Is the winter over for rehab in Scotland?

In the midst of winter here in Scotland when days are short, snow is on the ground and we’re in lockdown, it’s easy to get low. I’ve been thinking a lot recently about residential rehabilitation and where it fits into treatment options.

I think it’s true to say that rehab has felt a bit stuck in a kind of permafrost of neglect or obscurity. Rehab seems irrelevant to some and dangerous to others, yet those who have benefitted have often reported a transformative experience. Then there is the difficult fact that relatively little public funding supports the hundreds of people who go through rehab every year. The majority pay for their own treatment or are funded by insurance or charity. (For those not familiar with Scotland, almost all health interventions here are funded publicly). But there are glimmers of light, or, some might even say, beams of light, playing out now on our wintry shores and mountains.

It’s true that it’s only been a couple of months since our bleak drug-related deaths figures for 2019 were published, darkening the winter further, but this year the response has been different – after the outrage and sadness came listening and commitment to improve the situation – from the highest level in government. There have been brisk responses before admittedly – so what’s different this year?

As it turns out, quite a bit.

Changes afoot

In a significant move, Scotland’s first minister, Nicola Sturgeon, has appointed a new Minister for Drugs Policy who will lead on tackling our problems. In a speech yesterday, the Minister – Angela Constance MSP – pledged to ‘do more, do it better and do it faster’, in order to save lives.  

Ms. Constance said that she will continue to meet with those with lived experience, parents and other family members. She said she would build consensus both within and outwith the Parliament. I was happy to see that she will embrace both harm reduction and the promotion of routes to recovery, including residential rehabilitation. Polarisation has had its day. She rightly accepts that we need many solutions to our challenges.

The Minster also wants to ‘make sure that our own house is in order’. By this she means joining things up across different government departments – such as work on adverse childhood experiences (ACEs), mental health, homelessness, the justice system and tackling poverty and inequality. Over the years I’ve tried to do this on a much smaller scale locally, but multiple chains of command, clashing philosophies, competitive attitudes and differing priorities make joined-up work very difficult to operationalise.

Joined up for recovery

However, the vow to take this work forward is welcome news. Such coordinated approaches are essential for recovery-oriented systems of care (ROSCs) to work effectively. Remember, we’ve been trying to get ROSCs up and running for many years – the Essential Care report called for this as long ago as 2008. The development of ROSCs was a focus of the last, and the current, drug (and alcohol) policies. ROSCs were called for in the Independent Expert Review on Opioid Replacement Therapy in 2013. That report was stark:

The review found considerable variation in local delivery of even the core elements of recovery orientated systems of care (ROSCs). Many areas stated their plans were at very early stages of development. There was little evidence presented by some ADPs regarding a real impetus towards recovery. Stakeholder reports supported this view.

Independent Expert Review, 2013

Things may have come on a bit, but how much has really changed in the last 8 years? Our challenges have become all-too-familiar bedfellows.

The power of rehab

In her speech, Ms Constance acknowledged the urgent necessity to reduce harms now and cited ‘the power of residential rehabilitation’. I hope that’s a phrase we hear again and again. As a treatment option which is difficult (and in some areas impossible) to access, unless you are wealthy, this was gratifying to hear.

We need every treatment dish on the menu so that people can get the help that’s best for them and their families when they need it. Whether that’s access to safe injecting spaces, equipment for safer injecting, drug testing services or entry into medication assisted treatment programmes or residential rehab, all need clear access and easy-to-navigate links between services which, too often, seem to sit in silos.

We’ve actually started working on issues relating to rehab in Scotland already. The Residential Rehabilitation Working Group was set up last year by Joe Fitzpatrick, the then Public Health Minister. We published recommendations last month. You can read more about what we found here.

Commitment

Meantime, we have a profoundly exciting promise which does suggest the heralding of spring for residential rehab in Scotland. Ms. Constance said:

The First Minister will make a statement next week laying out how we will achieve a step change in the short, medium and longer term. That will include a commitment to increase the provision of residential rehabilitation and bring our bed numbers up to the European average.

Angela Constance MSP, January 2021

The way forward

Our group estimated that fewer than 5% of all treatment episodes in Scotland in 2019-20 were for residential treatment, compared to an average of 11% in Europe. This means we are setting an ambitious target. I’m a big fan of setting the bar high, but this means committing to a lot of hard work to sort out barriers to treatment. These include challenges around capacity, access and pathways, understanding the various models of treatment, setting standards, adequate duration of treatment, and of course, having sufficient and straightforward funding.

Then there is the difficult and somewhat perplexing issue of understanding and tackling the ambivalence, iciness, or even hostility that some professionals have towards rehab. This can result in a glacial rate of referrals from certain areas or teams.

The right to be involved in choosing what kind of treatment is right for you is set down in our drugs strategy, Rights, Respect and Recovery and this should apply as much to residential treatment as it does to other valid choices. Where attitudinal barriers exist, they need to be identified, discussions and education had, and channels opened up.

Finally, we need to address the dearth of evidence on outcomes from rehab. We only have one rehab study from Scotland  published in a peer-reviewed journal. That’s despite over a thousand people going through rehab in Scotland every year and rehabs being around for three decades or more. Who are these rehab graduates? What took them to rehab? Did they have prior episodes of treatment? What happens to them afterwards? What value does their recovery have to them, their families, their country and the recovery community? Does rehab have an effect on reducing alcohol and drug deaths?

Aren’t these interesting questions? Why the frigidity?

Can it ever be valid for someone to say ‘there’s no evidence that rehab works’ when the issue is nobody is interested in gathering and looking at the evidence? I don’t think anyone is claiming rehab is the answer to Scotland’s drug and alcohol harms and deaths. It should, however, be another valid option on the menu of treatment choices and currently in many places, it is not.

Hope

Once we’ve identified them, barriers and challenges can be overcome. With the right will, leadership and resources, there are things we can do quickly and there are things that need a bit more groundwork and planning, but which will thaw us out of winter and into spring. 

There’s a warmth in the wind. It’s feeling good.

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