Bath and North East Somerset Community Health and Care Services:

Substance Misuse Services

SD50

1. Introduction

The cost of alcohol to society is £21 billion: £11 billion of which is from alcohol-related crime; £3.5 billion cost to NHS and £7 billion in lost productivity through unemployment and sickness. 21,485 people died from alcohol-related causes in 2012 with a quarter of all deaths among 16-24 year old men are attributable to alcohol. Deaths from alcohol-related liver disease have doubled since 1980 [source: Public Health England (PHE)]. It is estimated that 24% of B&NES adult population is drinking at increasing or higher risk levels and that 6,854 of all people aged 18-64 years in B&NES are dependent drinkers. Hospital admissions for alcohol related conditions have risen by an average of 12% each year since 2002/03 and it is estimated that 60% of all alcohol related hospital admissions are for people over 60 years of age.

Deaths among heroin users are 10 times the death rate in the general population.Recent analysis by PHE suggests that there was an increase of at least 17% in the number of drug misuse deaths between 2012 and 13, and provisional data for 2014 suggests a further increase in drug related deaths [source: PHE]. The over-arching aim of drug treatment is to reduce drug related deaths.

Although heroin use is currently declining nationally, Bristol has been identified as one of 5 ‘hotspots’ for heroin. Avon and Somerset Police Drug Strategy Unit advises that B&NES is affected by the same drugs as Bristol, and B&NES is therefore recommended to continue to focus on heroin harm and ensure prompt access to treatment. Services are easy and quick for clients to access (all clients are seen within 3 weeks and almost 90% are seen within 1 week). Supporting opiate users to overcome dependence is challenging. In B&NES currently 6.1% of opiate clients successfully left treatment (and have not relapsed), compared to national performance of 6.8%, and may be an indicator that more complex clients remain in treatment. Over 70% of adults in treatment have either ‘high’ or ‘very high’ complexity (eg poly drug and injecting use). There are good outcomes for other drug users in B&NES where approximately 39% successfully leave treatment (and do not relapse) compared to 37% nationally.

Drug and alcohol interventions lead to better public health outcomes. Approximately 1,000 people per year engage in drug and alcohol services.

2. Purpose: Aims and Objectives

The aim of drug and alcohol services is to support substance misusers to full recovery, and to meet the aims of HM Government’s Drug Strategy ‘Reducing Demand, Restricting Supply, Building Recovery: Supporting People to live a drug-free life (2010); and HM Government’s National Alcohol Strategy (2012) by enabling substance misusers to overcome their drug and alcohol problems; to live healthy and crime-free lives in the community; and to maintain sustained abstinence. This is achieved by promoting engagement into structured treatment to individuals who are using drugs and alcohol problematically; retaining people in treatment for a period of

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usually at least 12 weeks to enable them to address the underlying causes of all of their drugs and alcohol misuse and build recovery capital (through engagement with inter-dependent agencies around housing or debt advice, skills/education gaps, physical and mental health issues); and reduce relapse through links with peer mentors and mutual aid organisations such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA) and SMART Recovery so that individuals can move to, and sustain, full recovery in as timely a way as is appropriate to them. Achieving this will mean that there will be:

More people living drug and alcohol-free lives More people reporting reduced substance misuse More people having improved physical and emotional well-being More young people supported to address substance misuse early in life to

prevent them going on to need adult substance misuse services Fewer incidents of drug and alcohol related crime, violent crime, and anti-

social behaviour Reduced drug and alcohol related hospital attendances and admissions Reduced number of people drinking to damaging levels Reduced risk of blood borne viruses Reduced drug related deaths More service users involved in the design, delivery and management of the

service.

3. National/Local Context and Evidence base

Policy and Standard Initiatives - National and Local

There are local processes and policies which complement the plethora of national guidance, policies, and indicators which support the delivery of safe, evidenced-based practice. Key policies, guidance and indicators are:

National National Institute for Health and Clinical Excellence (NICE) guidelines for

treating substance misuse including: CG51 Drug Misuse Psychosocial Interventions; PH18 – Needle Exchange and Syringe Programme; PH24 Alcohol-use Disorder – Preventing Harmful Drinking; CG115 – Treating Harmful Drinking and Alcohol Dependence; CG52 – Drug Misuse Opioid Detoxification; CG100 – The Treatment of Physical Health Problems caused by Drinking Alcohol; Implement NICE Guidance for the management of common mental health problems (eg CG22).

