Engelsk sammendrag av Fafo-rapport 2018:44
Evaluation of The escalation plan for the field of drugs and addiction Second status report
Inger Lise Skog Hansen, Maja Tofteng, Linn Sørensen Holst, Vegard Salte Flatval og Ketil Bråthen
24. januar 2019
The escalation plan for the field of drugs and addiction (2016-2020) was submitted to the Storting in November 2015 (Prop.15 S (2015-2016) and adopted in April 2016. In collaboration with Economics Norway and Ipsos, Fafo is undertaking a formative evaluation of the escalation plan. The evaluation of the escalation plan includes a summative evaluation of outcomes as well as processes. The evaluation assignment involves two general research questions:
Has the escalation plan for the field of drugs and addiction resulted in a better service for persons who are developing, or have developed, substance abuse problems, and for their next of kin?
Are the organisation of the work and follow-up of the escalation plan and the interventions that have been initiated appropriate for achieving the escalation plan’s goals and objectives?
Through the planning period we will present annual status reports with a final summative evaluation in 2021. The basis report – the first status report – was published in April this year (Hansen et al. 2018). This is the second status report from the evaluation.
The escalation plan for the field of drugs and addiction is an inter-ministerial plan and a cross-sectoral programme. The Directorate of Health has the main responsibility for implementation and coordination of the programme, while the Directorate of Labour and Welfare (AVdir), the Directorate of Norwegian Correctional Services (KDI), the Directorate of Education (Udir), the Directorate of Children, Youth and Family Affairs (Bufdir) and the Norwegian State Housing Bank all have independent responsibility for helping achieve the goals laid down in the plan.
The escalation plan focuses on three areas:
- Early intervention. More people should receive help before they develop substance abuse problems.
- Treatment. Strengthen the capacity and quality of the treatment service.
- Aftercare/follow-up services. Prioritise housing, work and activity.
Five primary goals have been drawn up for the escalation plan:
- Ensure genuine user involvement through a free choice of where they wish to be treated, more user-driven solutions and greater participation in the design of the services.
- Ensure that persons at risk of developing a substance abuse problem are identified and helped at an early stage.
- Everyone should be met with available, varied and coherent services.
- Everyone should have an active and meaningful life.
- Develop and increase the use of alternative penal sanctions and ways of executing sentences.
In addition, the government has defined 77 specific points that they will implement during the planning period.
The basis for status report no. 2
The first status report (Hansen et al. 2018) presented a set of indicators that had been designed to enable us to assess the goal achievement of the escalation plan. Baseline for most indicators is 2016, although data for some of the indicators are available only from 2017 and then defined as baseline.
This second status report provides measurements for this set of indicators two years after the escalation plan came into effect. The indicators have been updated wherever data were available. For the updated set of indicators, values are provided for 2016 and 2017, as well as the change in the indicator over these two years. Furthermore, we have coloured the change column to show whether the indicators change in line with the goals or not.
To obtain a better impression of the trends in the field of drugs and addiction and an impression of any changes in the measurable magnitudes (the set of indicators) we have undertaken case studies in six municipalities: Sandnes, Fjell, Kristiansund, Østre Toten, Vadsø and the Gamle Oslo district in the City of Oslo. Two gatherings of municipalities and other involved parties were held in 2018. The objective of these gatherings was to collect assessments and reflections from representatives from municipalities and other agencies regarding the prevailing trends in the field of drugs and addiction, in light of the escalation plan.
In preparation for this report we have also undertaken a group interview with representatives at the manager and advisor level in the Directorate of Health, whose responsibilities include follow-up of the escalation plan. A focus-group interview has been undertaken with the inter-directorate group established to ensure consistent and coordinated efforts from all directorates involved in the escalation plan. We have reviewed the directorate’s joint reports for all measures encompassed by the escalation plan, as well as the reports from the county governors’ offices for 2017 and activity plans for 2018.
The set of indicators is presented in seven different tables: one with indicators for general performance, one for societal effects and one for each of the fine main objectives. When looking at the totality of the indicators, it is evidently not possible to give an unequivocal answer regarding the tendency in the achievement of the objectives for the escalation plan from 2016 to 2017. The picture is highly complex.
Efforts have been stepped up, but still a long way to the goal of NOK 2.4 billion
This second status report shows that efforts are being stepped up in the field of drugs and addiction. The total increase in funds granted to follow-up of the escalation plan amounted to NOK 541 million in 2016 and NOK 438 million in 2017 (both in NOK value as of 2016). This increase is additional to what is already happening in this field, and comes in the form of increased framework funding for the municipalities as well as earmarked increases in grant schemes and other specific measures.
