Key messages
Drug and alcohol services in Scotland
Prepared for the Auditor General for Scotland and the Accounts Commission
March 2009
Auditor General for Scotland
Acknowledgements:

Audit Scotland would like to thank everyone who provided information and assisted us with this study.
 
Sally Thompson managed the project, with support from Mike McCarron (consultant), under the general direction of Claire Sweeney.

The Auditor General for Scotland is the Parliament’s watchdog for ensuring propriety and value for money in the spending of public funds. 

He is responsible for investigating whether public spending bodies achieve the best possible value for money and adhere to the highest standards of financial management. 

He is independent and not subject to the control of any member of the Scottish Government or the Parliament. 

The Auditor General is responsible for securing the audit of the Scottish Government and most other public sector bodies except local authorities and fire and police boards.

The following bodies fall within the remit of the Auditor General: 

•	directorates of the Scottish Government
•	government agencies, eg the Prison Service, Historic Scotland 
•	NHS bodies 
•	further education colleges 
•	Scottish Water 
•	NDPBs and others, eg Scottish Enterprise. 

Note:
Prior to September 2007, the Scottish Administration was generally referred to as the Scottish Executive. It is now called the Scottish Government. When dealing with the earlier period, this report refers to the Scottish Executive. Recommendations for the future refer to the Scottish Government.

The Accounts Commission
The Accounts Commission is a statutory, independent body which, through the audit process, assists local authorities in Scotland to achieve the highest standards of financial stewardship and the economic, efficient and effective use of their resources. The Commission has four main responsibilities:

•	securing the external audit, including the audit of Best Value and Community Planning
•	following up issues of concern identified through the audit, to ensure satisfactory resolutions
•	carrying out national performance studies to improve economy, efficiency and effectiveness in local government
•	issuing an annual direction to local authorities which sets out the range of performance information they are required to publish.

The Commission secures the audit of 32 councils and 41 joint boards (including police and fire and rescue services). Local authorities spend over £19 billion of public funds a year.

Audit Scotland is a statutory body set up in April 2000 under the Public Finance and Accountability (Scotland) Act 2000. It provides services to the Auditor General for Scotland and the Accounts Commission. Together they ensure that the Scottish Government and public sector bodies in Scotland are held to account for the proper, efficient and effective use of public funds.

Key messages
Background

1. The impact of drug and alcohol misuse in Scotland is widespread. Both individuals and society more widely are affected in terms of health, child protection, crime, community safety, housing, employment and social exclusion. Drug and alcohol misuse are problems across the whole of Scotland but particularly affect people living in deprived areas.1  

2. The links between drug and alcohol misuse and efforts to address them are complex and inter-related, and many services are aimed at both drug and alcohol misuse. Numerous public sector organisations are involved in providing services, including the NHS, councils, the police and the prison service. The voluntary sector is a key partner in delivering services for drug and alcohol misuse. Multi-agency partnership working for drug and alcohol problems has been in place for around 20 years.

3. The Scottish Government has launched new strategies for drugs and alcohol in the last 12 months: The Road to Recovery: A new approach for tackling Scotland’s drug problem in May 2008 and Changing Scotland’s Relationship with Alcohol: A framework for action in March 2009.

The study
4. The aim of our study was to identify how much the public sector spends on ‘labelled’ drug and alcohol services.2 We also assessed whether evidence of need or what works determines how this money is used and what impact the money has had. We examined: 

•	the extent and impact of drug and alcohol problems in Scotland
•	the main areas of spend on drug and alcohol services
•	how effectively this money has been spent 
•	joint working to plan and deliver drug and alcohol services. 
5. In this study, we:

•	analysed published information on services and reviewed national documents
•	collected and analysed expenditure data from all NHS boards and councils. In the absence of cost information from police services, we collected activity data from all police forces in Scotland to give an indication of expenditure
•	carried out focus groups with people who have problems with drugs and alcohol, families directly affected by drug and alcohol misuse, local drug and alcohol partnership support staff and voluntary and private sector service providers
•	interviewed staff and reviewed documents from agencies commissioning or providing drug and alcohol services. 
6. We did not collect information on the wider costs associated with drug and alcohol misuse as existing research is available and referred to in our report. This research covers costs relating to generic services such as accident and emergency (A&E) departments, and wider economic and human costs such as the estimated cost of lost earnings and deaths due to drug and alcohol misuse.

