Specific observations and comments

Access issues

Evidence regarding access issues was gained during the interview process and this was cross-checked with written program policies, especially admission policies and with information given to prospective clients. The information from these sources was generally relevant and consistent. There was variation observed between services regarding the extent of program information available on websites.

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Overall, there appeared to be a good spread of residential services with some specialisation to cater to the needs of young people, single women and family groups. Most services reported that they had a waiting time for participants to access their programs with estimates of waiting times ranging from 2 weeks to several months.

Waiting times were attributed to a range of factors including challenges for services in getting the right mix of clients in their residential programs at any given point in time, the service having no beds available, and difficulties experienced by services in relation to either recruiting relevant staff or staffing programs.

Single males appeared to have longer waiting times but also family groups wanting to access specialist family programs found access at times difficult. Improved knowledge of workers and program responses for clients with mental health problems has meant easier access for this client group and better retention of these clients in treatment. Some respondents commented on the difficulty of transition for clients exiting the prison system.

However, the consultants saw some good examples of supported transition in this area.

It was reported that clients with a history of violence, more complex mental health issues and those with acquired brain injury find it difficult to access rehabilitation services.

Most residential rehabilitation services require the person to have attended a withdrawal program prior to entry into a residential service. The consultants were told of difficulties coordinating withdrawal with longer-term residential support. Clients are at significant risk if they cannot make a rapid transition from withdrawal to rehabilitation services. Relapse while waiting for a rehabilitation bed is common and can result in the need for further withdrawal, a cost to both the person and the system.

While services reported that they gave priority to ACT residents, all said their catchment area included adjacent NSW areas with some extending to Sydney. Most reported significant numbers of Aboriginal and Torres Strait Islander people accessing their services – around 10% but they also welcomed the coming of an Aboriginal and Torres Strait Islander specific rehabilitation program currently under development in the ACT.

OMT in residential programs and Primary Health Care access were key reported access issues. The current move by Karralika Programs Inc and the Salvation Army - Canberra Recovery Service (CRS) to admit people on OMT received widespread support from those interviewed. The consultants also noted that Arcadia House wanted to recommence admitting people on OMT, having stopped doing so only when Calvary Hospital withdrew access to a dosing facility.

The consultants recognise the current predilection for the CRS to offer a Methadone to Abstinence (MTAR) program and for Karralika to offer a stabilisation and maintenance program. However, they encourage each service to have some flexibility to accommodate clients whose treatment goals may change during their time on a program. For example, whilst one client’s initial treatment goals may be to withdraw off OMT, they may decide during their time on a program to remain on OMT. The consultants understand that a process to support services and other stakeholders to further progress this work will be supported by the Alcohol, Tobacco and Other Drug Association ACT (ATODA) and will commence in early 2012.

A positive ancillary outcome the consultants noted was increased communication and cooperation between the residential rehabilitation services in the process of looking at the place of OMT. This could be further encouraged through other measures such as joint projects, staff visits and placements with the aim of building a culture of staff acknowledging the benefit of a suite of residential and non-residential services with differing, nuanced approaches. Staff would acknowledge that each service offered advantages for particular clients and have a preparedness to assist clients to find the best matching of their needs and to explore alternatives when one avenue appears inappropriate.

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The associated issue of problematic access to primary health care services by the clients of residential programs was also raised by several informants. The consultants are aware of a proposal from DIRECTIONS ACT to make changes to their primary care service, Althea Wellness Centre (Althea). DIRECTONS ACT are considering opportunities for Althea staff, including their general practitioner and nursing staff to regularly outreach into the rehabilitation and other service sites (historically Althea had only operated from DIRECTIONS premises in Woden). The consultants believe this merits careful and positive consideration. Such a service could assist with providing a comprehensive and knowledgeable GP service, and other primary care, with specific expertise in areas such as blood-borne virus screening, sexual health screening, mental health and vaccinations. However, the consultants would caution that such an approach would be detrimental if it led to community GPs reducing their work with ATOD clients in general and OMT provision in particular. Local general practices who currently see some clients of rehabilitation services should continue to be supported to do so. This extends to supporting clients not on OMT. Steps would also need to be in place to ensure clients were transitioned to their own GPs following residential treatment and that DIRECTIONS’ GPs were not left dealing with a large caseload of complex cases. It also highlights the importance of supporting and building ATOD GP specific capacity within the ACT.

Health Directorate Opioid Maintenance Treatment (OMT) and withdrawal management services The lack of access to a public OMT clinic in the growing northern area of Canberra was frequently raised in discussions. Informants felt this was an equity and access issue with OMT clients without vehicles needing to catch several buses to get to the Woden unit, sometimes daily, for dosing. This was seen as an impediment to clients commencing and continuing on the program. It was also seen as an impediment to some of those on OMT gaining employment and looking after children. Current planning of new and re-oriented health services, including those being developed by the ACT Government such as at Belconnen and Gunghalin, should include consideration of an OMT clinic in the north, possibly as an outreach service from Woden.

