemwhichistheleadagencyineachcaseasthispromotesclarityforclientsandfamilies.CSPSshouldalsoconsiderimprovinginteragencyliaisonbetweenthespecialistandgeneralistservicesbythecreationofasubstancemisuseliaisonorlinkworkerservice.

Involvingparentsandcarersinservicesforyoungersubstanceusersisnotonlyessentialforgoodpractice,butmayalsoimprovethetreatmentoutcomesthattheservicecanachieve.Anexceptiontothisiswhensomebodybelievesthatachildmaybesuffering,ormaybeatriskofsufferingsignificantharmwheresuchdiscussionandagreement-seekingtoreferringtosocialservicescouldplaceachildatincreasedriskofharm.

CSPplanningprocessesshouldensurethegoodpracticeidentifiedinthisframeworkforuniversaleducationprogrammes,prescribing,needleexchange,assessmentandhandlingtransitionsisputinplace.ThelocalCYPPprovidesabasisforthejointplanningofserviceprovisionacrossstatutorypartnersandvoluntaryproviders.

2.1 ChildrenAct2004TheChildrenAct2004buildsonandstrengthenstheframeworksetoutintheChildrenAct1989.Thereareanumberofprovisionsinthe2004Actwhichrelatedirectlyorindirectlytoagencies’responsibilitiestosafeguardandpromotethewelfareofchildren.Sections25,26and28requirelocalauthoritiesandtheirpartnerstoco-operatetoimprovethewellbeingofchildren(includingphysicalandmentalhealthandemotionalwellbeing)andtosafeguardandpromotetheirwelfare.

Section25establishesstatutoryChildrenandYoungPeople’sPartnerships•andsection27requiresleaddirectorsandmembersforchildrenandyoungpeople’sservices,toleadcooperationinthestrategicdirectionanddevelopmentofservicesatalllevels.TheWelshAssemblyGovernmentissuedguidance“StrongerPartnershipforBetterOutcomes”onthesefunctionsin2006.

Section26ofthe2004ActrequireseachPartnershiptopublishaChildren•andYoungPeople’sPlan(CYPP),settingouthowtheywillworktogethertoimprovethewellbeingofchildrenandyoungpeople.TheCYPPisa3yearstrategicplanthatwillprovidestrategicvision,statetheagreedprioritiesthatwilldirecttheworkofallpartners,setagreedjointtargetsandprovideabasisforthejointplanningofservices.Itisthekeystatementofplanningintentforchildrenandyoungpeopletowhichallotherplans,includingthosecoveringsubstancemisuseservicesforchildrenandyoungpeople,musthaveregard.FurtherdetailscanbefoundinguidanceentitledSharedPlanningforBetterOutcomes,publishedontheAGwebsite.Firstplans,covering2008-11arerequiredtobeadoptedby31July2008andpublishedby30September2008.

2.2 Safeguardingchildren(section28)Safeguardingandpromotingthewelfareofchildrenisaboutprotectingchildrenfromabuseandneglect,preventingimpairmentoftheirhealthordevelopment,andensuringthattheyreceivesafeandeffectivecaresoastoenablethemtohaveoptimumlifechances.Improvedoutcomesforchildrencanonlybedeliveredandsustainedwhenkeypeopleandbodiesworktogethertodesignanddelivermoreintegratedservicesaroundtheneedsofchildrenandyoungpeople.

Providingtherangeofeducation,preventionandtreatmentservicesforchildrenandyoungpeoplewhomisusesubstancesisakeycomponentofsafeguardingandpromotingthewelfareofchildren.

Serviceprovidersmustensurethattheirworkingpracticescomplywiththestatutoryguidance,SafeguardingChildrenworkingtogetherundertheChildrenAct2004,issuedbytheWelshAssemblyGovernment,October2006.Thisguidancesetsouthoworganisationsandindividualsshouldworktogethertosafeguardandpromotethewelfareofchildren.

2.3 PlanningTheAssemblyGovernmentwishestoseeincreaseduseofjointplanningtoprovideservicesforchildrenandyoungpeople.Section25(6)ofthe2004Actgivesthelocalauthorityanditsmainstatutorypartnersthepowertopoolfundingandshareresources.Chapter4ofguidanceonlocaldutiestocooperate-Stronger Partnerships for Better Outcomes (WAG 2006)-setsoutthebackgroundforthedevelopmentofsucharrangements.EachCYPPprovidesabasisforjointplanninglocally.Shared Planning for Better Outcomes (WAG 2007),reinforcestherequirementtoconsideropportunitiesforuseofpooledfunding(paragraphs12.24-12.26).Pooledfundingcanbeparticularlyvaluableinprovidingservicesforchildrenandyoungpeoplewithcomplexneedswhorequirepackagesofcarefromanumberofagenciesandpartners,suchassubstancemisuseservices.

2.4 TheNationalServiceFrameworkforChildrenYoungPeople andMaternityServicesinWales(NSF)TheNationalServiceFrameworkforChildrenYoungPeopleandMaternityServicesinWales(NSF)10-yearstrategysetsnationalstandardstoimproveandreducevariationinservicedeliveryforchildrenandyoungpeople.Itcontains21crosscuttingstandardsand203specificandmeasurablekeyactions,whichputchildren,youngpeopleandtheirfamiliesatthecoreofservices.Thestandardsandkeyactionsarebasedonthe42articlesoftheUNConventionontheRightsoftheChildandtheAssemblyGovernmentssevencoreaimsforchildrenandyoungpeople.

KeyactionsintheNSFuniversaltoallchildrendefinesstandardsfortheuniversalserviceswhichallchildrenandyoungpeopleinWalesshouldreceiveinordertoachieveoptimumhealthandwellbeing.

Para:2.46statesthatCYPPs(undercoreaim3)shouldcoverkeyelementsoflocalstrategies,includingsubstancemisuseservices.TheywillthereforeunderpinthedeliveryofaLocalSubstanceMisuseActionPlandevelopedbytheCommunitySafetyPartnerships.

2.5 ChildandadolescentmentalhealthservicesTheaimoftheChildandAdolescentMentalHealthServices(CAMHS)strategyistoensurethatservicesareeffectiveandefficientandwhich,aboveall,uniteallprofessionsinadeterminationtoputtheneedsofchildrenandyoungpeopleattheheartofourapproachtoCAMHSinWales.

Itisaimednotjustathealthservices,managersofhealthcareservicesatalllevelsandhealthprofessionals,(suchaschildandadolescentpsychiatrists,paediatricians,nursesandtherapists)butalsoatstaffandmanagementofsocialservices,education,youthjusticeagenciesandthevoluntarysector.Allhaveaparttoplayandallarevitaltothejointendeavourtotacklementalhealthproblemswhichaffectyoungpeople,theirfamiliesandcarers,andwhichcontributesignificantlytowiderproblemsinsociety.

Thisstrategyisissuedasguidanceagainstwhichserviceswillbemonitoredandassessed.

2.6 MentalCapacityActTheMentalCapacityActislegislationthatisenablingandsupportiveofpeoplewholackcapacity,notrestrictingorcontrollingoftheirlives.Itaimstoprotectpeoplewholackcapacitytomakeparticulardecisions,butalsotomaximisetheirabilitytomakedecisions,ortoparticipateindecision-making,asfarastheyareabletodoso.

2.7 ServiceuserinvolvementThedevelopmentofsubstancemisuseservicesrequiresparticularattentiontotheviewsofserviceusers.Aspecialistsubgroupconsistingofkeystakeholdersandpartnershasproducedserviceuserinvolvementgoodpracticeguidance.Thisguidancewaspublishedin2008asamoduleoftheSubstanceMisuseTreatmentFramework(SMTF).

2.8 ChildreninneedandtheirfamiliesChildren’sneedsandcircumstancesarevariedandcomplex.Understandingwhatishappeninginachild’slifeandwhetherheorshewouldbenefitfromservicesisacoreprofessionalactivityforthoseworkingwithchildrenandfamilies.

Achildshallbetakentobeinneedif:

a) heisunlikelytoachieveormaintainortohavetheopportunityofachievingormaintaining,areasonablestandardofhealthordevelopmentwithouttheprovisionforhimofservicesbyalocalauthority;

b) hishealthordevelopmentislikelytobesignificantlyimpaired,orfurtherimpaired,withouttheprovisionforhimofsuchservices;or

c) heisdisabled.

And“family”inrelationtosuchachild,includesanypersonwhohasparentalresponsibilityforthechildandanyotherpersonwithwhomhehasbeenliving.

Allstaffmemberswhohaveormaybecomeawareofconcernsaboutthewelfareorsafetyofachildorchildrenshouldknow:

whenandhowtomakeareferraltolocalauthoritychildren’ssocialservices;•

whatservicesareavailablelocally;•

howtogainaccesstothem;•

whatsourcesoffurtheradviceandexpertiseareavailable;and•

whotocontactinwhatcircumstances,andhow.•

2.9 ReferralsandsharingofinformationAtanearlystage,substancemisusestaffshoulddeterminewhethertheyneedtoinvolveSocialServices.Staffshouldhavereceivedtrainingtoassistthemtoidentifyindicatorsthatachildmaybe‘inneed’orwheretherearechildprotectionconcernsandhowtoreferappropriately.

Localauthoritychildren’ssocialservices,alongwithotheragencies,haveresponsibilitiestowardsallchildrenwhosehealthordevelopmentmaybeimpairedwithouttheprovisionofservices,orwhoaredisabled(definedinsection17oftheChildrenAct1989aschildren‘inneed’).Allagencieswithsucharesponsibilityshould:

agreewithLSCBpartnerscriteriawithlocalservicesandprofessionalsas•towhenitisappropriatetomakeareferraltolocalauthoritychildren’ssocialservicesinrespectofachildinneed;

haveanagreedformatformakingareferralandsharingtheinformation•recorded.