Medications in Recovery: Re-orientating drug dependence treatment’ (Strang et al 2012) http://www.nta.nhs.uk/news-2012-rodtfinal.aspx

Drug Misuse and Dependence – UK Guidelines on Clinical Management (Updated 2007 – known as the ‘Orange Book’)

Routes to Recovery http://www.nta.nhs.uk/uploads/itep_routes_to_recovery_summary_180209.pdf

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Drug Treatment and Recovery http://www.nta.nhs.uk/uploads/drugtreatmentandrecovery2010-11.pdf

Public Health Outcome Framework (PHOF) key indicators (for successful completions from treatment; reducing harm caused by blood borne viruses; reducing drug related deaths, waiting times, safeguarding children (successful outcomes for parents)

National Drug Treatment Monitoring System (NDTMS) which collects data (via core data set M, and clients’ self reporting via Treatment Outcome Profile (TOP), a self-reporting validated tool used at the beginning of treatment, at 6 monthly review, and at the end of treatment), analysis and reports on treatment effectiveness at a national and local level (there is currently consultation on additional changes for the data set N)

Immunisation against Infectious Diseases (known as the Green Book)

Local: B&NES Substance Misuse Needs Assessments (2012 Adults; and 2015

Young People) B&NES Early Help Strategy 2016 B&NES Single Point of Entry (SPOE) for all referrals to treatment B&NES substance misuse Residential Treatment Services Process B&NES Alcohol Strategy (adopted 2012) B&NES Joint Strategic Needs Assessment B&NES Children and Young People’s Plan 2014-17 B&NES Crisis Concordat B&NES CCG Operational Plan 16/17

4. The policy context

The following legislation, guidance and policy documents (and subsequent revisions thereof) are pivotal to the delivery of substance misuse services:

Misuse of Drugs Act 1971 The Psychoactive Substances Act 2016 HM Government’s Drug Strategy ‘Reducing Demand, Restricting Supply,

Building Recovery: Supporting People to live a drug-free life’ (2010) HM Government’s Alcohol Strategy (2012) Department of Health ‘Healthy lives, healthy people: our strategy for Public

Health in England’ (2010) NICE Guidance Medicines Act 1968 Care Act 2014 Data Protection Act 1998 Criminal Justice Act 2003 Transforming Rehabilitation 2014 Healthy Lives, Healthy People (November 2010)

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No Health without Mental Health (February 2011) Equalities Act 2010 Future in Mind

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/414024/Childrens_Mental_Health.pdf

Fair Access to Care (2002)

The Mental Health Act 1983, 2007 The Mental capacity Act 2005 Human Rights Act 1998 Public Health England’s – Minimum Data Set for Drug Treatment (current core

Data Sets are M for adults and L for young people) Building Recovery in Communities (2012) National Treatment Agency – Models of Care (2002, updated 2006), National Treatment Agency – Opening doors to Treatment Health of the Nation (1992) National Treatment Agency – Supporting and involving Carers (2008) Royal College of Psychiatry – Practice Standards for Young People with

substance misuse problems (2012)

This is not an exhaustive list and the service should be provided in line with all relevant guidance.

5. Service Delivery and Model

B&NES Substance misuse services are delivered primarily in the community, either from the client’s GP practice; or at treatment centres in Bath and at Midsomer Norton. Services are available Monday to Friday 9am-5pm, Saturday morning, and a minimum of one evening per week, to ensure that clients with work or caring responsibilities have access to service. Clients may be seen occasionally at home, if appropriate, subject to capacity.

Young People’s services (for people under 18 years) are delivered from a young people specific base in Bath or, if appropriate, young people can be seen by outreach workers.

Referrals come from a range of sources, including from GPs, criminal justice agencies, health and social care agencies and self-referral. Clients can telephone or drop-in to access support via the single point of entry (SPOE).

All clients receive a triage assessment and harm reduction intervention/advice and, where their needs indicate a need for structured treatment, clients will be given a full, holistic assessment and support package. The assessment follows the national model as set down in the National Drug Treatment Monitoring System (NDTMS) data set M for adults, and L for young people (and any revisions thereof). The primary aim of structured treatment is to promote sustained engagement and long term recovery outcomes. There is a key focus in B&NES on community based treatment and the provision of holistic psychosocial interventions supported by peer mentors

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and mutual aid programmes – AA, NA and ‘SMART’ Recovery. There are a number of Public Health Outcome Framework targets to measure long term recovery (see Public Health Outcome Framework (PHOF) target 2.15 for more information).

Treatment Outcome Profiles (TOP) forms part of the assessment process for all clients over the age of 16 at the start of structured treatment, as part of the 6 monthly review, and at the end of treatment. Clients have prompt access to services within 3 weeks of referral, with priority groups (eg criminal justice clients, young people) waiting less than 1 week.