The consultants note that, unlike most tertiary alcohol and drug services, there is no Outpatient Clinic currently operating from the Canberra Hospital other than the Opioid Treatment Service– a service gap that could potentially assist to meet the needs of many clients with complex AOD problems who may not need residential drug and alcohol treatment.

The consultants understand that planning for the Canberra Hospital (TCH) envisages an expanded AOD inpatient unit. The consultants recommend a review of similar inpatient units, in consultation with the ATOD sector including consumers, so that any expanded services can efficiently fulfil a broader role. In particular, the consultants recommend that specialist ATOD services need clearer definition and greater medical support from Resident Medical Officers and the Hospital. This will support the mainstreaming of ATOD work and encourage the unit to adopt a greater leadership role, thereby benefiting the ATOD sector through strong advocacy, liaison, professional advice and support, and clinical outreach to non-government ATODTSS . This could be

accomplished through an interdisciplinary team approach. A nurse practitioner could play a valuable role in such a team.

An associated issue raised by a number of informants concerned the need to better support, recognise and integrate GP OMT prescribers into the AOD sector of residential and non-residential services.

The consultants also recommend that any plans for further tobacco-smoking bans on the TCH site be carefully managed in relation to the expanded AOD inpatient unit, including due consultation processes and stakeholder engagement to ensure enhanced workplace policies and procedures and improved smoking cessation and reduction support for staff and clients.

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Day and Evening Rehabilitation Program

The research shows that, for some clients, participation in a non-residential program is at least as effective as residential treatment and that costs are significantly lower. A small number of day rehabilitation programs based on a variation of the Therapeutic Community model are running in Australia and overseas (see section 4 above).

Day and evening programs target clients who are unable or unwilling to attend residential programs. Issues such as family and employment obligations, inflexible housing arrangements and legal requirements can prevent a person from entering a residential program. Day and evening programs often involve participation in the range of activities normally provided in a residential setting – groups, recreational activities, ‘housekeeping’ activities, community participation etc. Some informants were aware and supportive of proposals to offer day and evening rehabilitation program(s) as an alternative or in addition to residential rehabilitation. Others, when informed of this model, were enthusiastic about the idea. The consultants found good support for a pilot day rehabilitation program (based on research and evaluation of other successful programs), located centrally to facilitate access and with ready access to good childcare. There may be merit in exploring a cooperative pilot project with a single lead agency and drawing on expertise from a number of non-government ATODTSS and the ADS.

Consumer Representation and Participation

A parallel process of consumer consultation informs this review. During the site visits, it was possible to interview only a few consumer representatives during the week. However, most of the informants stressed the need for more effective and representative consumer participation in treatment planning, service planning and delivery, and policy development and implementation. There was acknowledgement of a need to involve a broader range of consumer advocates from potential service users, OMT clients, graduates from residential programs, parents/family members and 12 step group members. Investments should be made to support services to strengthen their work in this area.

Workforce and Staffing issues

Informants noted the range of pay scales available in the residential and other services, usually pointing out their low base and resultant difficulties associated with recruitment and retention. There is a perceived need to provide a better salary scale for many workers in residential and other non-government ATODTSS programs and to combine this with greater inducement for workers to attain higher qualifications and skills, and for these to be adequately rewarded. Almost all informants spoke of the increasing complexity of clients with co-occurring ATOD and mental health problems amongst the majority of their clients. It was perceived that this required better qualified and experienced staff and access to high quality and diverse training, factors that are adding

significantly to their cost structures.

There was general recognition that the Certificate IV in Alcohol and Other Drugs, Comorbidity or Mental Health should be a starting point rather than sufficient qualification for workers. Further training should be tied to specific practice skills crucial for effective practice in the ATOD field, particularly:-

 advanced Motivational Interviewing skills

 Cognitive Behavioural Therapy skills

 group work skills and

 interpersonal communication skills

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Adequate night staffing was mentioned by a number of informants. The consultants found a range of night staffing patterns from no overnight staff cover to three staff actively on duty at all times. Given the difficulties staff have in coping with a rotating roster involving night duty (it is often cited as a reason for resigning from a workplace), there are good reasons for services, particularly co-located services, to explore cooperative efforts to provide adequate night cover while freeing up more staff to be available during active program times.

Ngunnawal Bush Healing Farm

While all services felt that they had effective processes in place to provide a culturally sensitive service for Aboriginal and Torres Strait Islander clients, most services also recognised opportunities to make improvements in this area. Informants were supportive and enthusiastic about the pending bush healing farm which will offer residential rehabilitation to Aboriginal and Torres Strait Islander clients. Efforts should be made to ensure this program is integrated into the broader ATOD treatment field with its workers accessing ATOD sector training opportunities and managers involved in the ATOD networks. The centre should also be supported to ensure that its programs and practices are based on best available evidence of effective programs for Aboriginal and Torres Strait Islander people.