Key messages

1
 Scotland has high levels of drug and alcohol misuse compared to the rest of the UK. Drug and alcohol-related death rates are among the highest in Europe and have doubled in the last 15 years. Drug and alcohol misuse are found across society but people who are likely to be excluded from society and those living in deprived areas are most affected. 

7. Scotland has high levels of drug and alcohol misuse compared to the rest of the UK. The levels of problematic drug misuse in Scotland are double that of England and the levels of alcohol dependency are a third higher.3, 4  

8. Alcohol misuse is a bigger problem than drug misuse both in terms of the number of people misusing and the harm caused to health. Almost two per cent of the population are estimated to be problematic drug users while almost five per cent of the population are estimated to be dependent on alcohol.5, 6, 7   

9. Drug and alcohol-related death rates are among the highest in Europe and have doubled in the last 15 years.8, 9  Scotland has the highest recorded rate of drug and alcohol-related deaths in the UK.10 

10. There is a clear link between poverty and problematic drug use, particularly heroin and crack cocaine.11 The relationship between alcohol and deprivation is more complex. People in professional households are more likely to exceed the recommended weekly limits, but those living in the most deprived communities experience more health problems because of their drinking.12  People living in the 20 per cent most deprived communities are around six times more likely to be admitted to hospital and to die due to alcohol misuse than those from the most affluent areas.13 

11. People who are likely to be excluded from society, such as prisoners, homeless people and people with mental health problems are more likely to have problems with drugs and alcohol than the rest of society. Up to three in four people using drugs have mental health problems, and up to one in two people with alcohol problems may have a mental health problem.14 Audit Scotland is publishing an overview report of mental health services in Scotland in May 2009. 

2
 In 2007/08, the public sector spent £173 million on drug and alcohol services in Scotland, £84 million specifically on drug services and £30 million on alcohol services. The remainder was spent on joint drug and alcohol services. Funding arrangements are complex and projects can have a number of separate funding streams, each with different timescales and reporting criteria. This is an added difficulty for those planning and providing services.

12. It is currently estimated that the wider economic and social costs of drug and alcohol misuse in Scotland are almost £5 billion a year, £2.6 billion for drug misuse and £2.25 billion for alcohol misuse.15, 16 Both figures are believed to be under-estimates.

13. These estimates include wider health economic costs and the cost to the Scottish economy. For example, criminal justice costs of £2.7 billion include estimates of police time dealing with alcohol misuse (£288 million) and the costs of dealing with drug-related crime (£684 million). Health costs include A&E attendances (£46 million) and hospital inpatient care (£273 million). The health costs for alcohol misuse are greater than those for drug misuse. Costs to the economy include people being absent from work (£286 million). 

14. Using locally provided data, plus national labelled spend, we estimate that a total of £173 million was spent in 2007/08 on drug and alcohol services by the public sector, including NHS boards, councils, police, the Scottish Prison Service and the Scottish Government. 

15. There are, however, differences in the way budgets are recorded in each local area and the way that services are provided. Many services for people misusing drugs and alcohol are delivered as part of general services and funding will not be labelled as specifically for drug or alcohol services. This makes it difficult to give comprehensive figures for what is spent on drugs and alcohol.

