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© Crown copyright June 2008
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
© Crown copyright June 2008
CMK-22-04-045 (082)
D1430809
1
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
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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
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Purposeofdocument
Substancemisuseinchildrenandyoungpeoplepresentsamajorpublichealthchallenge.TheUKhassomeofthehighestratesofyoungpeopleaged15-16usingormisusingsubstancesinEurope.Currentlytherearerisingtrendsintheuseofalcohol(particularlybyyoungwomen)andbingedrinkinghasincreaseddramatically.
Thisdocumentaimstoassistplannersandserviceprovidersinestablishingeffectiveservicesforyoungpeopleinrelationtosubstancemisuse.Althoughevidencefortheeffectivenessofinterventionsinthisareaislimitedthereareemergingthemesofgoodpracticethatcanhaveapositiveimpact.Thisguidanceaddressesandhighlightstheseandpresentsaframeworkfororganisationsandagenciesthathaveresponsibilitiesandaninterestinthisarea.
Thedocumentisinfoursections:
SectionA-SummariesofGoodPractice
SectionB-Context
SectionC-Programmesandinterventions
SectionD-Planning
ThedocumenthastobereadinthecontextofpreviousgoodpracticeframeworksforsubstanceissuedbytheWelshAssemblyGovernmentparticularlythoseforneedleexchange,inpatientcareandresidentialrehabilitation.
SimilarlytheframeworkneedstobeconsideredinthecontextofstrategiesaimedatthehealthandwelfareofchildreninWalesandrelevantlegislationsomeofwhicharehighlightedbelow.ThisincludestheMentalCapacityAct2005.
TheFrameworkhasbeenproducedbyasubgroupoftheWelshAssemblySubstanceMisuseProjectBoardandisbasedonworkcommissionedfromtheWelshInstituteofHealthandSocialCarein2006.
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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.
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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
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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;
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.•
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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.
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ThisissuesuicidepreventionisaddressedinmoredetailintheWelshAssemblyGovernmentSuicidePreventionActionPlan.
2.13 KeycomponentsThisframeworkaddressesthekeycomponentsofacomprehensiveresponsetothethreatsposedtochildrenandyoungerpeoplebyavarietyofsubstances.Thesecomponentsare:
UniversalEarlyEducationProgrammes• -theseconveyaccurateandbalancedinformationaboutsubstancesandtheiruseandmisusetochildrenandyoungpeople;
TargetedProgrammes• -thatenablechildrenandyoungpeopletotakepartindiscussionsamongthemselvesandwithwell-informedadultsaimedatimprovingtheirunderstandingofhowtheycanrespondtotheendemicpresenceofsubstancesinourcommunities;
InterventionsToImprovePotential• -theseexisttopreventchildren,youngpeopleandyoungadultsmovingfromusetomisuseofsubstancesbyanticipatingtheimpactsofrisk/protectivefactorsandincreasingindividuals’resilience;
IndicatedProgrammes(generallyreferredtoastreatment)• -theseareprovidedasindividualisedandplannedprogrammesofassessment,interventionandcareforcertainidentifiedchildrenoryoungpeoplewhoaremisusingsubstances.
GoodpracticeisreferredtothroughoutPartBofthedocumentandanumberofmoredetailedappendiceshavebeenincludedformoredetailedspecificgoodpracticeinareassuchasprescribingandassessment.
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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.•
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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;•
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physicalillhealth;•
teenageparents;•
childrenofparentswhomisusesubstances;•
childrenandyoungpeoplewhoarecarers;•
childrenofparentswithamentaldisorder;•
involvedwithcrimeandyoungerpeopleincontactwiththecriminal•justiceservices;
childrenlookedafterbylocalauthorities;•
homelessyoungerpeople;•
subjecttoprostitutionorsexualexploitation;and/or•
exposedtosexualabuse.•
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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.
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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.
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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.
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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.
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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.
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Manypreventionservicesalsoincludeattentiontoreducingriskfactorsandbuildingresilience.Theyare,therefore,compoundsofthetwobroadtypesofselectiveortargetedprogrammers.Forexample,preventionpackagesmayincludesocialinclusionprogrammersthatofferarangeofsportsandotheractivities.Theparticularintentionistoensurethatchildrenandyoungpeoplestayengagedwiththemorespecificorspecializedcomponentsoftheprogrammedandarebetterabletore-engagewiththeirfamilies,educationandthecommunitywithoutrunningtheverysamerisksthatcontributedtothemmisusingsubstances.
Preventionservicesalsorequirethecapacityandcapabilitytofacilitatetheirclients’accesstoawiderangeofcommunityservices.Again,theintentionistoensurethattheyoungerpeopleinvolvedhaveaccesstocorehealth,education,housingandfamilysupportservicesandthattheyalsohavepromptaccesstospecialistsubstancemisuseservicesforyoungerpeoplewhentheresultoftheassessmentisthattheyarerequired.
Generallythekindsofinterventionprovidedbypreventionservicesareearlyinterventionservicesthatareaimedatyoungerpeoplewhohaveusedsubstancesbuttoalowlevelofseverity.Youngerpeoplewhoseneedshavegonebeyondtheselevelsusuallyrequiretheindicatedservicesofspecialisedsubstancemisusetreatmentagencies.
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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
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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.
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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);
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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.•
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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
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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;•
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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
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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
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collaborationwithsocialservices.Peoplewhoattendsubstancemisuseservicesarenotalwaysregardedashavingneedsthataresufficientwhentheyarecomparedwiththeproblemsfacedbyotheryoungpeoplethatthesocialservicesencounter.Effectivechildprotectionservicesareespeciallyimportantforyoungpregnantusersofsubstancesandtheremaybeanumberofyoungwomeninthissituationinsomeareas.
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SectionD-planning
9. Purposeofsection
ThissectiondescribesaWelshAssemblyGovernmentframeworkfororganisingplanningServicesforChildrenandYoungPeoplewhoUseorMisuseSubstancesthroughoutWales.
Itisrecognisedthattheplanningpartnershipsneededtomaintainanddevelopthecomprehensivepatternofsubstancemisuseservicesrequiredbyyoungpeoplerequirescloseco-operationbetweenhealthandsocialcareplanners.Theseplannersrequireclarityabouthowresponsibilitiesforplanningservicesistobeallocatedbetweenthevarioussectorsandaframeworkwithinwhichtheplanningauthoritiescancometogethertoagreelocal,regionalandnationalplans.
ThissectionsuggestsbringingtogethertheplanningbodiesintopartnershipsandusestheFourTierStrategicFrameworkasatooltodescribethis.
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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.
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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
CSPs
EducationServicesLASSDNHSCSPsYJBCJS
Planning Tier 2 Functions
Planning Tier 3 Functions
Regional Planning Groups
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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.
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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.
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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.
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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.
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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?
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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.
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Onesuchserviceisalreadyavailable:QualityinAlcoholandDrugsServices(QUADS).‘OrganizationalStandardsforAlcoholandDrugTreatmentServices’2isahelpfuldocument.
2Drugscope,1999.