Tendering and Funding issues

Non-government ATODTSS significantly value-add to the funding they receive from both ACT and Australian Government grants. The consultants noted concern from the non-government sector about the introduction of new wage rates following the Equal Pay determination. In particular, they felt that planning should commence to ensure service provision is not compromised during the progressive introduction of new salary scales. It was also noted that the expectations regarding these pay increases may be high, whereas the reality may be drawn out and not sufficient to address the staffing issues raised above.

An associated issued raised by some informants was the impact of competitive tendering processes on the continuity of effective service provision, especially the impact on service delivery of abrupt changes in staff, locations and programs following a change in the service provider. They also felt that services should not be forced into cost cutting involving low wage rates for jobs that require skilled, qualified and experienced staff.

Informants acknowledged the need for the ACT or Australian Government as the purchaser of services to be able to select the best service provider but felt that a capacity enhancement model would better safeguard the client, service and purchaser. The capacity enhancement model would allow for current service providers identified by the funding body as needing to improve outcomes being supported to do this. In situations where this support is not successful the service would then be put out to competitive tender with provision for an orderly transition process from one provider to another with efforts to ensure continuity of service through such

measures as retention of some staff, gradual change to other models of service delivery and engagement of consumers in the change.

All services reported that a significant proportion of their clients came from NSW and other states. This is to be expected given the catchment area for Canberra services often includes a significant stretch of coastal and inland Southern NSW.

Access to subsidised childcare

Cooperative efforts to improve access to subsidised childcare was raised by a number of informants and this should be explored further. Flexible access to appropriate childcare would enable better access to day programs and to participation in after-hours activities. While some services have very good resources and access for child care for their clients, others do not and it was proposed that some sharing and coordination could enable those

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programs to address this barrier to access. Several informants said that the child care providers required some specialisation in the needs of the children and parents in this target group as their issues were often complex and long-standing and often involved a care and protection order. A childcare facility located near a centrally-located day rehabilitation program could be considered.

Computer-based learning

Discussion with some informants covered prospects of increased integration of computer-based learning and discovery in residential programs. The consultants were told of some initial attempts to explore access issues and of some of the concerns services had of allowing greater access to the internet. There was recognition of the potential benefits of greater use of web-based resources, but also caution about its integration. There was interest in furthering this exploration and its integration should be encouraged. The example of the ‘IT Futures’

program at the Salvation Army’s Toward Independence program in Adelaide could inform this process.

Resource and infrastructure

The consultants observed and informants reported ageing infrastructure at some services. The consultants were told of difficulty for some services in meeting costs associated with periodic maintenance and asset

replacements. They saw premises in need of repair and painting, outdated IT systems and were told of difficulties for some services with motor vehicle replacement. Some services also pointed out cramped residential and program activity areas. Rationalisation of premises could enable some services to utilise staff more efficiently eg by providing overnight staff support.

It is common for clients, particularly newer clients, to have a number of appointments and commitments – medical, personal and legal – that require attention and support. Much staff time can be consumed with this work, arranging appointments, transporting clients and participating in court hearings, reviews etc. Services have little option but to support their clients, indeed this work is often crucial to enabling the person to settle into the service and reduce outside pressures on them. Senior clients may be able to assist in some of this work.

Good staff levels and available vehicles, including small buses contribute to reducing the impost of this aspect of a program’s operations. Resource-sharing among services also deserves consideration.

An Infrastructure Redevelopment Fund was advanced as a systematic, long-term response to this situation.

There could also be a parallel process looking at opportunities for resource sharing amongst services, such as a casual worker pool, buses, recreational equipment and child-care. Such a fund may also allow programs to look at what efficiencies they could achieve through upgrading premises or through relocation.

Service-Specific Issues

A number of other issues specific to individual services were also raised. These require examination in greater detail:

1. While all other ATODTSS in the ACT that the consultants talked with receive almost all their funding from government sources, the Salvation Army’s CRS program receives only about 10% of its funding from government. While the consultants were impressed with the dedication of staff and management, it was apparent that the CRS program is in need of increased funding to enable the program to offer staff better pay and conditions (currently they rank second lowest in the sector according to the ACT Alcohol, Tobacco and Other Drug Workforce Qualification and Remuneration Profile 2011). Their recent expansion to admit women and their proposal to admit clients on OMT could provide the vehicle for greater government support around employment of more and higher qualified staff, infrastructure development and program development. The Salvation Army will be required to significantly increase

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its funding of the CRS with the introduction of the Equal Pay wage rates. Special consideration may need to be given to them and other organizations that substantially fund services from their own income streams rather than from Government grants.

2. DIRECTIONS ACT sought support for its efforts to operate their Inside/Out Program and secure funding

2. DIRECTIONS ACT sought support for its efforts to operate their Inside/Out Program and secure funding