Whether the pace of the escalation is sufficient to reach the government’s goal of increasing the total allocations to the field of drugs and addiction by NOK 2.4 billion over the 2016–2020 period is uncertain. Looking at the growth in allocations for follow-up of the escalation plan so far (cf. the incumbent government’s budget proposal for 2019), we find a need for grants of approximately NOK 600–700 million in 2020 to reach the goal (depending on price adjustments during the period).
More man-years and better competencies in the municipalities
The increase in resources for the field of drugs and addiction also appears to entail more man-years in the municipalities. A considerable growth in the number of employees is reported in the municipal services for mental health and addiction. From 2016 to 2018, there has been an increase corresponding to approximately 2000 man-years over this period. The increase in man-years goes in tandem with an upgrade of competence levels; the municipalities are hiring more personnel with long and specialised training.
Efforts in the specialist health services level off
The considerable upscaling of the efforts in the municipalities during this period is not paralleled in terms of inter-disciplinary specialised addiction therapy (TSB). Only a marginal increase in the total cost of TSB is observed for the period 2016–2017. ‘The golden rule’ has not been followed up in 2017. The golden rule indicates that the growth in mental health care and TSB should exceed the growth in somatic health care, i.e. that these areas should be prioritised by the specialist health services. This was the case for TSB in 2016, but not in 2017.
Some areas need increased attention
Based on the review of developments regarding the five main areas in the escalation plan with a view to the set of indicators as well as the case studies, we finally point to certain areas that will need special attention in the time to come:
- More systematic involvement of users and their next of kin.
- Increased attention to addiction problems in the regular services to enable early identification and follow-up of users who do not seek out specific services for mental health and addiction problems.
- Methods that can reach young people at an early stage of a substance abuse problem.
- Upgrade of competencies with regard to elderly people and alcohol use, for example in the home-based services.
- Better accessibility to services with a low threshold for contact and access to help, and better accessibility to services outside regular working hours.
- Problems in providing high-quality services to users with combined addiction and mental health problems.
- Better cooperation between the municipalities and the specialist health services.
- Although the housing situation has improved, the municipalities still experience challenges in access to suitable housing.
- A continuing need for efforts to help more persons with addiction problems find work, engage in meaningful activities and establish a satisfactory social network.
Increased local level of ambition, but major variations
In the report, we have shown that all the case municipalities devote attention to the field of drugs and addiction. Furthermore, we have shown that the level of ambition in this area also appears to have been raised. Considerable development work is being undertaken. On the other hand, the study shows that there are large variations between different municipalities in the area of drugs and addiction. Some municipalities provide a wide range of options and services, whereas others have far fewer programmes and also find themselves devoid of options for certain groups. Some municipalities have well established FACT teams and a number of outreach teams that follow up the target group, other municipalities have no such initiatives. Some have gone a long way in implementing recovery-oriented programmes, while others are just starting to develop this type of perspective. Some have active users’ organisations and involve users at the system level, whereas others do not. There is still a need to develop service provision in the municipalities, but there is variation in the range of challenges locally.
The regional actors have an impact
This status review shows that the escalation plan for the field of drugs and addiction has an effect on the efforts undertaken in the municipalities. The real escalation in resources devoted to the field of drugs and addiction is one aspect, but the attention which is paid to the escalation plan and not least the efforts undertaken by the regional actors (the county governors and the regional knowledge centres) to promote development in the municipalities in line with the goals in the escalation plan also have an impact. The case study shows that the municipalities are seeking to develop local service provision in line with the goals in the escalation plan. Varying degrees of attention are being paid to the escalation plan in the municipalities, but the goal structure is well known and corresponds with general trends and provisions for the field of drugs and addiction. A number of municipalities are seeking to implement new methods and models, and the contributions made by the county governors and knowledge centres are appreciated. It is worth noting that the BrukerPlan mapping studies have become crucial for the development efforts in the municipalities, and both the knowledge centres for drugs and addiction and the county governors’ offices provide essential support to this work.
A more pro-active phase in the directorates
As the coordinator of the directorates’ follow-up of the escalation plan, the Directorate of Health appears to have entered a new phase, with a stronger emphasis on highlighting places where there is a need for stronger efforts to improve the achievement of the goals in the plan, and not only on reporting the status for specific measures or initiatives. This is also reflected in a joint report to the Ministry of Health and Care Services from all the involved directorates. Little attention is still being paid to the follow-up of the work undertaken by the ministries that are engaged in the inter-ministerial plan. The letters of allocation for 2018 have provided the directorates with few governance signals, and the work on the plan is still not high on the agenda at the management level in the directorates involved.
In parallel, a number of ongoing processes in the field of drugs and addiction must be assumed to have a major impact on the achievement of the goals in the plan. This applies not least to the introduction of the standardised patient pathways in January 2018 and the Competency Plan 2020, which also includes mental health and addiction. The field of drugs and addiction is high on the government’s agenda, and the challenge to those involved in the follow-up of the escalation plan is to succeed in establishing it as an umbrella for all these activities.