In this section:
- Background and context
- A focus on health inequalities
- Summary of the development process
- How to use the framework
Background and context
Scotland's national drugs strategy The Road to Recovery: A New Approach to Tackling Scotland's Drug Problem  was launched in May 2008 and affirms that it is essential to recognise the impact of action that a wide range of policies will have in tackling the factors associated with problem drug use. The policy clearly states the association between socio-economic disadvantage, deprivation and health inequalities and progression to problem drug use. The strategy focuses on recovery and reinforces the message that services should support people to move on towards a drug-free life, as active and contributing members of society.
A set of Core Outcomes and Indicators  for Alcohol and Drug Partnerships (ADPs) have been agreed between ADPs, COSLA and the Scottish Government. These outcomes and indicators support the embedding of outcomes based planning and reporting at local level, helping ADPs to self-assess their performance (including benchmarking against other ADPs) and to articulate their contribution to their local Single Outcome Agreement(s). They also help provide a national picture of progress in alcohol and drug prevention, support and treatment.
The development of a full outcomes framework for problem drug use was agreed with Scottish Government as part of NHS Health Scotland’s support to Alcohol and Drug Partnerships. Aligned to The Road to Recovery, using an evidence-informed approach the outcomes framework aims to inform effective action and demonstrate progress against the national strategy and partners’ collective contribution to achieving common national outcomes.
The Scottish Public Health Observatory (ScotPHO) drugs misuse information,produced by NHS Information Services Division (NHS ISD), on behalf of the Scottish Government, brings together information and data on drugs misuse in Scotland. 
Interactive reports on health and wellbeing related to drugs misuse by local area are also available using a purpose-built online profiling tool. Using a range of indicators at ADP (DEfine) and NHS Board level, the profiles provide relevant information to help service providers, planning teams, policymakers and the public to make informed decisions and identify priorities to improve health in relation to alcohol and drugs. 
In the context of national estimates, problem drug use is defined by NHS ISD  as the problematic use of opiates (including illicit and prescribed methadone use) and/or the illicit use of benzodiazepines and implies routine and prolonged use as opposed to recreational and occasional drug use.
Outcomes framework for Problem Drug Use and a focus on health inequalities
The outcomes framework for problem drug use in Scotland is currently aligned to the priorities in the Road to Recovery. Building on the ADP Outcomes Toolkit (2009) the strategic outcomes logic model has mapped the agreed ADP Core Outcomes in order to demonstrate their role in contributing to the delivery of the national strategy and national high-level outcomes defined in the National Performance Framework.
The premise of the national policy, the Road to Recovery, is to tackle problem drug use by fully addressing the needs of people affected. Based on the concept of recovery the policy sets out a programme of reform in the way that drug services are planned, commissioned and delivered to support people with problem drug use, to help them recover and rebuild their lives.
Informed by the widely accepted association between deprivation and vulnerability to problem drug use the outcomes framework is based on the principle of proportionate universalism. This concept has been defined in a recent briefing by NHS Health Scotland  as:
‘resourcing and delivering universal services at a scale and intensity proportionate to the degree of need. Thus services are universally available and not only for the most disadvantaged, and are able to respond to the level of presenting need’.
The briefing describes that planning for proportionate universalism will:
‘require an assessment of need and understanding of the impact of social inequalities on health outcomes, as well as a judgement as to how much additional resource should be allocated per ‘unit’ of additional need (the weighting)’.
It is intended that the framework provides a planning resource for the design and delivery of services based on local assessments that determine the level and extent of needs of different groups to inform a targeted approach.
The purpose of the outcomes framework is to identify key outcomes for problem drug use and outline which activities can be carried out to achieve them based on evidence or plausible theory. The framework does not try to explain all of the interactions between activities and outcomes. The framework does not depict the true complexity of problem drug use; it only attempts to clarify some of the key paths to achieving intermediate and long-term outcomes in an attempt to illustrate that interactions occur between components of the response as well as between the response and the delivery context of settings and services and for individuals within the system as outcomes and activities are linked. Ultimately, the framework is a resource for policy makers and planners to help them clarify what outcomes they want to achieve and what can be done to achieve those outcomes. The framework presents a snapshot of what is currently known about problem drug use. It will be reviewed and updated to reflect changes.