Ifsomebodybelievesthatachildmaybesuffering,ormaybeatriskofsufferingsignificantharm,thens/heshouldalwaysreferhisorherconcernsassoonaspossibletothelocalauthoritychildren’ssocialservices.Inadditiontosocialservices,thepoliceandtheNSPCChavepowerstointerveneinthesecircumstances.Whileprofessionalsshouldseek,ingeneral,todiscussanyconcernswiththefamilyand,wherepossible,seektheiragreementtomakingreferralstolocalauthoritychildren’ssocialservicesthisshouldonlybedonewheresuchdiscussionandagreement-seekingwillnotplaceachildatincreasedriskofsignificantharm.

Sharingofinformationaboutcasesofconcernwillenableorganisationstoconsiderjointlyhowtoproceedinthebestinterestsofthechildandtosafeguardchildrenmoregenerally.Furtherguidanceoninter-agencyinformationsharingisgiveninSafeguardingChildren:WorkingtogetherundertheChildrenAct2004chapter14.

Confidentiality

Manyprofessionalsareunderadutyofconfidentiality.Thisisimportantinmaintainingconfidenceandparticipationinservicesandtherebyhelpingtoprotectchildren’shealthandwellbeing.But,asrelevantguidelinesmakeclear,thedutyofconfidentialityisnotabsoluteandmaybebreachedwherethisisinthebestinterestsofthechildandinthewiderpublicinterest.Safeguarding Children: Working together under the Children Act 2004 chapter 8 and chapter 14 refers.

Whenayoungerpersonhasbeenidentifiedaspossiblyhavingneedsthatmightarise,atleastinpart,fromtheiruseormisuseofsubstances,itisimportantthatacomprehensiveassessmentofthoseandtheirotherneedstakesplace.Tothisend:

ifachildisfelttobeachild‘inneed’(asdefinedintheChildrenAct1989)•areferralshouldbemadetosocialservicessothattheycanundertakeanassessmentofthechild’sneeds.Iftheyfeelthechildisinneedtheyshouldco-ordinateaplanofsupportandinterventionforthatchild(drawingonotherservicestomeetspecificneedssuchasthesubstancemisuseservice).Thesameprocesswillapplyifthechildisinneedofprotectionorlookedafter.InthesecasesSocialServiceswillleadtheoverallco-ordinationofthecase.

Aspecialistsubstancemisuseassessmentistobecarriedoutbysubstance•misuseserviceproviderstoidentifyallthechild’ssubstancemisuseneeds.Ifsocialservicesareinvolvedthiswillformanelementoftheoverallplanforthechild.

IfSocialServicesdonotfeelthechildisachild‘inneed’theymaynot•becomeinvolvedbutthechildmaystillhaveneedsthatcanbemetbyotheragenciesforexamplethesubstancemisuseservicesmaycontinueaninterventionplanforthatchild.

TheCommonAssessmentFramework(http://www.cafwales.co.uk)maybe•awayinwhichitmightbepossibletosupportmoreeffectivepreventionandearlyinterventionbyhelpingtoidentifychildrenwhowouldbenefitfromadditionalservicesatastagebeforereferraltosocialservicesisrequired.Itcanalsohelpworkersandagenciestodecidewhowouldbebestplacedtoprovidetheseservices.TheAssemblyGovernmentiscurrentlyrunningpilotprojectsinWalestotesttheeffectivenessofaneCAFITbasedsystemtoensurethatCAFcanworktoitsfullpotential.However,alllocalChildrenandYoungPeoplePartnershipsandtheirconstituentagencieswillbeestablishinglocalarrangementsthatjoinuptheplanninganddeliveryofservices.TheseshouldincludeotherrelevantPartnershipsintheprocessas,forexample,CommunitySafetyPartnershipshaveresponsibilitiesrelatingtosubstancemisuseforwhichtheCAFisrelevant.TheimplementationoftheCAFwillassistthisprocessbyprovidingintegrationattheearlieststagesofjointpractitionerledinterventionthroughtohigh-levelstrategicdevelopments.

Thespecialistsubstancemisuseassessmentmustinclude:

thelevelofuseofsubstances;•

therouteofuse;•

considerationofthepossibilitythatyoungerpeoplehaveormaybecome•dependentonoraddictedtosubstances;

themeaning,consequencesandcomplicationsforeachyoungerperson•andtheirfamilyoftheirpatternofsubstanceuseormisuse;

physicalandmentalissues;•

riskfactors-thiswillindicatewhetherthecaseneedstobereferred•toSocialServices.

2.10 AssessmentframeworkTheFrameworkfortheAssessmentofChildreninNeedandtheirFamilies(NAW,HomeOffice2001)wasdevelopedtoprovideallthoseworkingwithchildrenandfamilieswithasystematicwayofgathering,analysingandrecordingwhatishappeningtochildrenandyoungpeoplewithintheirfamiliesandwidercommunityinwhichtheylive.TheAssessmentFrameworkisinformedbytheory,researchfindingsandpracticeknowledgefromanumberofdisciplines.Thiswasusedtoidentifythekeyelementsthatinfluencedthedevelopmentofchildren,andwhichanyassessmentoftheirneedsmustconsider:

thechild’sdevelopmentalneeds;•

thecapacityofparentstorespondtotheseneedsand;•

thewiderfamilyandcommunitywithinwhichthechildlives.•

Theanalysisofthesedomainsandtheirrelationshiptooneanotherprovidesprofessionalswithanunderstandingofwhatareinevitablycomplexissuesandinterrelationships,clearprofessionaljudgementscanthenbemade.Thesejudgementsincludewhetherthechildbeingassessedisinneed,whetherthechildissufferingorlikelytosuffersignificantharm,whatactionsshouldbetakenandwhichserviceswouldbestmeettheneedsofthisparticularchildandfamily.

Theneedsofchildrencannotbemetbyoneagencyalonetheassessmentframeworkwasdevelopedtoprovideacommonconceptualframeworkthatcouldbeusedbyallagencies.

Itshouldbenotedthatwhereachildisaccommodatedinahealthoreducationsettingforlongerthan3months(orhasbeenplanned),areferralismadetosocialservicestodeterminewhetheranholisticassessmentisrequiredunderthisAssessmentFramework.

2.11 LookedAfterChildrenChildrenwhoareaccommodatedbyorinthecareoflocalauthoritiesaredescribedas‘looked-afterchildren’.Theyareoneofthemostvulnerablegroupsinsociety.Themajorityofchildrenwhoremainincarearetherebecausetheyhavesufferedabuseorneglect.

Itisvitalthatalllookedafterchildrenwithproblemsarisingfromorrelatedtosubstancemisuseareidentifiedearlythroughtheirhealthassessment,reviewsandcareplanningprocessesandreceiveappropriateinterventionsasaresult.

Corporateparentingemphasisesthecollectiveresponsibilityofthelocalauthoritytoactasagoodparenttothechildrenitlooksafterandtheneedforallagenciesandprofessionalstocontributetoachievingthebestoutcomesforlookedafterchildren.Forlookedafterchildrentheroleoftheirdaytodaycarerse.g.fostercarerswillbeimportantinthiscontext.

2.12 Suicide,attemptedsuicideandsubstancemisuseServicesshouldbeawareoftheassociationbetweensubstancemisuseandattemptedandcompletedsuicide.Researchsuggestsastrongassociationwithcompletedsuicideafterprevioussuicideattemptsandthatsubstancemisusersweremorelikelythanothersuicideattempterstomakerepeatattempts.Disinhibitionproducedbyalcoholintoxificationprobablyfacilitatessuicidalideasandoftenonimpulseleadstothoughtsbeingtranslatedintoaction.

Youngpeoplewhohavemultipleproblemsarethosemostatriskofsuicide.Currentresearchsuggeststhatthestrongestriskfactorsforsuicideinyoungpeoplearementaldisorders,particularly,affectivedisorders,substancemisuseandantisocialbehaviours.Frequentlysuicidalbehaviourinyoungpeopleappearsasaconsequenceofadverselifeeventsinwhichmultipleriskfactorscombinetoincreasetheriskofsuicidalbehaviour.

Itisimportantthatservicesincontactwithvulnerableyoungpeopleriskassesstheyoungpersonwithappropriateadviceandsupportgiven,includingsupporttoaccessspecialistservices.

ThisissuesuicidepreventionisaddressedinmoredetailintheWelshAssemblyGovernmentSuicidePreventionActionPlan.

2.13 KeycomponentsThisframeworkaddressesthekeycomponentsofacomprehensiveresponsetothethreatsposedtochildrenandyoungerpeoplebyavarietyofsubstances.Thesecomponentsare:

UniversalEarlyEducationProgrammes• -theseconveyaccurateandbalancedinformationaboutsubstancesandtheiruseandmisusetochildrenandyoungpeople;

TargetedProgrammes• -thatenablechildrenandyoungpeopletotakepartindiscussionsamongthemselvesandwithwell-informedadultsaimedatimprovingtheirunderstandingofhowtheycanrespondtotheendemicpresenceofsubstancesinourcommunities;

InterventionsToImprovePotential• -theseexisttopreventchildren,youngpeopleandyoungadultsmovingfromusetomisuseofsubstancesbyanticipatingtheimpactsofrisk/protectivefactorsandincreasingindividuals’resilience;

IndicatedProgrammes(generallyreferredtoastreatment)• -theseareprovidedasindividualisedandplannedprogrammesofassessment,interventionandcareforcertainidentifiedchildrenoryoungpeoplewhoaremisusingsubstances.

GoodpracticeisreferredtothroughoutPartBofthedocumentandanumberofmoredetailedappendiceshavebeenincludedformoredetailedspecificgoodpracticeinareassuchasprescribingandassessment.

