Residential Rehabilitation: Supporting Public Health Scotland with their National Mission

Background to the research

The level of harms from alcohol and drugs in Scotland are high in comparison to the rest of the UK and Europe.[i] We know from our work across many policy areas that individuals who use alcohol and drugs often have multiple and complex support needs, including challenges around physical and mental health, poverty, and unstable housing.[ii]

The Scottish Governments’ National Mission (January 2021) was launched as a series of interventions designed to ensure tackling drug-related deaths and harms became an even higher national priority.[iii] As part of this, one of the aims is to increase capacity and use of rehabilitation services.[iv]

Residential rehabilitation offers person-centred, evidence-based support, for as long as people need it. This is based on evidence that suggests this leads to reduced substance use, improved health and quality of life.[v]  Ease of access to residential rehabilitation services has been highlighted as important, as has high-quality treatment, wrap-around services to support preparation for residential rehabilitation, and available aftercare[vi] to sustain recovery.

We were commissioned by Public Health Scotland (PHS) to evaluate two of their work packages around residential rehabilitation, on behalf of the Scottish Government:

• One of these explored the perceptions of residential rehabilitation from organisations that had the capacity to refer people into it, including those in voluntary and statutory drug and alcohol support services, criminal justice and primary care services.
• The other work package we evaluated was around the provision of post-residential rehabilitation housing, employability, and recovery support services.

These were part of Public Health Scotland’s wider evaluation of the Scottish Government’s Residential Rehabilitation programme. In both studies, the aim was to capture a baseline of evidence to inform development of the  programme and assess progress in the coming years.

Our methods

To understand the views of referrers, we conducted scoping interviews with Alcohol and Drug Partnerships and associated stakeholders to help inform our survey design, and to build the sample of referral organisations across Scotland. Our survey research focused on baselining attitudes and perceptions to residential rehabilitation, and exploring what was shaping them. By the end of our research, we had 168 completed surveys from a range of organisations across Scotland. Most participants we spoke to worked at statutory or third sector drug and/or alcohol services, with a smaller proportion working for criminal justice services or other organisations.

Challenges of the research

Accessing a sample of organisations that could refer to rehabilitation was challenging. Public Health Scotland weren’t aware of exactly how many organisations were referring in each geographical area, so it was also difficult to have a clear sense of what a good level of response should be.

We overcame this challenge by working collaboratively with Public Health Scotland and Scottish Government to help us access specific referrers from existing databases and widen our sample through their networks with colleagues in criminal justice and primary care (primarily GPs). We made approaches to all organisations we found details for. However, it is likely that those who are more interested or engaged with residential rehabilitation were more likely to have taken part so we cannot claim the sample is truly representative.

With the second study, we also found engaging with organisations providing post-rehabilitation support was a challenge. We put a lot of energy into the recruitment for the three workshops covering recovery, housing, and employability support, but participants were overwhelmingly from the third / voluntary sector. We didn’t have good representation from public sector or private sector providers of post-rehab support.

Findings of the referrer survey

Our survey indicated that:

• General awareness of residential rehabilitation facilities and treatment provision was high, but was lower for specific support such as women or family focused facilities.
• Only a small proportion of clients seen, ended up being referred to residential rehabilitation.
• Previous exposure to residential rehabilitation and referral to it tended to create more favourable attitudes towards it as a treatment option (and vice-versa).
• Views around residential rehabilitation tend to be complex – it’s seen as both an effective treatment option by many, but also is seen as potentially creating additional vulnerabilities post support and can be felt to increase the risk of death too.
• Clients losing motivation was the most common barrier to referral, as well as client understanding and clients not meeting facilities’ abstinence requirements.
• Lack of spaces and long waiting times – both for rehabilitation itself and for related services such as detox – were also a common challenge.
• Referrer suggestions for overcoming barriers included greater provision of aftercare, increased funding and resourcing, and more information and guidance.

Recommendations

• We recommended that exploring options for a national framework of common standards in referral – this could streamline processes and help referrers feel more confident in their decision making, while reducing the potential for historical biases against residential rehabilitation as a treatment option.
• We also suggested that to increase referral rates overall, simplifying the referral process, making it more consistent and more effectively engaging to referrers who have less experience with residential rehabilitation will all be important steps to follow. Removing practical barriers such as waiting times for referral and ensuring there are clear links to (and availability of) aftercare services will also be important.

Findings of the post-rehab workshops

Our findings indicated that:

• More work is required to support joined-up working between residential rehabilitation providers and post-rehabilitation providers, despite this being the most common route to post-rehabilitation support.
• Good information sharing about referred clients’ needs, knowledge sharing about different support methods, and providers training other providers in specialist types of intervention all helped to support joint-working.
• There are opportunities to enhance collaboration in two key stages of clients’ rehabilitation journey.
  • First, at the beginning, between residential rehabilitation providers and housing and employability support services.
  • Second, after rehabilitation, between third sector support providers and the statutory sector.
• Factors supporting joined-up working included more funding being available to the post-residential rehabilitation support sector to help reduce competition between providers, and to encourage greater use of remote communication tools to build close relationships between staff across different providers.
• Overall, we found the post-residential rehabilitation support provision sector to be not yet be fully aligned with a person-centred approach, with potential to improve.

In terms of how we might move forward, we suggested that:

• Eligibility criteria for different statutory support providers can be inconsistent so it is important to consider how to remove any barriers this provides to support. Similarly measuring outcomes more consistently across different providers practical and legal guidance to help them share data more effectively will help to support more effective joined-up working.
• We recommended that developing a formalised network of post-residential rehabilitation support providers may help to encourage collaboration and knowledge sharing, including helping to raise awareness of new/evolving support across the system.

Next steps

These were two fascinating pieces of research in a complex and evolving policy area. We had the opportunity to share our findings with a huge range of stakeholders from across the public health system in Scotland and know that these findings have provided important input into the next phase of the National Mission to tackle drug deaths in Scotland.

[i] Drug-related deaths in Scotland in 2021, Report (nrscotland.gov.uk)

[ii] National Mission on Drug Deaths: Plan 2022-2026 (www.gov.scot)

[iii] Drugs policy – update: statement by the First Minister – 20 January 2021 – gov.scot (www.gov.scot)

[iv] National Mission on Drug Deaths: Plan 2022-2026 (www.gov.scot)

[v] Residential Rehabilitation: A Review of the Existing Literature and Identification of Research Gaps within the Scottish Context (www.gov.scot)

[vi] Residential Rehabilitation: A Review of the Existing Literature and Identification of Research Gaps within the Scottish Context (www.gov.scot)