The high-level outcomes in the outcomes framework define four areas of focus: Prevention, Recovery, Families Affected and Enforcement. It is intended that the related short-term outcomes described in the nested logic models for each area highlight where services can demonstrate their influence and show progress over the next 3 to 5 years towards these longer term outcomes.
The aim of the rationale documents that accompany the nested logic models was to map available evidence that relate to the links and pathways between the stated outcomes, with a view to highlighting effective interventions and initiatives supported by policy and practice guidance. The aim was not to retrospectively set out current delivery but rather to provide a tool for planning in identifying the direction of travel for commissioners and area partnerships to determine service delivery based on local needs assessments.
The evidence review relied on existing sources of evidence and Scottish or UK specific literature and key studies and is not necessarily a comprehensive critical appraisal of all the material. Where available, evidence has been drawn from key sources: National Institute for Health and Care Excellence (NICE) public health guidance (and relevant NHS Health Scotland Commentaries/ Scottish Perspectives); NICE and Health Development Agency (HDA) public health briefings; Scottish Intercollegiate Guidelines Network (SIGN) clinical guidelines; the Cochrane Collaboration and the University of York Centre for Reviews and Dissemination. We have called this information ‘highly processed evidence’.
Additional sources of evidence and theory have been drawn from relevant key systematic reviews and literature reviews and reports commissioned by the Scottish Government, the UK Government and national organisations and collaborators. Further papers were identified in conjunction with lead stakeholders and topic experts. Scottish policy and practice notes from national strategies and guidance documents are also cited. References are provided throughout the framework, where relevant.
There are gaps in the evidence pathways sometimes supported by plausible theory and emerging practice. Rather than being the definitive account of the evidence on interventions for problem drug use, it is intended that the outcomes framework offers a indicative picture of where evidence exists and remains a work in progress to be developed and updated from learning through practice and emerging research. Over time we anticipate that further research will enable areas where little evidence is available to be strengthened and the model modified and refined to reflect the changes in our understanding of problem drug use.
Health inequalities are unfair differences in health across social classes or between population groups. All public sector and many private sector agencies have a contribution to make to reducing health inequalities. Health Inequalities Impact Assessment (HIIA) is a tool which offers an integrated approach to impact assessment encompassing legally protected characteristics , human rights, wider population groups and social determinants of health. The main aim of HIIA is to strengthen the contribution of policies and plans to reducing health inequalities by improving equity of access, ensuring non-discriminatory practice and acting on the social determinants of health.
HIIA encompasses all legal requirements associated with Equality Impact Assessment (EQIA) but additionally seeks to define the likely impacts of a policy in relation to health and human rights and the population groups who will bear them. This provides a means to systematically consider the extent to which the policy can mitigate, prevent or undo inequalities. The assessment should aim to identify unintended consequences of a policy that may increase inequalities as well as to proactively plan to reduce inequalities.
For the purposes of the problem drug use outcomes framework the rationale and validation process of the links in the nested logic models has, where possible, given due consideration to HIIA. Consequently as part of the rationale documents, a summary note on ‘HIIA’ is included where any characteristic(s) of participants or vulnerable groups have specifically been identified within the evidence that has informed the development of this outcomes framework (please see the Resources pages to download the full Framework).
In addition, there are a number of rights from the Human Rights Act that may be engaged by the actions taken to deliver in the areas of prevention, recovery, families affected and enforcement. These include the right to Life (Article 2, ECHR); Freedom from ill-treatment (Article 3, ECHR); Liberty (Article 5, ECHR); Fair hearing (Article 6, ECHR); Private and family life (Article 8, ECHR); Freedom of thought, conscience and religion (Article 9, ECHR); Freedom of expression (Article 10, ECHR).
It is intended the HIIA process supports transparent decision-making. NHS Health Scotland encourages policy-makers and practitioners to carry out HIIAs on strategies and interventions which are developed using the outcomes framework. HIIA helps to raise questions about how proposed policies or activities will impact on the fundamental causes, wider environmental influences and individual experiences of health inequalities. Through adopting a human rights based approach, HIIA can be used to stimulate discussion and action to achieve the highest attainable standard of health for everyone.