Young People’s Drug and Alcohol Services

All young people, up to the age of 18, with problematic drug and/or alcohol use who are referred for specialist treatment, will have a comprehensive and holistic substance misuse assessment completed by a substance misuse worker that contributes to, and complements, any existing multi-agency plans. Where required, assessments input to a CAF or statutory assessment. Following assessment a care plan and package of care is put in place to cover the following domains:

Substance use Physical and psychological functioning Social functioning Criminal involvement Safeguarding children

Approximately 123 young people use drug and alcohol services each year.

The Young People’s Needs Assessment was undertaken in December 2015 and key changes include:

An increase in the complexity of issues faced by young people (eg mental health, or parental substance misuse, crime etc)

An increase in cases of children at risk of sexual exploitation (a project has been established to identify and respond to presenting needs)

The Royal United Hospital (RUH) emergency department now refers directly to Project 28

Performance continues to be excellent with 97% of young people successfully completing their specialist support – compared to 80% nationally (with low re-presentations of 2% locally versus 7% nationally).

The Health Related Behaviour Survey was undertaken in 12 secondary schools (by the School Health Education Unit (SHEU)) with 3,048 pupils from year 8 and 10 taking part and there is a positive downward trend, for example:

The numbers who drank alcohol in the last week: 15% of boys in 2015 compared to 24% of boys in 2013 and 12% of girls compared to 21% of girls in 2013

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The numbers who smoked cigarettes at least sometimes: 12% of boys in 2015 compared to 21% of boys in 2013 and 8% of girls compared to 11% of girls in 2013.

Adult Drug and Alcohol Services

Adult drug and alcohol services are delivered to an evidenced-based and recovery orientated integrated community service model, with psychosocial support delivered mainly in group work programmes alongside peers. A full range of group work is available to support full recovery (including dialectical behaviour therapy groups, relapse prevention, preparation for detoxification, managing anxiety).

Approximately 1,000 clients per year engage in structured treatment services.

Where appropriate, complex clients with prescribing needs will have their package of treatment complemented with detoxification from drugs and/or alcohol; or opiate substitution therapy.

Detoxification is available to all clients who require it, at all points in their treatment journey.

Criminal justice Services Specific programmes are available for up to 60 clients subject to Drug Rehabilitation Requirements (DRR), Alcohol Treatment Requirements (ATR) or who require opiate substitution therapy. The objective is to engage individuals who are causing the most harm to themselves, their families and society. Programmes are aligned with best practice guidelines and delivered within a multi-agency coordination, treatment, and through-care service that spans both the community and custody with the aim of reducing re-offending, achieving recovery and reintegration into the community. Needle and Syringe Programme (NSP)

Adult injecting drug misusers permanently or temporarily residing in B&NES have access to a Needle and syringe service and harm reduction advice from the treatment centres, and at a range of pharmacies throughout B&NES. The aim of this service is to reduce the hierarchy of risks associated with injecting to the individual by preventing sharing, promoting safer injecting, promoting the return of used needles for safe disposal, encouraging the move from injecting to smoking, stopping illicit drug use and entering into treatment to cease further use. A range of appropriate packs and injecting equipment is available.

Blood Borne Virus Services (BBV)

Services are promoted to all drug clients to prevent the spread of BBVs by providing hepatitis C testing to all previous or current injectors; and immunising all eligible clients against Hepatitis B. B&NES BBV pathway has been commended by PHE.

Alcohol Services

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Evidence-based alcohol community services will be available to higher risk and dependent drinkers. Assessment will include the use of identification tools such as the World Health Organisation’s approved Alcohol Use Disorders Identification Test (AUDIT). The aim of the service is to reduce alcohol related harm to the individual and the community and improve health and social functioning; promote safer drinking and reduce dependence on alcohol. Evidence from Probation services shows that B&NES offenders report a high level of problematic alcohol use. Reducing alcohol harm is a B&NES Council priority.

Hospital Alcohol Liaison Services

There is an Alcohol Liaison Services at the RUH (funded by B&NES CCG and Wiltshire Council) which supports clients who attend or are admitted to hospital as a result of their alcohol use. The aim of this service is to reduce repeat hospital attendances/admissions by supporting people to access treatment in their locality, and to provide training to hospital staff to recognise and support patients whose alcohol use is harmful to their health, or who are in alcohol withdrawal. The service sees approximately 550 people per year. Demand for the service is higher than this, with 400 out-of-hours referrals.

The ED department staff screen for alcohol misuse using the Paddington Alcohol Test (PAT). During 2015-16 21,281 people were screened (40% of ED attendees); 2,085 screened positive (9.8%: 64% were male and 36% female); approximately 175 people per month screen positive and are given an NHS alcohol leaflet and business cards with support service details, and a follow up call by alcohol recovery workers.