3. Scopeofdocument

3.1 TheclientgroupInthisframework,termsusedinrelationtoagearedescribedbelow:

Children: Peoplewhoareagedfrombirthtotheeveoftheir11thbirthday

Youngpeople: Peoplewhoareagedfrom11totheeveoftheir18thbirthday

Youngadults: Peoplewhoarebetween18yearsofageandtheeveoftheir25thbirthday

Youngerpeople: Agenerictermreferringtoallpeoplewhoareunder25yearsofagethat,therefore,encompasseschildren,youngpeopleandyoungadults

Thisframeworkcoversthese4groupings.

3.2 SubstancecoveredbytheframeworkThisframeworkcoversthefullrangeofsubstancesthataremisusedinWalesincluding:

illegaldrugssuchasheroin,cocaine,ecstasy,amphetamines,LSD,cannabis•

alcohol•

prescription-onlymedicinessuchasanabolicsteroidsandbenzodiazepines•

over-the-countermedicinessuchaspreparationscontainingcodeine•orephedrine

volatilesubstancessuchasaerosolpropellants,butane,solvents,glues.•

4. Patternsofsubstanceuseandmisuse

4.1 PathwaysItisalsodifficulttoidentifywithconfidenceparticularpathwaystosubstancemisuse.

Althoughitseemslikelythatusingsubstancesisrelatedtonumerousriskfactors(familybackgroundandtheinfluenceofdrug-usingpeersaresomeofthemostimportant),itisstillimpossibletopredictwithanycertaintywhetherayoungpersonwilldecidetoinitiateuse,continueuse,ormaintainusesufficientlytodevelopdependenceand/orassociatedproblems.

Researchconfirmsthat,ingeneral,thereisacomplexinterplaybetweenthefactorsinyoungpeoples’livesthatmakethemmorelikelytodevelopproblemsandthefeaturesthatpromotetheirresilience.Forexample,asthenumberofoccasionsrisesonwhicheachchildoryoungpersonisexposedtodisadvantage,stressfullifeeventsandotherfactorsthatincreaserisk,thegreateraretheirchancesofdevelopingproblemsofavarietyoftypesincludingsubstancemisuse.Also,researchinotherareasrelatingtopoorhealthsuggeststhattheeffectsofriskfactorsandwhetherornotchildrenhavetheirneedsmetisusuallymediatedthroughtheircaregiversandthefactorsinclude:

povertyandfailuretomeetchildren’smaterialneeds;•

problemswithparentingpractice;•

unsatisfactoryattachmentpatternsandrelationships;•

parentalpsychopathology;and•

failureofservicestorespondtotherangeofchildren’sneedsand•tointervenepreventativelyinpotentiallyresolvablecircumstances(e.g.notprovidingadequateresponsestobullying).

Together,thefeaturescitedaresomeofthehallmarksofsocialexclusion,atermthathaslargelydisplacedtermssuchaspovertyanddeprivationindescribingthenatureofcontemporarypatternsofsocio-economicdisadvantage.Itisdistinctiveasaconceptinsofarasitemphasisesmulti-faceted,relationalanddynamicnatureofdisadvantage.

4.2 AtriskgroupsOnthebasisoftherisksandassociationspresenteditisprobablethatchildrenandyoungpeoplearemoreatriskofusingandmissingsubstancesiftheyhave/are:

learningproblems;•

learningdisabilities;•

persistenttruantsandyoungpeoplewhoareexcludedfromschool;•

youngerpeoplewhoarenotineducation,employmentortraining;•

youngerpeoplewholiveindeprivedandthelessaffluentareas;•

mentalhealthproblemsormentaldisorders;•

physicalillhealth;•

teenageparents;•

childrenofparentswhomisusesubstances;•

childrenandyoungpeoplewhoarecarers;•

childrenofparentswithamentaldisorder;•

involvedwithcrimeandyoungerpeopleincontactwiththecriminal•justiceservices;

childrenlookedafterbylocalauthorities;•

homelessyoungerpeople;•

subjecttoprostitutionorsexualexploitation;and/or•

exposedtosexualabuse.•

5. Thefour-tierstrategicframework

Theguidancecontainedinthisdocumentrequiresasubstantialnumberofsectors,agencies,organisationsandprofessionstocometogethertoproducethecomprehensiveservicesthatarerequired.Inthiscontextreferenceismadetothefour-tierstrategicplanningconceptwhichisbasedonthefunctionsrequiredofservicesinrelationtothelevelorcomplexityofyoungerpeople’sneedstheiropinionsandthelevelsofspecialisationoftheservicesthattheyrequire.

Thetiersare:

Tier1: Universalprimary-levelservices

Tier2: Youth-orientedservices

Tier3: Servicesprovidedbyteamsthatspecialiseintreatingyoungpeoplewhomisusesubstances

Tier4: Veryspecialisedservicesforyoungpeoplewhomisusesubstances

Thetieredconceptisintendedtobeaflexibleanddynamicstrategicapproachthatprovidesaframeworkwithinwhichtoconceptualisethefunctionsofcomprehensiveservicesandrelationshipsbetweentheirplannersandprovidersandbetweentheservicesbothhorizontallywithintiersandverticallyacrosstiers.Itemphasisesactivitiesandfunctionsratherthanthedisciplinesofprofessionalsortheidentitiesofsectorsandagenciesandpromotesintegrationbetweensectors,agenciesanddisciplines.Italsomapsbroadlyontothecategoriesadoptedfordescribingcomprehensiveservicesin2above.

Itisimportanttoemphasisethatmanyprovideragenciescanlegitimatelydeliverservicesofmorethanonetypeandwhichfallintomorethanonetier.

SectionC-programmesandinterventions

6. Universaleducationservices

6.1 ContextEducationservicesthatinformandhelpyoungerpeoplewithhandlingthepressurestousesubstancesthattheyarelikelytoexperiencearerequiredbyallyoungpeopleinWalesagedbetween11and18years.TheyremaincentraltothedeliveryofaneffectiveresponsebyallCSPs.

Theprimaryintentionofeducationprogrammesistoconveyaccurateandbalancedinformationaboutsubstancesandtheiruseandmisuse.Theyshouldbeuniversallyavailableandbegivenonacontinuinganditerativebasisthatfitswiththeeducationalcapacityofeachchild.

ThedevelopmentofaneffectivePSEcurriculumandsystemasanadjuncttoeducationaboutsubstancesisessentialtodeliveringprogrammesofthissort.

6.2 AccessandobjectivesAccesstoinformationaboutsubstancesshouldbeprovidedthroughthestatutoryeducationsystemandtherelevantstatutoryandvoluntarysectorbodies.Additionalfacilitiesarerequiredofthestaffofagenciesthatareengagedindeliveringservicesatallofthetiers.Thisisbecauseeducationaboutsubstancesandsubstancemisuseisapartofmostinterventionandtreatmentregimes.

Theapproachtakenshouldincorporatethefollowingobjectives:

Increasingknowledgeaboutsubstancesincludingalcoholandtobacco.•

Providinganenvironmentinwhichthenormistoremaindrugandtobacco•freeandrespectthesensibleuseofalcohole.g.bybecomingahealthpromotingschool.

reducingconsumptionand/ordelayingtheonsetoffirstuse.•

contributingtominimisingharmcausedtopeoplewhouseor•misusesubstances.

6.3 ContentcharacteristicsEducationalmaterialsshouldbedefinedbyadherencetokeyprinciples.Youngpeoplehaveindicatedthattheyrequirelearningmaterialsthatare:

factual;•

accurate;and•

non-judgmental.•

Theprimerequirementofyoungpeopleisforinformationinrelationtouseofsubstancesandfordetaileddescriptionsofeffectandriskfromtheuseofspecificsubstances.Theyalsoneedtobehelpedtodevelopvalues,attitudesandskillswhichwillhelpthemmakedecisionsrelatedtotheuseofsubstances.

Teachers,youthleaders,etcshouldmakeacriticalevaluationofmaterialstoensurethattheyarenotcontradictingpupil’spersonalexperiencesorappeartobebasedonadultsexaggerations.Learningmaterialsshouldreflectthewishesofyoungpeopletobeabletoidentifythedifferentsubstancesthatareincirculationandroutestoservicesforhelp.Thus,thecontentoftheirteachingshouldreflectbothservicepatternsandprovidedetailsofpointsofcontact.

6.4 DeliveryandstyleGoodpracticeinprogrammedeliverysuggestsmethodsshouldbe:

interactive;•

participative-motivatingandconfidencebuilding;•

correctingoferroneousbeliefs;•

abletoprovidealternativediscursiveopportunitiestochallengepeerbeliefs•whilegivingvaluetoyoungpeoples’opinions;

relevanttoyoungpeoples’socialrealities;and•

innovativethroughemployingarangeoflearningstyles.•

6.5 Agencies,personnelandvenuesThefollowingagencieshavearoletoplayindesigninganddeliveringeducationregardingsubstancesandsubstancemisuse:

LEAPSEadvisers;•

thepolicethroughtheallWalesschoolsProgramme;•

WelshNetworkofHealthySchoolSchemesco-ordinators;•

voluntarysectorsubstanceuseandmisuseagencies(e.g.formore•specialisedadviceonsubstancesandinformationaboutotherrelevantservices);

localeducationauthoritiesthroughinitiativestoprovideanadequate•infrastructurewithinschoolsandyouthcentresthatarecompatiblewithdeliveringeffectiveandacceptableeducationonsubstancesandsubstancemisuse.

Additionally,itmaybehelpfultoinvolveotherstatutoryagenciesandorganisationsasandwhenthatisseenasrelevant(e.g.paramedicsfromtheambulanceserviceandstaffofHMPrisonService).

Schoolsareevidentlyimportantplacesfordeliveringeducationprogrammesandteachingstaffhaveasignificantroletoplay.However,theprimaryimportanceofschoolsasavenueisthattheyprovideopportunitiesforawiderangeofexternalagenciestoprovideexpertiseandspecialism.Thepoliceandvoluntarysectoragenciesbringexpertiseandperceivedcredibilitythatstudentsdonotnecessarilyascribetoteachingstaff.Teacherscansupportthisexpertisebyprovidingacontinuingeducationthatunderpinscontributionsmadebyvisitingexperts.