NHS Health Scotland’s Equality Team offers the following practical support:
- Awareness raising sessions on the Health Inequalities Impact Assessment approach, delivered locally;
- Supporting your own local teams to carry out a HIIA, including co-facilitating workshops to help staff and key stakeholders consider the impact of a policy, service or decision;
- Organisational expertise in the interpretation and use of evidence;
- Sharing examples of application of the approach in Scottish Government and NHS Boards.
NHS Health Scotland full impact assessment guidance materials are available online: http://www.healthscotland.com/equalities/hiia/index.aspx
A collaborative approach was adopted in developing the outcomes framework. The work was initiated with a national Development Group comprising NHS Health Scotland, the Scottish Government, Alcohol and Drug Partnerships, Community Justice Authority and third sector national agencies.
A draft strategic logic model was agreed to demonstrate the long-term desired direction of travel. Following a national consultation with stakeholders, a distilled version was produced based on the feedback received. These intermediate and long-term outcomes formed the basis of developing the nested logic models to identify the required short-term outcomes to achieve these aims. The logic models for Prevention, Recovery, Families Affected and Enforcement were developed at a national development event with key stakeholders from across Scotland.
Once the draft models were agreed a review of the key sources of evidence and plausible theory was undertaken to refine and validate the links between the various components of the models. The Outcomes Framework (the logic models and rationale documents) was revised and finalised following feedback from an external expert review.
How to use the framework
The Outcomes Framework for Problem Drug Use supports the national policy by communicating pathways to achieving the desired outcomes and meet aspirations set out in the Road to Recovery. As a common framework for action, using an evidence-informed approach, the logic models identify broad needs. The outcomes framework is not a fait accompli; it represents our best understanding of problem drug use at this point in time and involves a process of reflection and continual improvement.
The outcomes frameworks and the logic models that underpin them can be used in various ways by different stakeholders, enabling planning in local areas to be more systematic and evidence informed - with local plans based on local adaptations of the outcomes frameworks. The models may shape a monitoring and evaluation programme assessing a range of health and non-health outcomes identified in local strategies. The outcomes framework will need to be reviewed regularly and locally modified to reflect local priorities as we continue to understand more about problem drug use over time.
The finalised outcomes framework was disseminated to ADPs via Chairs and Coordinators. The full framework and rationale is available to download here: http://www.healthscotland.com/scotlands-health/evaluation/planning/problemdruguse.aspx
Additional planning resources are also available here: http://www.healthscotland.com/OFHI/Resources/Resources_planning.html
The next steps will be considered based on uptake by stakeholders, for example it may prove useful to provide links to the indicators with which to measure outcomes and map the indicators agreed for the ADP Core Outcomes and the recovery indicators identified for the new national Alcohol and Drug Information System (DAISy) currently in development by NHS Information Services Division on behalf of the Scottish Government to support monitoring and evaluation.
The Road to Recovery: A New Approach to Tackling Scotland’s Drug Problem Scottish Government (2008) The Road to Recovery: A New Approach to Tackling Scotland's Drug Problem. Edinburgh: Scottish Government. Available from (external link, 5.4MB) : http://www.gov.scot/Publications/2008/05/22161610/0
Scottish Government (2013) Core Outcomes For Alcohol and Drug Partnerships. Edinburgh: Scottish Governement. Available from (external link, 251.3KB): http://www.scotland.gov.uk/Resource/0039/00394539.pdf
Drug Misuse Information Scotland. Available from (external link): http://www.scotpho.org.uk/behaviour/drugs/introduction
ScotPHO profiles - online profiles tool. Available from (external link) http://www.scotpho.org.uk/comparative-health/profiles/online-profiles-tool
Scottish Government (2009) Delivering Better Outcomes: An Outcomes Toolkit for Alcohol and Drugs Partnerships Version 1. Edinburgh : Scottish Government. Available from (external link): http://www.scotland.gov.uk/Publications/2009/04/23084349/1
Macdonald, W. Beeston, C. McCullough, S. (2014) Proportionate universalism and health inequalities. NHS Health Scotland
NHS Health Scotland’s full impact assessment guidance materials are available online: http://www.healthscotland.com/equalities/hiia/index.aspx
For full details see the Equality Act (2010), available online at (external link): http://www.legislation.gov.uk/ukpga/2010/15/contents
For full details see the Human Rights Act (1998), available online at external link): http://www.legislation.gov.uk/ukpga/1998/42/contents