Detoxification and Residential Rehabilitation Services

Approximately 125 drug and alcohol detoxifications are delivered in the community or from 2 detoxification suites within a dry house in Bath (based on being assessed as clinically appropriate for this service. There is a pathway into the RUH for hospital in-patient alcohol detoxification for complex clients where this is assessed as a need and agreed by the RUH Gastroenterology Consultant. The detoxification suites can be used to divert people from the RUH, or to facilitate early discharge from the RUH to continue recovery support in the dry house.

Where appropriate, and where clients lack secure housing and are motivated to become and maintain abstinent of all mood-altering substances, an individual’s package of community treatment may be complemented with a residential placement in the drug and alcohol ‘dry house’.

Where is it recommended by the substance misuse multi-agency clinical case review group that a client’s needs cannot be meet in the community, or in the ‘dry house’, and the client is motivated to become and remain abstinent of all mood altering substances then, following assessment, the case can be taken to the Local Authority’s single placement panel for discussion and to seek approval for funding for a package of residential detoxification and rehabilitation. Approximately 6 clients per year use this service.

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6. Service Development - Opportunities and Issues to be addressed

Adult Drug and Alcohol Services:

In B&NES the average time in treatment for opiate clients is higher than national average at 5.2 years against national 4.6 years; and at 6 monthly review the rates of (adjunctive) alcohol improvement and abstinence are less than expected levels. There is an opportunity to improve the outcomes for opiate clients by looking holistically at all substances used - including alcohol - to support full recovery. Alcohol is a major factor in drug related deaths.

Clients who engage in treatment for alcohol issues (and have no adjunctive drug misuse) have good recovery outcomes (over 40% successfully complete treatment) and where these clients are parents they have very good treatment outcomes (with over 50% successfully completing treatment).

Young People’s Drug and Alcohol Services:

In B&NES an Early Help Strategy was developed in 2016 with the vision that all children, young people and families will have access to well-coordinated, good quality and timely Early Help when it is required, so needs can be identified and addressed to promote fulfilling family lives.

The concept of Early Help is simple: by working together with children, young people and families we can often prevent problems occurring, or provide better support when they do in order to stop them getting worse.

There are ongoing opportunities to support the implementation of the strategy by ensuring the substance misuse is identified early amongst young people and that those that require an assessment and treatment are referred through to the young people’s drug and alcohol service, Project 28.

The young people’s needs assessment 2015 found that 34% of adults in treatment are parents who have their children living with them at least part of the time. A key aim is to prioritise support for families, and there are opportunities to develop services across adult and children’s services.

7. Whole system relationships

An effective substance misuse system supports clients holistically to build recovery capital; delivers psychosocial support as an integrated part of all clients’ treatment packages (which may also include opiate substitution therapy); offers detoxification at all points within the client’s treatment journey; supports clients to address dependence on all drugs, including alcohol, and tobacco; enables clients to become and sustain long-term full recovery whilst minimising the risk of relapse and substance misuse harm, through relationships with peer mentors, Mutual Aid organisations (AA, NA and SMART Recovery), and Housing, Education, Training and Employment agencies.

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8. Interdependencies and other services

The main interdependencies are:

Primary Care - the relationship with GP practices supporting patients with alcohol and opiate/drug misuse.

Mental Health Services - the relationship with Avon and Wiltshire Mental Health Trust Services (AWP); and Oxford Health NHS Foundation Trust (OXFT) for Child and Adolescent Mental Health Services.

Criminal Justice Services - the relationship with Avon and Somerset Police; the Youth Offending Team; the National Probation Services; Working Links (Ministry of Justice commissioned Community Rehabilitation Company); Swanswell (commissioned by the A&S Police and Crime Commissioner to deliver arrest referral service within the custody suites); the Prison Services (particularly HMP Bristol; HMP Eastwood Park; and HMP Leyhill); and Court Assessment and Referral Service (CARS) which is an ageless liaison and diversion service for offenders with mental health issues (delivered by AWP).

RUH - ED, medical assessment unit (MAU), and medical speciality wards where drug and alcohol misusers present/are admitted for support relating to their alcohol and/or drug misuse (particularly hepatology and gastroenterology and the children’s ward).

A range of public sector, community and voluntary agencies including social care and health; South West Ambulance Service; housing support and homeless providers; domestic abuse organisations; and organisations which support clients to address education and skill gaps.

Mutual Aid/Peer support: (AA, NA and ‘SMART’ Recovery), who support people to sustain abstinence.

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TABLE OF DRUG AND ALCOHOL KEY PERFORMANCE INDICATORS

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