16. Sixty-eight per cent of direct expenditure on drug and alcohol services is spent on treatment and care, including residential treatment and community treatment such as methadone. The recent Scottish Government strategies for drugs and alcohol emphasise the importance of prevention. However, in 2007/08, only six per cent of direct spend was on preventative activities. This includes interventions for children affected by parental substance misuse.17  Enforcement and regulation activities account for five per cent of the direct spend on drugs and alcohol.18,19  

17. In 2007/08, almost half of the money spent by NHS boards and councils was on dedicated drug services (£77 million) and a sixth on dedicated alcohol services (£26 million).20 This does not reflect the scale of the respective problems, for example the number of alcohol-related deaths in Scotland in 2007 (1,399) was three times higher than the number of drug-related deaths (455). The amount spent on alcohol services should increase as the Scottish Government has allocated an additional £85.3 million for alcohol misuse over the three years from 2008/09 to 2010/11; most of this money will go to NHS boards 
(£24.8 million in 2008/09).

18. The amount that NHS boards and councils spend on drug and alcohol services varies across the country, from almost £14 per head of population in the Borders to just over £53 in Greater Glasgow and Clyde.21  The scale of this variation in spend is not explained by differences in the levels of drug and alcohol misuse in a local area or by the levels of harm caused as a result of the misuse, for example, spend does not reflect local  levels of drug misuse (Exhibit 1).

19. Funding for drug and alcohol services is complex and can be short term with money coming from a variety of sources. Funding can come from NHS ring-fenced allocations, NHS unified budgets, council general allocations, specific grant funding, the voluntary sector, the police and the Scottish Prison Service. This can make transparency of funding, planning and long-term stability for services difficult and creates a significant administrative burden on service managers. 

20. The voluntary sector provides many drug and alcohol services. In 2007/08, around a third of direct expenditure on treatment and care was spent on services provided by the voluntary sector. In our focus group, voluntary sector representatives reported that the funding arrangements are particularly challenging for them, as projects are often supported by numerous funding streams with different timescales and reporting mechanisms. The funding arrangements of the voluntary sector project Greater Easterhouse Alcohol Awareness Project (GEAAP) in Glasgow highlight the complexity of these arrangements. This is despite the Addictions Partnership in Glasgow coordinating funding on behalf of a range of statutory agencies in an attempt to streamline arrangements (Exhibit 2, overleaf). 

21. The introduction of the concordat between the Scottish Government and COSLA in April 2008 has given councils, with their partners, greater discretion to allocate resources according to perceived local needs and priorities.22, 23 This has been achieved through the removal of ring-fenced funding. However, there is a risk that without good information systems in place it will be difficult to know whether drug and alcohol projects secure the necessary funding. 

3
There is variation across Scotland in the range and accessibility of drug and alcohol services. The Scottish Government has not set out minimum standards in terms of range, choice and accessibility that service users and their families can expect to receive. Spending decisions are not always based on evidence of what works or on a full assessment of local need. 

22. The drug and alcohol services that people receive vary depending on where they live. There is no direction from the Scottish Government on what money for drug treatment and care services should deliver.  Although the Scottish Executive developed National Quality Standards for Substance Misuse Services in 2006 there is no national monitoring of whether they have been implemented. A different approach is taken in England where the government has set out and monitors a required range of drug services which should be in place and minimum standards of access.

23. There is direction from the Scottish Government on what additional money for alcohol services should deliver. The Scottish Government’s additional  allocation of £24.8 million on alcohol services to the NHS in 2008/09 has come with a clear instruction to use some of the money to provide screenings and brief interventions to prevent people from developing serious problems with alcohol and the remainder on supporting additional treatment and prevention services.24 

24. Information on the activity, cost or impact of services designed to reduce drug and alcohol problems exists in some local areas but the type and quality of data collected vary across Scotland. National information on cost, activity and quality of services is not available. 

25. The lack of consistent, comparable and shared information makes it difficult to plan and commission prevention, treatment and care services, and to influence how services develop based on evidence. 

26. Local monitoring of services generally focuses on numbers of people in a service and activity rather than on the quality of the service delivered or the outcomes achieved. Public bodies do not routinely evaluate the effectiveness of drug and alcohol services to ensure they meet local needs. There are, however, some examples of good practice where there has been a comprehensive review of all drug and alcohol services in an area (Case study 1).

