Arising from the recommendations outlined in the report of the Working Group on Drugs Rehabilitation,1 a National Drugs Rehabilitation Framework (NDRF) was developed.2 Its purpose is to improve the provision of rehabilitation services to current and former drug users by creating integrated care pathways (ICPs) with the co-operation of different service providers. The NDRF was piloted in a number of locations and the evaluation of the pilot was recently published.3 Ten sites were selected for the pilot, but the evaluators report that only six implemented the framework.
As part of the evaluation, data were collected from 14 service users via a structured questionnaire and in-depth interviews. All 14 service users had completed an assessment as part of engaging with the NDRF, all had been allocated a key worker and two thirds had been allocated a case manager. When asked about their experience with their key workers and case managers, service users were generally very positive about the support they had received. They spoke about the benefits of connecting with services. For example, they highlighted care planning as a direct benefit; the majority had a clear idea of their goals and aspired to build on current successes. Overall, service users reported being satisfied with the service they had received through the NDRF.
Data were also collected from 48 key workers/case managers and 19 service managers. Three quarters of key workers/case managers reported always engaging in care planning, and the remainder reported engaging sometimes; similar levels of engagement in interagency meetings were reported. Service managers reported some difficulty in undertaking comprehensive assessments with clients. All bar one service manager said care planning was being implemented but, of these 18, all but three reported difficulties. Around three quarters of service managers reported some difficulty in implementing confidentiality protocols. Service managers also reported varying levels of access to support services such as addiction services, education and employment, housing, justice and law reform services. All service managers reported some engagement in interagency working but all reported some difficulty implementing service level agreements. Both service managers and key workers/case managers reported an improvement in communication, in sharing of information and in making referrals following implementation of the framework.
The authors point out that the evaluation was ‘an examination of procedures and process rather than outcomes, with input from mostly service providers’ (p. 80). This means that they do not know how the majority of service users were experiencing the work practices within the NDRF and do not know how effective these practices were in delivering identified outcomes. However, what they can say is that for a small number of service users engaging with the framework, their experience of care planning seems to have been beneficial. From the perspective of service providers, there were difficulties in implementing the NDRF; in particular, there was a need for better access to services for clients including housing, education and employment. There was also an identified need for improved inter-agency working between services engaging with the framework.
In conclusion, the authors suggest, ‘…there is much goodwill towards the framework and a real desire for it to be implemented and supported in full…’ (p. 97).They identify a number of overarching themes relevant to refining and implementing the framework in the future. A brief note on each theme is presented below.
Sustainability
Fears were expressed that the momentum, which was said to have carried through from the publication of the NDRF to the pilot phase of implementation, could be lost when the pilot evaluation concluded. Respondents wanted a re-emphasis of support for the principles of the NDRF from the relevant government departments.
New ways of working
In many locations the introduction of case management was reported to be problematic. Linked to this were problems with inter-agency working. Moving from the principle of inter-agency working to its implementation has to be actively worked on; these issues can be resolved through strong and consistent leadership.
Culture
New ways of working that are promoted in the NDRF, particularly inter-agency working, challenge existing cultures of working in the sector. Appropriate training to address these local cultural issues is required as part of implementation.
Non-implementation
It came as a surprise to the authors that some sites were not implementing the framework. It would help if the requirements around implementation were more direct and less open to misinterpretation.
Client-centeredness
Most respondents agreed with the principle of putting the client at the centre of care planning and case management. However, respondents in statutory services had differing views from those in non-governmental organisations, with the former displaying a greater degree of scepticism.
Framework instruments and information technology
There is a tension between rigorous documentation and excessive paperwork. The majority of service provider respondents felt that the framework errs on the side of the latter: it is not possible to track service users’ progress through the various steps in the framework, owing to the burden of paperwork and information technology requirements.
Structures
In the event of further of further evaluation, structures need to be strengthened in order to avoid a situation where pilot sites are unsure whether they are in or not, as happened with this evaluation.
Concluding remarks
This evaluation provides insights into how the NDRF is both perceived and used. Clearly there were differences in perceptions both within and across the sites that participated in the evaluation; on the one hand, there appears to be general support for the framework, while on the other hand, issues remain around some key components such as inter-agency working. In addition, some service providers clearly have difficulties in implementing elements of the framework, for example care planning. Finally, the overarching themes identified during the data analysis speak to a need for a ‘cultural shift’ that recognises the need for a new way of working with people in addiction recovery services – a way that facilitates people on their journey of recovery, while promoting and encouraging the organisational change that is also needed.
- Working group on drugs rehabilitation (2007) National Drugs Strategy 2001–2008: rehabilitation. Report of the working group on drugs rehabilitation. Dublin: Department of Community, Rural and Gaeltacht Affairs. http://www.drugsandalcohol.ie/6267/
- Doyle J and Ivanovic J (2010) National Drugs Rehabilitation Framework document. Dublin: Health Service Executive. http://www.drugsandalcohol.ie/13502/
- Barry J and Ivers J H (2014) Evaluation report of the National Drugs Rehabilitation Framework pilot. Dublin: Health Service Executive. http://www.drugsandalcohol.ie/21600/