Additionally,theyouthservices,socialservicesandothercareagenciesandcommunityorganisationsareimportantsecondarypointsofcontact.Theseagenciesmaybetheonlypointsofcontactforyoungerpeoplewhoaremostatriskincludingchildrenwhoareexcludedfromschool,lookedafter,and/oralienatedfromschool.Servicesarerequiredthatsupportdeliveryofconsistentmessagesacrossschoolsbyensuringthatyoungpeoplewhoarenotinregularattendanceatschooldonotfailtoreceiveeducationaboutsubstances(e.g.theGetSortedprogrammeinRhonddaCynonTaff).Creativityisrequiredtoensurethattheseservicesareavailable.

Thisapproachrequirestrainingandsupportforteachersandstaffinservicesforyoungpeopleonhowtodelivereducationaboutsubstancesandsubstancemisuseandwiderdisseminationofcurriculum-basedmaterialsthatprovideconsistentmessages.

Usingpeoplewhohaveahistoryofsubstancemisusetodelivereducationprogrammesmaybeusefulbutprogrammesofthiskindrequiremonitoringtoensuretheirqualityandconsistencyandtrainingshouldbegiventoex-usersbeforetheyareusedaseducators.

Peer-lededucationofferspotentialadvantageswithinauniversalandcomprehensiveplanthatlinksdifferentapproaches.Thismayhaveparticularvaluewithstudentswhoaredifficulttoreachandfor‘hidden’groups.Peer-lededucationalsooffersadvantagestotheyoungpeoplewhotraintobepeereducators;itraisestheirknowledge,awarenessandself-esteem.

Youngerpeopleshouldnotbeexcludedfromeducationprogrammesonaccountofanylearningdifficulties,problemsordisabilities.Therefore,noprogrammeshouldrelyonwritteninformationorfailtobeinformedabouttheimplicationsforeducationthatstemfromyoungerpeople’sproblemswithreading.Caremustbetakenindesigningpresentationformats,theircontentsandeffectiveaids.

Children who truant or are excluded from school are at much higher risk of substance use and misuse. No child or young person therefore should be denied access to a universal education service because they are out of or excluded from mainstream schooling for any reason. This calls for innovative community-based approaches to delivering a full universal education programme in which the roles, activities and messages transmitted by schools and other community agencies are well-coordinated.

Trainingshouldbeavailableforallrelevantprofessionalsandadvancedtrainingisrequiredbydesignatedstaffwhohaveresponsibilityforeducatingyoungpeoplewhoattendtheirinstitutions/organisationsaboutsubstancesandsubstancemisuse.

UniversalprogrammesshouldbeavailabletoeverychildandyoungpersoninWalesandtheirplanninganddeliveryshouldbeco-ordinatedonalocalbasisatthelevelsoflocalauthorities,localhealthboardsandcommunitysafetypartnerships.

7. Selectiveortargetedprogrammes

7.1 DefinitionSelectiveortargetedprogrammesarethoseprogrammesthatareaimedspecificallyatgroupsofchildren,youngpeopleoryoungadultswhoseprofileofriskandresiliencefactorsisconsideredtoplacethematgreaterriskofeitherusingsubstancesormovingfromtheirusetomisuse.

Therearetwobroadtypesofselectiveortargetedprogrammes:

thosethatfocusonattendingtoriskfactorsandraisingresilience.•(Theseprogrammesanticipatetheimpactsofriskandprotectivefactorsbyactingtoenhanceindividuals’resilienceandtotackleandreducethefactorsintheirlivesthatputthematgreaterriskofsubstancemisuseby,forexample,promotingtheirsocialinclusionorassessingthemandarranginginterventionsforanyassociatedproblemsordisorders);

specificsubstancemisusepreventionprogrammes.•

Selectiveprogrammesmaybedeliveredasstandaloneinterventionsortheymaybeprovidedasdevelopmentsfromuniversalprogrammes.Goodexamplesofprogrammesofthiskindareschool-basedapproachestoreducingbullyinganditsimpactoncertaingroupsofyoungpeople.Themainintentionofthesetypesofselectiveprogrammeistoreducetheriskrunby,andtoincreasetheresilienceof,certainidentifiedgroupsofchildrenandyoungpeople.Similarly,someparentingprogrammesareofferedtoallasuniversalprogrammeswhileothersmaybemorefocusedinresponsetotheparticularneedsofchildrenandyoungpeopleandtheirfamilieswhoaremoreatrisk.

7.2 Servicesthatprovidemoredetailedinformationandadvice ondrugsandservicesTargetedorselectiveservicesarerequiredthatprovidesimilarfunctionsasthosethatareuniversallyavailable.Someagenciesthatofferinformationandadvicemayofferbothuniversalandselectiveadvisoryservices.

7.3 PreventionservicesThemainfocusofservicesthatofferpreventionprogrammesistodelayorreducetheprospectsofidentifiedchildren,youngpeopleandyoungadultsmovingfromusingtomisusingsubstances,ortodecreaseuseandparticularly,whererelevant,toavoidthemprogressingto‘dependentuse’.Broadly,theseprogrammesshouldbeoneoftwosorts:

primaryprevention• -programmesthatareintendedtoassistyoungerpeoplewhoareusingsubstancestoresistordelaymovingintomisuse;and

secondaryprevention• -programmesthatareintendedtoreducethelevelofmisuseorharminwhichayoungerpersonisengaged(i.e.returningtouseratherthanmisuse)ortoassistidentifiedyoungerpeoplewithreturningtoabstinence.

Manypreventionservicesalsoincludeattentiontoreducingriskfactorsandbuildingresilience.Theyare,therefore,compoundsofthetwobroadtypesofselectiveortargetedprogrammers.Forexample,preventionpackagesmayincludesocialinclusionprogrammersthatofferarangeofsportsandotheractivities.Theparticularintentionistoensurethatchildrenandyoungpeoplestayengagedwiththemorespecificorspecializedcomponentsoftheprogrammedandarebetterabletore-engagewiththeirfamilies,educationandthecommunitywithoutrunningtheverysamerisksthatcontributedtothemmisusingsubstances.

Preventionservicesalsorequirethecapacityandcapabilitytofacilitatetheirclients’accesstoawiderangeofcommunityservices.Again,theintentionistoensurethattheyoungerpeopleinvolvedhaveaccesstocorehealth,education,housingandfamilysupportservicesandthattheyalsohavepromptaccesstospecialistsubstancemisuseservicesforyoungerpeoplewhentheresultoftheassessmentisthattheyarerequired.

Generallythekindsofinterventionprovidedbypreventionservicesareearlyinterventionservicesthatareaimedatyoungerpeoplewhohaveusedsubstancesbuttoalowlevelofseverity.Youngerpeoplewhoseneedshavegonebeyondtheselevelsusuallyrequiretheindicatedservicesofspecialisedsubstancemisusetreatmentagencies.

8. Indicatedprogrammes(includingtreatment)

8.1 Assessment8.1.1 Definition

Assessmentistheprocessthatinitiatesintervention.Thewayinwhichitishandledisoftenanimportantmatterindeterminingwhetheryoungerpeopleandtheirfamiliescontinuetousetheservicestheyareoffered.

Assessmentisaprocessratherthananevent.Itsgeneralaimisthatitshouldleadtowell-integratedandwell-targetedservicesbeingprovidedbythevarioussectorscomingtogethertomeeteachyoungerpeople’sindividualeducation,work,developmental,social,relationship,recreation,healthcareandspiritualneeds.Thefocusedaimofassessmentistocapturetheextenttowhichsubstanceshaveanimpactonthehealth,care,educationandwellbeingofeachyoungerpersonwhoisbeingconsidered.

8.2 DefinitionIndicatedprogrammesareprovidedasindividualisedandplannedprogrammesofassessment,interventionandcareforcertainidentifiedchildrenoryoungpeoplewhoaremisusingsubstances.Theseprogrammesincludeassessingthefullrangeofeachchild’suniquearrayofneedsandprovidingresponsestomeetthoseneedswiththeintentionofremedyingcurrentproblemsandrestoringindividualstonon-useofsubstances.Wherethatisnotpossible,indicatedprogrammesareaimedatminimisingtheharmtotheyoungerpeopleand/ortoothersthatmayoccuriftheycontinuetomisusesubstances.

Often,indicatedprogrammeswillconsistofanumberofdifferentcomponents.Theprospectsofincompleteresponsestoindicatedprogrammesandofrelapsearegreaterifthebackgroundriskfactorsfacedbyeachchild,youngpersonoryoungadultarenotalsotackledasapartoftheirprogramme.

Comprehensiveindicatedprogrammesshouldincludeinterventionsthataredirectedatassistingyoungerpeoplewith:

thespecificordirecteffectsofthesubstancesthattheyaremisusing;•

reducingfactorsintheirlivesthatmaybemaintainingtheiruse•ofsubstances;

developingtheirresilience;•

healthcareneedsthatareassociatedwithsubstancemisuse;and•

meetingneedsthatareconsequentialontheirmisuseofsubstancesorthe•secondaryeffectsofbecominginvolvedinlifestylesinwhichsubstancemisuseisapart(includingpossibleinvolvementincrime,poorhousingandhomelessness,unemploymentandfailureatschool).

Onceapersonhasbeenassessedasinneedofindicatedprogrammesofintervention,theymayrequiretheservicesofaspecialisedsubstancemisusetreatmentagency.However,acomprehensiveresponsemayinvolvenotonlyspecialisedagencies.Someoftheservicesrequiredmayincludeactivitiesthat

areincludedwithinthecategoryofselectiveandtargetedprogrammesbutalsotheservicesofavarietyofotheragenciesthatmaynotthinkofthemselvesasdealingdirectlywithsubstanceuseormisuse(e.g.schools,colleges,highereducationinstitutions,employersandhousingservices)indeliveringindicatedprogrammesthataremorelikelytobeeffective.

