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Lessons from Holland
SDF Director David Liddell visited a range of services in Holland at the end of March as a guest of Iriszorg, the main provider of treatment care and rehabilitation services in the south of the country. He describes here his impressions of the approach to drug treatment there.
IRISZORG is an addiction care centre and social help organisation which was created following a merger at the beginning of 2007 of a number of large and small non-government organisations. It provides nearly all the services for people with alcohol and drug problems in the South of Holland, and for homeless people.
My three-day visit to Holland left me with three distinct impressions. Firstly, that the Dutch are a very humane society, often stating – with justifiable pride – during my visit the notion that a society should be judged on the basis of how it treats its most vulnerable.
Secondly, pragmatism is a constant theme running through their response. In many respects Holland is a conservative country – despite its “hippy” image - but the Dutch manage to put moral considerations to one side when making decisions about what type of services should be offered and how they should be delivered.
Thirdly – and possibly because of the first two principles - the amount of resources devoted to the problem are much greater than those devoted to the problem in Scotland. Iriszorg has an annual income of income of 62 million Euros (about £40 million pounds) with 1200 workers working with 11,000 clients a year in 70 locations.
Returning to the Dutch “humane” approach, it was clear to me that the prevailing view in Holland is that everyone is deserving of a service. Having established that, low threshold services are the cornerstone of the response, thus making sure that those unable to stick to more rigid treatment regimes which require a greater degree of motivation are still provided with a service.
purpose-built
For example, in Arnhem I visited De Boei (translates as lifebelt) which is a boat - or more correctly, a ship - moored on the banks of the Rheine. There were difficulties in obtaining planning consent for a building in the centre of Arnhem, so the local council commissioned the building of a purpose built ship at a cost of eight million euros.
It has been in operation since 2004 and provides a range of low threshold services including, shelter accommodation for 35 people, safer drug using rooms (with separate rooms for smokers and injectors), laundry facilities, a music room, an art room, gym and cafe/restaurant. Methadone is dispensed on the ship.
This service is primarily funded through the clients’ health insurance and therefore, is dependent on sufficient numbers of clients. There have been fears that a proposed heroin prescribing programme to be based elsewhere in Arnhem could potentially jeopardise the economic viability of the existing boat-based service. Therefore, a clear feature of the Dutch model was that service provision was dictated by client need. Services have to adapt to changing client needs and patterns of drug use – or quickly wither on the vine.
protect
Another example of Dutch pragmatism was the tolerance zone for ‘addicted prostitutes’ in an industrial location on the edge of Arnhem. The view held there is that women with drug problems who engaged in prostitution should have everything done to protect them both in terms of their safety and health.
One of the solutions was to construct a small lane within the tolerance zone which had a turning circle at the end. Customers would drive up the lane where the woman were standing, pick up someone and drive into a number of purpose-built cubicles which were constructed so that the door on the driver’s side could not be opened once in the cubicle.
In between customers, women could attend a nearby clinic for health care needs etc. This project was developed in repsonse to local need but it is hoped locally that the facility can be phased out soon when the heroin prescribing programme starts – the idea being that most of the women would no longer need to work as prostitutes in order to fund their drugs supply.
For those able to move onto a more structured environment, a range of move-on facilities from the Ship was available, dependent on issues such as the stage of clients’ drug use and motivation levels. For example, one 16-place residential unit was available for stays of up to three months.
It asked more of people than the low threshold service (people were not allowed to use street drugs and they had to participate in the centre’s programmes, for example) but still appeared to go at a pace set by the client.
respite
Many of those staying in the facility use it as a respite from the street and the chance to get to grips with the problems they face and many are prescribed maintenance methadone. This facility was full and normally has a waiting list, though there are plans to develop a further facility, operating along the same lines.
The funding for this would straight-forwardly come from health insurance, so in essence if there was a need it could be met. This was in clear contrast to Scotland where recommendations over 12 years ago on the need to develop crisis respite centres for Dundee and Aberdeen have lain dormant.
In many ways comparing the Dutch and Scottish responses is like comparing night and day, but the overriding impression in terms of a humane and compassionate approach is that they have got it right…and that we, to say the least, have some way to go.