27. There are no comparable unit costs for drug and alcohol services in Scotland (with the exception of criminal justice interventions) to help local areas evaluate cost-effectiveness of services.

4
Given the scale of drug and alcohol problems in Scotland and the range of agencies involved, clarity of roles and accountability is essential. It is important for the Scottish Government to set out the direction and the roles and responsibilities of partner agencies and how performance will be assessed.

28. Partnerships for drugs and alcohol have been in place since the late 1980s. Limited national guidance has been issued to partners, despite the creation of new partnership bodies and advances in understanding the problems of drug and alcohol misuse.

29. Given the limited guidance, drug and alcohol partnerships have evolved to work in different ways across Scotland. Some partnerships have operated strategically while others have had a more detailed focus on specific services. 

30. Although in general a lack of coordinated information about needs, funding and the effectiveness of services has limited the ability of partnerships to achieve their aims, there is some evidence of good practice.

31. The Scottish Government plans to issue revised guidance on drug and alcohol partnerships in spring 2009. This guidance will be the result of four years’ work at a national level to review local partnership arrangements for drugs and alcohol. The guidance  originally planned to be published in November 2008.

32. Under the new proposals, drug and alcohol partnerships will sit within Community Planning Partnerships (CPPs). If there is more than one drug and alcohol partnership in a NHS board area the partnerships will be expected to coordinate activity. The local partnerships will be held accountable for Single Outcome Agreement commitments through CPPs and for health targets through NHS partners. A health target for alcohol, introduced in 2008, relates to brief interventions. A health target for waiting times for drug services will be introduced in 2009/10, although the details of this are still unclear.

33. There are 32 councils, 14 NHS boards, eight police forces and eight Community Justice Authorities, each with different boundaries.25 There is a risk that drug and alcohol partnerships may continue to find it difficult to ensure that drugs and alcohol are priorities in each local area, not least because of the variety of agencies they must work with.

Key recommendations

The Scottish Government should:

•		set clear national minimum standards for drug and alcohol services including their range, quality and accessibility; receive assurance that these standards are implemented in line with set timescales; and ensure performance is regularly monitored and publicly reported 
•		clarify accountability and governance arrangements for the delivery of drug and alcohol services in Scotland and set out clearly the responsibilities of all organisations and partnerships involved in planning or delivering these services. 
Public sector bodies should:

•	 	ensure that all drug and alcohol services are based on an assessment of local need and that they are regularly evaluated to ensure value for money. This information should then be used to inform decision-making in the local area 
•		ensure that service specifications are in place for all drug and alcohol services and set out requirements relating to service activity and quality. Where services are contracted, this specification should be part of the formal contract 
•		set clear criteria of effectiveness and expected outcomes for the different services that they provide and undertake regular audits to ensure services adhere to expected standards
•		use the Audit Scotland checklist detailed in Appendix 4 of the full report to help improve the delivery and impact of drug and alcohol services through a joined-up, consistent approach.