Indicatedprogrammesshouldbeavailabletoeverychild,youngpersonandyoungadultinWalesonthebasisofneed.

Protocolsshouldalsobeinplacewithotherstatutoryservicestoensureallchildren’sneedsaremet.(Safeguarding Children: Working together under the Children Act 2004 Chapter 8.19 refers)

8.3 SpecialisedinterventionsAwiderangeofinterventionsor‘treatments’shouldbemadeavailableforyoungerpeoplewhomisusesubstancesandfortheirfamilies.Theseinclude:

psychologicaltherapiesofferedinone-to-one,grouporfamilysettings,•dependingontheassessedindications

pharmacologicaltreatmentsthataretargetedatthesubstanceofmisuse•inthecasesofdependentusers(seePracticePoint2)

pharmacologicaltreatmentsthataretargetedatcomorbidmentaldisorders.•

Itisvitaltoengageandretainyoungerpeopleininterventionsofthekindthatareprovidedbyspecialisedsubstancemisuseagenciesbecausedurationoftreatmentislinkedtoimprovedoutcome.Interventionshouldencompassassessment,treatmentepisodes(howeverdefined)andaftercareandfollowthrough.Collaborativeworkingwithotheragenciesandprofessionalsisacorecomponentofeffectiveinterventionsforyoungerpeoplewhomisusesubstances.

Thecomponentsofspecialisedinterventionservicesmaybedescribedas:

pre-treatmentservices;•

community-outpatient-basedinterventionsandtreatmentservices;•

Inpatienttreatment;and•

otherresidentialservices.•

8.3.1 Pre-treatmentservices

Youngerpeoplewhoareassessedasrequiringtheservicesofaspecialisedsubstancemisusetreatmentagencymayrequire,inadditiontoafullassessmentandaccesstospecialisedinterventions,theservicesthathavealreadybeendescribedundertheheadingsofuniversalandselectiveortargetedprogrammes.Theyinclude:

primaryprevention,healthpromotionanduniversaleducationservices;and•

earlyinterventionservicesthatareaimedatyoungerpeoplewhohaveused•substancesbuttoalowlevelofseverity.

TheseaspectsofacomprehensiveresponseprovidedbysomespecialisedsubstancemisuseagenciesarecalledPre-treatmentServices.

8.3.2 Communitybasedspecialistinterventionsandtreatmentservices

Therearethreelevelsofintensityofspecialisedinterventionservicethatshouldbeofferedtoyoungerpeopleoutsideofaninpatientsetting.Theyare:

non-intensiveoutpatientprovision(sometimesdefinedaslessthan10hours•perweekofattendanceatanagency);

intensiveoutpatientprovision(sometimesdefinedas10to20hoursper•weekofattendanceataservicethatisofferingastructuredprogramme);and

dayserviceintervention(whichmaybedefinedasmorethan20hoursper•weekofattendanceataservicethatisofferingastructuredprogramme).

Specialisedserviceswillneedtoprovidethefollowinginterventions:

screening/specialisedassessments;•

educationalgroups(e.g.ontheeffectsofdrugs);•

educationservices;•

self-helpprogrammes;•

relapsepreventionprogrammes;•

drugtesting;•

detoxification,substancereductionandmaintenancetreatments;•

mentalhealthservices;•

group,familyandindividualtherapy;•

recreationalactivitiesandpeersocialisationprogrammes;•

linkstospecialistsexualhealthservices;•

otherspecialisedgroupinterventions(e.g.culturalsensitivity;HIV,pregnancy•andparenting;tobaccocessation;independentlivingskills;healthandnutritionetc);

emergencyandout-of-hoursservices;•

home-basedservices,outreachservices,liaisonservices;•

liaisonsubstancemisuseworkerswhoserolesaretoprovideadvice,•signposting,training,consultationandco-workingwithotheragenciesandtothoseagenciesthatprovideotherservicefunctions;

HarmMinimisatione.g.needleexchange(SeePracticePoint3).•

8.3.3 Inpatientservices

Amuchsmallernumberofyoungerpeoplearelikelytorequireinpatientservices.

Theseservicesneedtohaveclearlydefinedoutcomesuccessfactors.

Threelevelsofprovisionforyoungerpeoplewhorequireresidentialservicesareidentified:

medicallymonitoredservices-forthoseyoungerpeoplewhohavesevere•substancemisusedisordersandwhoneed24-houradaysupervisionandmonitoring(usuallyovera7to45daystay);

medicallymanagedservices-thatofferroundtheclockmedicalandnursing•services(e.g.byprovidinglifesupportorsecureservicesusuallyovera7to45dayperiodforeachyoungerperson);and

Medicallydirectedintensiveresidentialcare-foryoungerpeoplewhohave•complexproblemsincludingcomorbidity(maybeforupto6monthsineachcase).

Therangeofinterventionsofferedinresidentialsettingneedtobethesameasofferedincommunityanddayserviceswithanincreasedemphasisonvocationalservices.

ItisimportanttodrawattentiontoWelshHealthCircular(2002)125whichsetsouttheWelshAssemblyGovernment’spolicyontheagerangepatientstreatedbyCAMHS.TheWelshAssemblyGovernment’slongtermobjectiveisthatnochildoryoungpersonshouldneedtobetreatedinanadultfacility.

NSFkeyaction2.8states:‘Whenachildoryoungpersonrequiresadmissiontohospitalorresidentialplacement,eitherinoroutofcounty:

Theyareplacedinsettingswhicharemostappropriatefortheir•developmentaswellasclinicalneeds;

Theyareonlyadmittedtoadultsettingsinexceptionalcircumstances;•

Whenplacedinadultsettings,systemsareinplacetoprotectthem•fromharm.”

8.3.4 Residentialservices

Therangeofpotentialresidentialservicesincludes:

therapeuticcommunitiesforpsychosocialrehabilitation(maybeforup•to6months);

halfwayhouses;•

grouphomes;and•

Specialisedfostercare.•

Fewprovidersofspecialistservicesareabletoofferafullrange.

However,accesstoservicesofthesekindsislikelytorequireanationalapproachtoplanningandshouldincludethecapacityandcapabilitytoarrangeadmissionstothesefacilitiesifandwhenthatisnecessary.

NB Inpatient and residential settings may be more appropriate for younger people who:

have more serious disorders related to substance misuse together with •significant comorbid problems;

are at risk of significant withdrawal syndromes; and/or•

have failed to respond to community-based intensive or day interventions.•

8.4 Organisationofcomprehensivespecialisedintervention servicesBroadly,therearetwopotentialmodelsinwhichcomprehensivespecialisedinterventionservicesofthisbreadtharedelivered:

creatingsingleagenciesorbringingtogetherseparateagenciestoact•asasingleentity;

creatinganetworkofmorelooselyrelatedagencies.•

Intheformercase,forexample,anNHS-fundedspecialistservicemightcometogetherwithavoluntarysectoragencytoprovidenotonlyindicatedbutalsoafullrangeofselectiveortargetedprogrammes.

Ineithercase,networksofrelationshipswithanumberofotherstatutoryandvoluntarysectoragenciesarerequiredinordertocreateopportunitiesforplanninganddeliveringbroad,individualised,needs-led,comprehensiveandwellco-ordinatedpackagesofassessment,intervention,treatmentandcare.

Therefore,Tier3isprovidedbymulti-disciplinaryteamsofstaffwhoareparticularlytrainedandskilledforworkwithyoungpeoplewhomisusesubstancesand/orhavesubstancemisusesyndromes.Workatthisleveloftenrequirescollaborationbetweenchildandadolescentmentalhealth,addiction,education,paediatric,socialandvoluntarysectorservicesandtherearemanyorganisationalpossibilities.

Approachestoensuringthisaggregationofknowledgeandskillsinclude:

creatingnewteamswithinasingleagencyeitherbybringingelements•ofseveralagenciestogetherorbysecondingstaff;

drawingonavarietyofagenciestogathertheappropriateskillsaround•particularyoungerpeopleandtheproblemstheypresentonaneeds-ledandcase-managedbasis(i.e.caseandcaremanagementareusednotonlytodelivercross-agencyactionplansorcareplansbutalsoasavehicletobringagenciestogetheratthestrategicandoperationallevels);

creatingservicenetworksorvirtualteams.Together,theteams,whether•withinasingleagencyprovidedbyseveralagenciesworkingtogetherorthroughvirtualteams,shouldbeabletoassessandmanagethecomplexneedsofyoungerpeoplewhohavemoreseriousproblemsanddisorders.

StafffromtheservicesthatprovidespecialistTier3functionsshouldbeavailabletoadvisestaffwhodeliverTier2functions.StaffwhodeliveractivitiesthatfallintoTier3shouldbeawareofthevariouslocalagenciesandofthereferralpathwaystothem.

8.5 Keyissuesforservicedelivery8.5.1 Leadagencyandleadprofessional

Integrationandcoordinationrequiretheagenciestosubscribetoagreedmodelsofcareand/orcasemanagement,particularlywheninter-agencyplanningisrequired.Providedbyeachoftheothers.Thisframeworkadvocatestheconceptthat,wherethereismorethanasingleagencyinvolved,theyshouldagreebetween

themwhichistheleadagencyineachcaseasthispromotesclarityforclientsandfamilies.WhenSocialServicesareinvolvedbecausethechildisdeemedtobe‘inneed’,onthechildprotectionregister,lookedafteroracareleaverChildren’sServiceswillco-ordinatethecase.

Tothis,isaddedtheconceptofleadprofessional.Thisisthepersonfromtheleadagencywhoisresponsibleformanagingeachcaseandcoordinatingdeliveryofthecarethattheindividualpersonrequires.Localagenciesshouldcometogethertoagreemechanismsforcareorcasemanagement.

