COMBATING POVERTY AND SOCIAL EXCLUSION IN SCANDINAVIA - THE SWEDISH LECTURE
[13 April 2010.]

A Seminar with international participants was held in March organized byNordic House Foundation, Finnagora, MEREK. Hereby you can read the text of the Swedish lecture.

How to support participation and democracy for patients in treatment and care of drug addicts

In Sweden there is a new democratic movement among people who are - or have been - in treatment for drug-addiction/abuse. The intention of this popular and national movement is to strengthen the perspective of democracy in the process of planning, conduct and evaluation of healthcare and social programs for the group concerned. RFHL, the National Association for Aid to Drug Abusers, is one of the organizations now supporting groups of patients/clients – “users councils” - and others with interest in social rights. We are offering education in legislation and, not the least, the intention of the Swedish law in terms of ensuring the citizens rights to influence services provided by the social and healthcare insurance system.

The background of this quick development at this time - except for our organizations interest in these questions since the start in 1965 - is diverse.
At first – people with problems with alcohol and drugs are faced with a lower status in the care system than before. At the same time our population has now bigger problems with both drugs and alcohol than a few years ago, terrifying enough. For example, every tenth person is a risk consumer of alcohol. We have more than 200 000 people who has developed addiction to legally prescripted drugs, such as morphine and benzodiasepines.  And the economic crisis has of course the effect on the social insurance system, were we often see that the local authorities chose to cut down on expenses for care for problems with addiction or abuse. Cut downs that we all know eventually will cost more in both suffering for those in need and in money.
All together this means that people who need this care now also needs to mobilize to take part in the decision process – nor we or society can afford lack of democracy ay more in this area.

But there is also a formal, and we think very hopeful, background for this development. It is a process were we actually now see that authorities a trying hard to give our organizations opportunity to take part in the discussions on the present and future care programs. I will now describe such an important formal condition on the national level, which I further on in this speech will refer to as the Swedish way of integrating the Open Method of Coordination: Shortly the Swedish respond to the democratic intention in the Lisbon Strategy.

In April 2008, the Swedish Association of Local Authorities and Regions (SALAR) entered into an agreement with the government on support for the implementation of the national guidelines for the care of those suffering from substance abuse and addiction.

The central idea in the agreement is that the local authorities and county councils will assume a joint responsibility for development. SALAR undertakes to uphold the know-how and expertise that exists locally and regionally and to build up a long-term structure for knowledge acquisition and development. This entails, in collaboration with the principals at the county level, building up a structure for professional support to local authorities and county councils and developing a structure for collaboration between local authorities, county councils, local R&D bodies and universities and colleges.

The government has allocated SEK 58 million for the development work in 2008 and 2009. The development work will be conducted under the name “Knowledge to Practice”.

Co-ordination of primary care, social services, psychiatric care and addiction care

SALAR has concluded written agreements with all the 21 counties where SALAR undertakes to:

• co-ordinate efforts at the national level
• support key personnel in the counties in the implementation work
• train process managers
• offer forums for the exchange of experience
• train trainers in different approaches and methods
• provide financial support to principals at the county level to develop professional support for local authorities and county councils.

The principals at the county level undertake to:

• appoint a steering group with representatives from the social services, primary care, psychiatric care and addiction care
• initiate the work on a governing document at the county level in which the roles of the various players are set out
• begin a dialogue on the development of abuse and addiction care in at least 30 per cent of the local authorities in the county and conclude written agreements with them together with the local health services
• support the implementation work and the development of systems for following up the work in the local authorities and county councils.

Local agreements

In order to make it easier for the local authorities and county councils to assume a joint responsibility for the development work and to clarify the roles of the various players in the field of abuse and addiction care, written agreements will also be concluded at the local level within local authority boundaries. 
Closer co-operation and a clearer division of roles are necessary so that at an early stage, and in a co-ordinated way, people with alcohol or drug abuse problems can be offered better support.

Further training of politicians and managers

In order to enable the development of abuse and addiction care, “Knowledge to Practice” offers all the development counties a one-day, introductory training course for politicians and managers.

This day includes a brief presentation of the content of the national guidelines, the importance of developing evidence-based practice and how the activities of the health services and the social services can be integrated in so-called integrated clinics. The course also emphasises the importance of the politicians supporting development by demanding standardised assessments as a basis for decisions, and of politicians and managers setting clear operational objectives.

Training process managers

A four-day course for process managers will be offered to the principals at the county level so that they will be able to act as a support in the development work.

The role of the process mangers is to help the local authorities, together with the local health services, to survey what is being done and what is lacking in relation to the guidelines. The process managers also act as a sounding board in the work to prioritise areas for improvement. When the local authorities, together with the local health services, have set priorities for areas of improvement on the basis of the needs of the target groups, the role of the process managers is to support further training and implementation in the areas that are to be developed.  

Training of trainers in approaches and methods

In those counties with which SALAR has written agreements, “Knowledge to Practice” has offered to train trainers who can then act as a resource in the implementation work.

SALAR has so far offered to train trainers in the screening instruments AUDIT Alcohol Use Disorders Identification Test and DUDIT (Use Disorders Identification Test) and in the assessment instrument ASI (Addiction Severity Index).

A training course for trainers has also been started in motivational interviewing (MI).

National further training of all occupational groups

“Knowledge to Practice” has appointed a group of experts consisting of researchers and practitioners whose role is to develop two further-training plans – one that the principals at the county level can offer their personnel and one that can be offered to students at universities and colleges.

The first further-training course, “Risk use, abuse and addiction – Knowledge to Practice”, is a national general course aimed at all the occupational groups in the public, private and non-profit sectors that meet and/or work with people whom are either at risk or who are abusers and/or addicts. 

“Risk use, abuse and addiction – Knowledge to Practice” is a four-day course that aims to provide basic knowledge regarding the components of the problem and to give personnel working in the social services and the health services the same knowledge.

Work on drawing up a manual for further-training is now being planned in outmost counties.

So – what is our role as NGO:s in this work? For the first time since the seventies, when our movements had an strong position in the forming of the national social policy, a central part in the work from behalf of the authorities is the users voices. That is: in this agreement between SALAR and the government the dialog with the users of the different services now is not only stressed, but highlighted.

This is why? Evidencebased practicing – which is what everybody now strives for - in the care of this group is not possible without listening to the group itself – that is the users and their organizations. This the scientific research supports, this the international – and of course national – experience in the field of helping people in care support.

And this the Swedish law support explicitly. We also have a strong tradition in the peoples participation in the local democracy. Not the least in broad movements of people combating drinking and fighting for social rights, movements emerging as long ago as from the 19th century.

Yet Sweden today is far from best in the class when it comes to on how the users of the efforts made by the public are listened to and treated when the ask for the help. Help that Swedish citizens by the same laws are entitled to.

This is the field in were we no work intensively to mobilize as many organizations with interests in addiction and abuse care as ever possible. During the last year we have visited more than half of the counties, had some hundred meetings and have started councils in most of them. It is SALAR that finances this work, and we are now enetering a new agreement with SALAR to continue the job til the end of 2010 – that means for as long as SALAR itself is financed to work exclusively with this political filed – drug and alcohol addiction and abuse. We all now hope that the next government will fulfil the hopes from both NGO:s and profession not to stop this effort, but to file in to the work that is planned in the field of social care in general within a new agreement between SALAR and the government.

It has been a very interesting year from our point of view.