1	Drug misuse and the environment, The Advisory Council for the Misuse of Drugs, 1998.
2	We have defined labelled expenditure as direct identifiable expenditure for drug and/or alcohol specific-services or specific drug and alcohol-related contributions for use in other services, for example, a dedicated addictions worker in a housing project.
3	2007 National Report to the EMCDDA, UK Focal Point on Drugs, October 2007.
4	Psychiatric morbidity among adults living in private households 2000, Office of National Statistics, 2002.
5	Drug misuse figures relate to people aged between 15 and 54-years-old specifically misusing opiates such as heroin and benzodiazepines.
6	Estimating the National and Local Prevalence of Problem Drug Misuse in Scotland, Gordon Hay, Maria Gannon, Neil McKeganey, Sharon Hutchinson and David Goldbery, 2004.
7	Psychiatric morbidity among adults living in private households 2000, Office of National Statistics, 2002.
8	http://gro-scotland.gov.uk/statistics/deaths 
9	Although nationally drug and alcohol-related deaths are increasing, there is local variation. 
10	Trends and geographical variations in alcohol-related deaths in the United Kingdom 1991-2004, Office of National Statistics Health Statistics Quarterly 33, 22 February 2007.
11	Drug Misuse and the Environment, The Advisory Council for the Misuse of Drugs, 1998.
12	http://www.drugscope.org.uk/resources/faqs
13	Alcohol Statistics Scotland 2008, Information Services Division (ISD) Scotland, 2009.
14	Mind the Gaps; Meeting the needs of people with co-occurring substance misuse and mental health problems, Scottish Executive, 2003.
15	Due to the absence of Scottish estimates of the wider economic and social costs of drug misuse we have used the methodology from Social and economic costs of Class A drugs in England and Wales 2003/04, Home Office, 2006 and applied Scottish prevalence figures.
16	Costs of alcohol use and misuse in Scotland, Scottish Government, May 2008. 
17	Figure includes NHS and council spend, the cost of police campus and liaison officers and Scottish Government labelled expenditure (eg, Know the Score and Choices for Life).
18	The Association of Chief Police Officers in Scotland (ACPOS) highlight that this is likely to be a significant under-estimate as it does not include work undertaken by operational uniformed officers or plain clothes divisional units who will deal with drug offenders or make routine licensed premises visits as part of their routine activities.
19	The remaining 21 per cent was spent on criminal justice services (nine per cent), essential services (three per cent) and other costs such as administration and capital (nine per cent).
20	The remaining £53 million was spent on joint drug and alcohol services. 

Exhibit 1
NHS and council spend on drug and combined drug and alcohol services per 1,000 population, 2007/08

Spend on drug specific and combined drug and alcohol services does not reflect drug misuse prevalence rates.
Note: Combined drug and alcohol spend is spend on joint services that cannot be differentiated.
Source: Audit Scotland, 2008

21	Figures expressed by NHS board area but include NHS and council spend.
22	The Convention of Scottish Local Authorities (COSLA) is the representative voice of Scottish local government and also acts as the employers’ association on behalf of all Scottish councils.
23	The concordat also introduced Single Outcome Agreements (SOAs) between councils, and their local partners, and the Scottish Government on priority areas for improvement and the expected outcomes. 

Exhibit 2
Funding for the Greater Easterhouse Alcohol Awareness Project in Glasgow, 2008/09

Local projects often receive funding from numerous different sources, and for different time periods.
Source: Audit Scotland, 2008

Case study 1
Comprehensive review of addiction services in Greater Glasgow

Before the review: In 2003, addiction services in Greater Glasgow were run across three agencies: NHS Drug Problem Service, NHS Alcohol and Drug Directorate and Social Work Addiction services. The service people received depended on where they lived. 

The review: A series of strategic reviews focused on different services such as council services, homeless services and services paid for by the NHS and council but delivered by others (eg, residential services). Each strategic review included needs assessments, an analysis of levels of current use and service user views and a literature review of effectiveness. All this information was shared across agencies. 

After the review: There is now a single partnership with responsibility for the planning and performance of drug and alcohol services across Greater Glasgow. There are 13 Community Addiction Teams across Greater Glasgow with a single management structure, for both NHS and council, and single accountability. The service has 580 staff and a budget of £42 million per year which is managed through a joint financial framework. 

Source: Audit Scotland, 2008

24	An alcohol brief intervention is a discussion aimed at motivating or supporting someone to try to change their behaviour. It is often a discussion between a GP and their patient. 
25	Community Justice Authorities (CJAs) were established by The Management of Offenders, etc. (Scotland) Act 2005. The eight CJAs are: Fife and Forth Valley, Glasgow, Lanarkshire, Lothian and Borders, North Strathclyde, Northern, South West Scotland and Tayside.