8.5.2 Integratingservices

Integratedservicesforchildren,youngpeopleandyoungadultsarethosethatcollaborateandarewellcoordinatedbothwithinandacrossagencies.Boundariesbetweendepartments,withinservicesandagencies,andbetweenagenciesshouldnotbeallowedtobecomefaultlinesintheexperiencesofyoungerpeopleandtheirfamilies.

Goodpracticeinintegrationsuggestsservicesshouldbe:

basedonlonger-termplansandsustainedrelationshipsbetweenagencies;•

consideredfromtheperspectivesoftheirusers;•

commissionedbytheresponsibleauthoritiesonacoordinatedbasistoavoid•replicationandgaps;

basedonawarenessoftherequirementofmanyyoungerpeoplefortheir•needstobedealtwithbyanumberofdifferentagenciesconcurrentlyorsequentially,andaccordingtoagreedplans,timetablesanddistributionsofresponsibilitybetweentheagenciesandsectorsofcare;and

linkedbygoodcommunication,careandcaseplanning,andinformation•sharingprotocolsthatareunderpinnedbylessformalmeansofencouragingprofessionalcontactsandrelationshipsbetweenstaff.

8.5.3 Substancemisuseliaisonfunction(Link workers)

Oneapproachtoimprovingliaisonbetweenthespecialistandgeneralistservicesisforthecreationofsubstancemisuseliaisonorlinkworkers.ThesestaffshouldbehighlyskilledandexperiencedandaremembersofaSpecialisedSubstanceMisuseService.Althoughmostoftheirworkmaybeconductedawayfrombaseandoutsidethephysicalpremisesofaspecialisedservice,theyarespecialists.

Theirrolesarelikelytoinclude:

providingadvicetostaffwhodeliverthefunctionsofTiers1and2;•

advisingonthecontentsofuniversaleducationandselectiveandtargeted•educationprogrammes;

providingadviceonoperationofthecarepathway;•

providingplannerswithadviceaboutsubstancesandtheservicesthat•arerequired;

providingconsultationtostaffwhodeliverthefunctionsofTiers1and2;•

providingteachingandtrainingforthestaffwhodeliverthefunctions•ofTiers1and2;

linkingacrosstheagenciesinanareatoassistwithresolving•communicationproblems;

actingastheleadprofessionalforcertainyoungerpeoplewhohave•complexproblemsandrequirewell-coordinatedcareprogrammes.

8.5.4 Involvingparentsandcarers

Involvingparentsandcarersinservicesforyoungersubstanceusersandsecuringtheirsupportisessentialtoensurecoherentandconsistentmessagesarecommunicated.Familiesareprimaryinfluencesandtheiractiveparticipationislikelytoimprovethetreatmentoutcomesthattheservicecanachieve.

Therefore,servicesshouldworkinpartnershipwithyoungerpeopleand,ifappropriateaccordingtoageandcircumstances,withtheirparents,carersandotherclosefamilymemberstoaddresssubstance-relatedproblemsandtoprovideservicesnotonlyfortheyoungpeople,butalsofortheirfamiliesandfriends.

Mostparentsandcarerswishtobeinvolvedindecisionsmadeaboutinterventionsandtreatmentsandthattheirchildrenreceive.Thisframeworkrecognisesthevaluablerolesthatparents/carerscanplayinassistingyoungerpeoplewhohaveproblemsarisingfromsubstancemisuse.Servicesshouldactivelyencourageparentalinvolvementwithintheboundariesofpolicyandexistingstatuteandcaselawonconsentandconfidentiality.Theremayalsobecircumstancesinwhichparentalconsentismandatory.

Whileprofessionalsshouldseek,ingeneral,todiscussanyconcernswiththefamilyand,wherepossible,seektheiragreementtomakingreferralstolocalauthoritychildren’ssocialservicesthisshouldonlybedonewheresuchdiscussionandagreement-seekingwillnotplaceachildatincreasedriskofsignificantharm.

8.5.5 Handlingtransitions

Servicesshouldbeprovidedonthebasisofneednotonthecriterionofage.Therefore,ifapersonaged18oroverhasneedsthatcanbestbemetbyayoungperson’sservice,thenthisislikelytobethemostappropriateresponseaslongasthiscourseisnotdetrimentaltotheservicebeingofferedtootherclients.Thesamecouldbethecaseforyoungpeopleunder18whorequireaservicethatisbestprovidedbyaserviceforadults.Plannersshould,therefore,allowflexibilitywhenconsideringtransitionalarrangementsalthoughtheymustbeawareoftheregulatoryrequirementsrelatingtochildrenandanyservicesrequiringregistrationundertheCareStandardsAct2000.

Thefollowingpointsshouldalsobeconsidered:

theinterventionelementoftheyoungpeople’sstrandofthisframeworkis•foundedonthehopethatearlyinterventionwillreducetheneedforyoungpeopletouseserviceswhentheyareadults;

allyoungpeoplereceivingassessmentcare,and/orinterventionsfor•potentialoractualsubstancemisuseshouldhaveatransitioncareplanthatisdevisedpriortotheireighteenthbirthday.Thisshouldidentifyany

continuingneedsandtheorganisationsthatarebestabletomeetthoseneedsandincludeneedsarisingfromsubstancemisuse;

inordertoplantransitionarrangements,providersofservicesforadultsand•foryoungpeoplewhoaremisusingsubstancesshouldworktogetherandwiththeotherserviceprovidersthatareinvolved;

keysubstancemisuseworkerswithtransitionalresponsibilitiescouldbe•basedinservicesforadults,butalsoholdsomesessionsinsubstancemisuseservicesforyoungpeople;

acareco-ordinator,whowecalltheleadprofessional,shouldbeidentified•inthecareplanfromwithintheleadagencywhichwillbeSocialServicesifthechildisinreceiptofservicesfromSocialServicesdepartments.Inmanycases,youngpeopleof18whorequireservicesinrespectoftheirmisuseofsubstancesmayalsorequireinterventionsfromothermainstreamservices,suchashousing,educationandprimarycare;and

transitionsofyoungpeopletoservicesforadultsmaytakeplaceatdifferent•agesordevelopmentalstagesdependingontheagenciesinvolvedandtheexpectationsthatfallonthem(e.g.YOTs,SpecialistCAMHSandservicesforchildrenwhoarelookedaftermayhavedifferentarrangements).Transitionarrangementsshouldensurethatthesedifferentarrangementsareincludedinthecareplan,whentheyarerelevant.

8.5.6 Actualandvirtualteams

Agenciesandtheteamswithinthemvaryinstructureandgovernance.Deliveryofimprovedservicecoordinationandintegrationcouldbeachievedbystructuralchangestotheconstructionofteams.Otherwise,secondmentacrossagenciesmightprovideamechanismbywhichspecificexpertisecanbebroughttoexistingservicesinordertobuildmulti-disciplinarysubstancemisuseteamsthatarecapableofprovidingservicesinanarea.

Anotheroptionisthatofdevelopingvirtualteamsororganisationsinwhichprofessionalsfromavarietyofagenciesworktogether,often,innetworkstodelivercareprogrammesforparticularindividuals.Secondmentandvirtualornetworkedteamscanbeextremelyusefulandforward-lookingmechanismsandresultin:

affordingaccesstosubstancemisuseservicesinmainstreamor•genericsettings;

takingopportunitiestodevelopcompetencyinsubstance-related•mattersofgenericpractitionerswhoworkwithchildren,youngpeopleoryoungadults;

developingthefunctionsofferedbygenericormainstreamagencies;and•

developingcloserandbetterintegratedworkingrelationshipsbetween•disciplinesandagenciestominimiseprofessionalrivalryandduplication.

8.5.7 Childprotection

Respondingappropriatelytopotentialandactualchildprotectionconcernsisvital,howeverchallengingandproblematicitistoapplyinsomeinstances.Therefore,itisimperativethatsubstancemisuseservicesmaintaingoodcontinuing

collaborationwithsocialservices.Peoplewhoattendsubstancemisuseservicesarenotalwaysregardedashavingneedsthataresufficientwhentheyarecomparedwiththeproblemsfacedbyotheryoungpeoplethatthesocialservicesencounter.Effectivechildprotectionservicesareespeciallyimportantforyoungpregnantusersofsubstancesandtheremaybeanumberofyoungwomeninthissituationinsomeareas.

SectionD-planning

9. Purposeofsection

ThissectiondescribesaWelshAssemblyGovernmentframeworkfororganisingplanningServicesforChildrenandYoungPeoplewhoUseorMisuseSubstancesthroughoutWales.

Itisrecognisedthattheplanningpartnershipsneededtomaintainanddevelopthecomprehensivepatternofsubstancemisuseservicesrequiredbyyoungpeoplerequirescloseco-operationbetweenhealthandsocialcareplanners.Theseplannersrequireclarityabouthowresponsibilitiesforplanningservicesistobeallocatedbetweenthevarioussectorsandaframeworkwithinwhichtheplanningauthoritiescancometogethertoagreelocal,regionalandnationalplans.

ThissectionsuggestsbringingtogethertheplanningbodiesintopartnershipsandusestheFourTierStrategicFrameworkasatooltodescribethis.

10. Background

DeliveringthepatternofservicesthatimplementtheagreedprioritiessetoutinthelocalChildrenandYoungPeoplesPlan(CYPP)requiresthelocalauthoritiesandtheirpartnerstoco-operateintheplanningofservices.

TheAssemblyGovernmentwishestoseeincreaseduseofjointplanningtoprovideservicesforchildrenandyoungpeople.Section25(6)ofthe2004Actgivesthelocalauthorityanditsmainstatutorypartnersthepowertopoolfundingandshareresources.Chapter4ofguidanceonlocaldutiestocooperate-Stronger Partnerships for Better Outcomes (WAG 2006)-setsoutthebackgroundforthedevelopmentofsucharrangements.EachCYPPprovidesabasisforjointplanninglocally.Shared Planning for Better Outcomes (WAG 2007),reinforcestherequirementtoconsideropportunitiesforuseofpooledfunding(paragraphs2.24-2.26).Pooledfundingcanbeparticularlyvaluableinprovidingservicesforchildrenandyoungpeoplewithcomplexneedswhorequirepackagesofcarefromanumberofagenciesandpartners,suchassubstancemisuseservices.

TheWelshAssemblyGovernmenthasissued“FrameworkGuidanceforCommunitySafetyPartnershipstoCommissionSubstanceMisuseServices”whichemphasisestheimportanceofcomplementaryapproaches,namely:

takingastrategicandsystematicapproachtoplanningservices;•

promotingajointapproachbetweenagencieswithinCommunitySafety•Partnershipstoplanservices;

jointlyplanningacrossCSPboundaries.•

ThePoliceReformAct2002whichcameintoforceinWaleson1stApril2003requiresresponsibleauthoritiesinWalestoensurethataLocalSubstanceMisuseActionPlanisdevelopedandimplemented,theresponsibleauthoritiesarethecouncilforthearea,chiefofficersofpolice,thepoliceauthority,thefireandrescueauthorityandthelocalhealthboard.IndecidingwhattoincorporateintheirLocalSubstanceMisuseActionPlans,responsibleauthoritiesshouldworkinpartnershipwithothermembersofCommunitySafetyPartnerships.

CommunitySafetyPartnerships(CSPs)shouldensurethattheirplansreflectandinformthelocalCYPP.ThroughtheparticipationoftheirmembersinthelocalChildrenandYoungPeople’sPartnership,CSPswillcontributetothesettingofsharedprioritiesandbeabletoensurethattheirworktocommissionsubstancemisuseservicesisbasedonthem.Itisessentialthatbothpartnershipscooperateintheplanningofsubstancemisuseservicesforchildrenandyoungpeople-seeSharedPlanningforBetterOutcomesparagraphs1.27and1.28.

11. Thesuggestedplanningmodel

Withregardstochildrenandyoungpeoplespecificallysomeservices,suchasuniversaleducation,information,healthpromotionandinitialscreeningandassessmentservices(inTier1),arerequiredbyallyoungpeoplewhereasthemostspecialisedcombinationsofservices(atTier4)arerequiredbyaverymuchsmallernumberofpeople.AccesstothespecialisedservicefunctionsofTier3isrequiredbyanintermediatenumberofyoungpeople.

Therefore,Tier1functions(andmanyofthefunctionsofTier2)arerequiredtobeeasilyaccessibleinallcommunities.Tier4functionsaresuchthattheyarelikelytorequireplanningbypeoplewhohaveveryspecialisedknowledge.InbetweenliethespecialistfunctionsofTier3whichalsorequirespecialistknowledge.

Therefore,thisframeworkproposesalayeredframeworkfororganisingplanningfortheseclientsinWales.Figure7.1summarisesthisapproach.

Figure7.1:Aframeworkforplanning

Community Planning Partnerships

National Planning Consortium

Tier 1

Tier 2

Tier 3

Tier 4

Planning Pathway

EducationServicesLASSDNHSYJBCJS

EducationServicesLASSDNHSCSPsYJBCJS

Planning Tier 2 Functions

Planning Tier 3 Functions

Regional Planning Groups

Thismodelprovidesaframeworkfororganisingandallocatingresponsibilitiesforplanningservicesinwhichtheindividualresponsibleauthoritiesfromacrossthesectorsarerequiredtocometogetherinlocal,regionalandnationalgroupings.Inthisway,itisbelievedthatexpertisecanbedevelopedacrossthesectorstoenableeffectiveplanningoftheincreasinglyspecialisedandcomplexservicesatTiers3and4.Moredetailisgivenonthisapproachbelow.

11.1 PlanningTier1TheplanningofthefunctionsofTier1shouldbeorganisedandconductedatCommunitySafetyPartnershiplevel.Atpresenttheseplannerscometogetherindifferentpartnerships.TheplanningofChildrenandYoungPeople’sserviceswillrequireco-operationbetweenCommunitySafetyPartnershipsandChildrenandYoungPeople’sFrameworkPartnershipsineacharea.ApossibleoptionforcollaborationcouldbeaCommunityCollaborativePlanningPartnershipthroughwhicheachoftheplannersthatholdsstatutoryresponsibilityagreestosharethedevelopmentanddeliveryofajointlyownedplanforTier1andthentoplaytheiragreedpartinplanningtheservicesthatfallstotheirsector.

11.2 PlanningTiers2and3EffectiveplanningofTiers2and3functionsrequiresthepoolingofexpertiseandcloseco-operationbetweenareas.TherearemodelsdevelopinginWalesforregionalplanningofservices.OneexampleistheplanningoftheDrugsInterventionProgrammebasedonthepoliceauthorityareasanotheristhenewregionalsystemofCAMHSPlanningNetworks(Cans).

Responsibleauthoritiescouldalsocometogethertocreateregionalplanninggroupsinwhichrepresentativesofeachofthelocalplannersorcollaborativeplanningpartnershipsarebroughttogetherundertheleadershiponeplanningbodycouldthenbeidentifiedastheleadfortheregion.ParticipantscouldpoolbudgetsandstaffresourcesandjointlyemploystaffwhoareabletodevelopsufficientknowledgeandexpertisetoeffectivelycommissionthefunctionsofTiers2and3intheirregion.

11.3 PlanningTier4TheservicesrequiredtodeliverTier4functionsmaybebestcommissionedatanallWaleslevel.TheleadpersonnelfromeachoftheregionalplanninggroupscouldcometogethertoconstituteanationalplanningconsortiumthatcouldberesponsibleforplanningandmanagingtheperformanceofagenciesthatprovidetheTier4functionsrequiredbyalltheyoungpeopleofWales.

Itisrecognisedthatthevarioussectorshaveadopteddifferentapproachestoormodelsforplanning.HowevertheWelshAssemblyGovernmenthaspublishedguidancetoCommunitySafetyPartnerships(FrameworkGuidanceforCommunitySafetyPartnershipstoCommissionSubstanceMisuseServices)andthisguidanceshouldbetakenaccountofwhenplanningservices.

12. Goodpracticeinplanning

In1996,theNHSHealthandDrugsAdvisoryServices(HAS)publishedathematicreviewoncommissioningandprovidingservicesforchildrenandyoungpeoplewhouseandmisusesubstances1.In2001,theHealthAdvisoryService,asuccessorbodytotheHAS,reviewedtheHASreviewatthebehestoftheCabinetOffice.ThefirstHASreportcontainsasubstantialsectiononcommissioningservicesforyoungpeoplewhouseormisusesubstances.Thecontentsofthatsectionwereconfirmedinthereviewof2001.Theprinciplesofgoodpracticeinplanningservicesforyoungpeoplewhouseormisusesubstancesremainunchanged.Theyaresummarised,withupdating,below.

12.1 StrategyItisessentialthatagenciesthatareresponsibleforplanningservicesforchildrenandyoungpeoplebasetheirapproachonajointlyagreedstrategicapproachthatisunderpinnedbythelocalCYPP.Theyshould:

Build,whereverpossible,onexistingmachineryandpreviousstrategy;•

Aligntheirstrategicplanswiththeirbroaderstrategiesforbothchild•andadolescentmentalhealthservicesandforsubstancemisuseservicesforadults;

Includeabalanceofeducational,preventativeandintervention•andtreatmentorientatedapproachesintheirstrategicframework;

Ensurethattheirstrategicplansareagreedandownedbyallpotential•agenciesthathaveplanningresponsibilities,thereby,recognisingtheirinterdependenceinproducinganeffectivesystemofservices;and

Identifyandprioritiseintheirplansthehighriskgroups(e.g.intravenous•drugusers,pregnantdrugusersanduserswithahighriskofsuicide).

12.2 Developingtheknowledge-basePlannersofsubstancemisuseservicesforchildrenandyoungpeoplemusthavesoundknowledgeoftherequirementsofchildren,youngpeopleandyoungadultswhohaveproblemsarisingfromtheiruseormisuseofsubstancesandtheeffectivenessofpotentialinterventions.

Theinformationrequiredtodevelopsuchasoundknowledge-basefallsintoanumberofdifferentcategories.Theseinclude:theagreeddefinitionsofuseandmisuseadoptedbyWelshAssemblyGovernment;thenatureandextentofsubstancemisuseintheareatheycover;thenature,capabilitiesandcapacitiesofthenon-statutoryandstatutoryserviceprovidersintheirarea;andtheeffectivenessoflocalservices.JointneedsassessmentandmappingofcurrentprovisionareessentialtounderpinjointplanningandshouldbecarriedoutaspartontheintegratedprocessundertakenbytheChildrenandYoungPeople’sPartnershipinpreparingtheirCYPP.Theprocesswillbesupportedby:

1TheSubstanceofYoungNeeds,1996,HMSO.

Consultationwithnon-statutoryalcoholanddrugagenciesonthenumbers•oftheirclients,theirpatternsofuseandmisuse,andthenatureofservicesthattheyoffer;

Engagementwiththeservicesthatareinvolvedinsmokingreduction;•

Informationgatheredfromschools,socialservicesdepartments,theyouth•justiceservicesandYOT,theprobationserviceandthepolice;

Consultationwithcommunityorganisations,includinganythatworkwith•differentethniccommunities;

Understandingthevariousdefinitionsofuseandmisuseadoptedbylocal•agenciesandrecognisingiftheyaredifferentfromtheWelshAssemblyGovernmentdefinitionsinordertoestimatethewaysinwhichthesedefinitionseffecttheprocessesofneedsassessmentandtheirperceptionsofpeoplewhorequireservices;

Awarenessoftheclinicalandsocialeffectivenessofparticularservicesand•methodsofeducation,preventionandinterventionthatareavailablelocallyaswellasnationally;and

ReviewingliteraturefromorganisationssuchasAlcoholConcernandthe•StandingConferenceonDrugAbuse(SCODA)andacademicinstitutionswithaninterestinthetopicareas.

12.3 ResponsivenesstothelocalpopulationPlannersshouldberesponsivetotheneedsoftheirlocalpopulationtodevelopaneffectiveclimatewhendevelopingtheirplansandservices.Theyshouldbeawareofthefollowingkeypoints:

Thebaselineofpublicunderstandingandempathymaybelowinthisfield;•Plannersmaychoosetoinvestinpubliceducationinitiativestocounterthis;

Theremaybeadifferenceofviewsbetweenyoungpeopleandtheircarers•andeachvoicemustberecognised;

Carers’(usuallyparents’)needsshouldbemetinadditiontothoseof•theirchildren;

Theroleofthemediaissignificantinthisfield;itscontributioncan•beunhelpfulby,forexample,stigmatisingindividualsorganisations,schoolsorlocalities;oritcanbehelpfulbyaidingpubliceducation;

Buildingcontactswithdifferentethnicgroupsisessentialinworkingtowards•trustingrelationshipswiththeacceptedleadersofthedifferentculturalgroupsandplannersmustbeawareofthedangersofracialorculturalstereotyping;and

Thepopulationofyoungpeoplewhomaybenefitfromservicesmaybe•transient,especiallyininner-cityareas,andpeoplewhoareathighriskmayrequireliaisonacrossgeographicalboundariesifservicesaretobetargetedeffectivelyonveryvulnerableyoungpeople.

12.4 PartnershipswithprovidersofservicesDevelopingservicesforyoungpeoplewithproblemsarisingfromtheiruseormisuseofsubstancesdependsonthematurityofrelationshipsbetweenthevariousplannersandbetweentheplannersandtheprovidersofservices.Thefollowingissuesaresignificantinthisprocess:

Thereisawidevarietyofprovidersinthefieldandthismayresult•inindividualserviceshavingcontactswiththesameindividualswhethertheyknowitornot.

Therearemanyservicestowhichyoungpeoplewhoaremisusing•substancesmayturntoinemergenciesorformoreroutinecare.Stepsmustbetakentoensurethatpoorcontactsbetweenservicesorlackoffamiliarityofprofessionalswithsubstancemisusedoesnotjeopardisethecareofindividualsorreduceservicequality.

Manyprovidersareinthenon-statutorysector.Theorganisationalculture•oftheseagenciesisdifferenttothatofthestatutorysector.Plannersmustunderstandthesedifferencesinordertomaximisethecontributionofthevoluntarysector.

Itislikelythatdifferentprovideragenciesofferdifferentelementsof•theservicesrequiredbyyoungpeoplewhouseormisusesubstances.Plannersshouldleadbycreatingaclimateinwhichallprovidersoperatetogetherintheinterestsofyoungpeoplethrougheffectiveco-ordinationoftheircontributionsforacomprehensiveservice.

Appropriateinformationsharingisenabledbymutualorganisational•relationships.Providersofservicesshouldnotbeburdenedbyrequestsforinformationforwhichtheymaynotbeabletoseetherelevance.

12.5 EffectivecollaborationThelocalChildrenandYoungPeople’sPartnershipcansupportcooperationamongcommissioningauthorities,otherplannersandorganisations.Cooperationwillpromoteconsistentpoliciesprovidingintegratededucation,preventionandinterventionservicesforyoungpeople.Thefollowingshouldbenoted:

Thisfieldisparticularlyappropriateforjointplanning.Keyplannersare•localhealthboards,socialservicesdepartments,educationdepartments,housingdepartments,CommunitySafetyPartnerships,probationservices,andtheYouthOffendingService.Voluntarysectorprovidersalsohaveaparttoplayandcancontributeresourcestopooledfundingarrangements.

Anyplanforeducationandpreventionwill,ofnecessity,requireeffective•planningandserviceprovideralliancesthatinvolvehealth,socialandeducationservices,theyouthservices,theleisureservices,housingdepartments,theprisonservice,theYouthJusticeBoard,YouthOffendingTeamsandCommunitySafetyPartnerships.

12.6 Effectivenessthroughcontractingorservicelevel agreementsCommissioningagenciesshouldagreeeffectivecontractsorservicelevelagreementswiththeorganisationsthatprovideservices.Theseshouldincludedetailsonthemonitoringandperformancemanagementprocesses.Thismeansthat:

Contractsorservicelevelagreementswithnon-statutoryprovidersshould•bebasedinarobustframeworkmaximisethecontributionoftheseproviders(thatis,theyshouldbelonger-termagreements,whichcontainnegotiatedandrealisticperformancemanagementprocedures);

Whereverpossible,contractsorservicelevelagreementsshouldbebased•onmainstreamfunding;

Contractshoulddetailnotonlythedirectserviceneedsofindividuals•butalsotheneedsofstafffortraining,adviceandconsultancyandresearch;

Plannersshouldcollaborateoncontractingforspecialisedservicesat•Tiers2and3;

Withinthecontextofthelowbaselineofthededicatedservicesat•Tiers3and4,itisimportantthatplannersestablishcontracts/servicelevelagreementsthatrecognisetherolesofservicesnotspecificallydedicatedtomeetingtheneedsofyoungpeoplewhomisusesubstancesbutwhichmaybeappropriatelyusedforthispurpose.Betweenthemtheyshoulddeviseandofferaneffectivesystemofqualitycontrolthatiscapableofsustaininghigh-costlow-volume,highlyspecialisedservices;

Agreementsshouldfollowapurposefulstructurethatstatestheintended•rolesofproviderandcommissionerofferingclarityaboutjointlyagreedinputs,outputsandoutcomes.

12.7 Organisationalfitness/commissionerselfassessmentInordertodevelopaneffectiveplanningapproachtotheservicesrequiredbyyoungpeoplewhomisusesubstances,thecommissioningauthoritiesmusthavetheappropriateorganisationalcapability.Inthisrespect,plannersmayfindithelpfultoundertakeaselfassessmentbasedonthefollowingquestions.

Whointheauthority/organisationhasanyknowledgeofthisfield?•

Istheorganisationawareofitsresponsibilitiesassetoutintheframework?•

Howlargeistheorganisationaldividebetweenservicesforyoungpeople•whosmoketobacco,useormisusealcoholanduseormisusedrugs?

Howseniorarethepeoplewhohaveplanningresponsibilitiesofservice•inthisfieldandwhatownershipdotheauthoritieshaveforyoungpeopleinneed?

Doestheauthorityshoworrespondtoleadershipinaddressingtheneeds•ofyoungpeoplewhouseormisusesubstances?

Areanyservicesforyoungpeoplewhouseormisusesubstanceslost•intheorganisationalstructureofcurrentproviders?

Istheagencyclearastowhetheritisplanningeducationandhealth•promotionservices,preventionservicesand/orspecialistassessmentandinterventionservices?

Cantheagencyidentifytheresourcesthatitisininvesting,eitherdirectly•orindirectly,inservicesforyoungpeoplewhouseormisusesubstances?

12.8 PerformancemanagementPlanninginvolvesperformancemanagementaswellasdeterminingwhichservicesaretobedeliveredandbywhom.

Themostobviousroleinthissphererelatestothemeasurestakenbyplannerstoidentifywhetherornottheperformanceandqualityoftheagenciesthatprovideservicesisadequate.

However,itisimportanttoemphasisethatthequalityofperformanceofprovideragenciesisnotonlyrelatedtotheirowncapacity,capabilitiesandquality,butisaffectedsubstantiallybythequalityofperformanceoftheplanners.Experienceshowsthatthescope,qualityandvolumeofservicesdeliveredtothepublicarerelatedtothenatureoftheservicesthathavebeencommissionedandtheresourcesthatplannershavemadeavailabletotheirproviders.

Therefore,performancemanagementcanberelatednotonlytotheactivitiesofprovidersofservicesbutalsototheprinciplesofgoodplanningthataresummarisedinthissection.

12.9 Animprovementcycleforservicesforyoungpeoplewho useormisusesubstancesPlannersareprimarilyresponsibleforthemaindevelopmentsandchangescalledforinthisframework.ChildrenandYoungPeople’sPartnershipsandCommunitySafetyPartnershipssharecommonmembershipandshouldworktogethertoensurethattheirseparateandsharedplansdriveforwardtherequiredservicedevelopmentsinthefourtiersofserviceacrossawiderangeofactivities(i.e.ineducation,youthwork,housing,socialservices,healthservices,andemploymentsettings).ThisshouldleadtoappreciationofthesuccessesandthegapsinmountingservicesinWales.Thisinformation,takentogetherwiththisframework,shouldleadtheplannerstoidentifyannualimprovementcyclesorplansforservicesforyoungpeoplewhouseormisusesubstancesorareatriskofdoingso.

12.10StandardsandstandardsettingPlannersmaywishtoengageinconversationswiththeirproviderswithaviewtoexploringwhetheranetworkshouldbesetuptoestablishdevelopmentalstandardsforsubstancemisuseservicesforyoungpeoplethatreflectWelshpolicyandtheprinciplesofgoodpractice.Informationderivedfromsuchaserviceislikelytobehelpfulinensuringthatanincrementalapproachistakentodevelopingthequalityoftheservices.Thevalues,principles,aimsandobjectivesprovidedinthisframeworkalsoprovidesabaselinefordevelopinglocalstandardsagainstwhichservicesmightbeexpectedbytheirplannerstodevelop.

Onesuchserviceisalreadyavailable:QualityinAlcoholandDrugsServices(QUADS).‘OrganizationalStandardsforAlcoholandDrugTreatmentServices’2isahelpfuldocument.

2Drugscope,1999.

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