commissioning a recovery orientated substance misuse treatment system for bristol commissioning...

7/28/2019 Commissioning a Recovery Orientated Substance Misuse Treatment System for Bristol Commissioning Strategy 20

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Safer Bristol

Commissioning a RecoveryOrientated Substance MisuseTreatment System for Bristol

Commissioning Strategy

2012-2015

Author: Substance Misuse Team

September 2012


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Version Control

Document Review

Version Amendment Pg

2.1 Added sentence to Summary section highlightingthis is now the final commissioning strategyfollowing the consultation period.

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2.2 Defined recovery according to UKDPC definition. 6

2.3 Sentence added to explain that where the termsubstance is used in the document it refers to bothdrugs and alcohol.

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2.4 Sentence removed We will be expecting the finalframework to be published at some point during2012. A summary of responses from the BuildingRecovery in the Community document werepublished instead.

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2.5 Putting Full Recovery First document was added tothe Key Legislation and other drivers section.

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2.6 Consultation period section added. 28

2.7 Updated Recovery Model paragraph. 29

2.8 New recovery model added. 30

2.9 The names (and key components of the clusters)updated to reflect the new recovery model.

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2.10 Updated outcomes framework in response to theupdated recovery model.

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2.11 Expanded on the 8 best practice outcomes in theframework to be consistent with the strategy

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2.12 Paragraph in the Harm Reduction section added toreflect recent policy and guidelines that have beenpublished.

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2.13 As further information is released regarding fundinglevels sentence has been removed from theResource analysis section. This information is stillup to date as of the time of the final commissioningstrategy being published.

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2.14 Responding to consultation section removed from

this version as the consultation period has nowfinished.

N/A


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Contents

1 Summary ....................................................................................................................... 4

2 Introduction ................................................................................................................... 52.1 Key Demographics ....................................................................................................... 62.2 Key Priorities ................................................................................................................ 92.3 Current governance structure .................................................................................... 112.4 Values ........................................................................................................................ 122.5 Commissioning Principles .......................................................................................... 12

3 Legislation and other key drivers .............................................................................. 144 Needs assessment ...................................................................................................... 184.1 Substance Misuse Needs Assessment 2010/11 Key Findings .................................. 184.2 Drug Intervention Programme (DIP) .......................................................................... 204.3Alcohol Needs............................................................................................................ 215 Initial consultations and developing the market ...................................................... 245.1 Mapping and Gap Analysis ........................................................................................ 245.2 ROIS Survey.............................................................................................................. 265.3 Market Development.................................................................................................. 276 Formal consultation period........................................................................................ 286.1 Consultation Methods ................................................................................................ 286.2 Quantitative analysis of the online survey .................................................................. 286.3 Analysis of qualitative feedback ................................................................................. 297 Recovery Orientated Integrated System................................................................... 307.1 Proposed Model......................................................................................................... 307.2 Substance Misuse Recovery System Outcome Framework ...................................... 337.3 Monitoring and review arrangements......................................................................... 357.4 In scope services ....................................................................................................... 357.5 Out of scope services ................................................................................................ 377.6 Harm reduction work.................................................................................................. 397.7 Workforce development and equality & diversity ....................................................... 398 Resource analysis ...................................................................................................... 41

9 Risk assessment......................................................................................................... 42

10 Timeline ..................................................................................................................... 44

11 References ................................................................................................................ 45


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1 Summary

The Adult Drug Treatment Plan 2011/12 made clear the intention to develop athree to five year outcome focused commissioning strategy for Bristol.

This commissioning strategy sets out the intended strategic outcomes andagreed approach for the three-to five-year timeframe. It signals the strategicdirection for local services; highlights commissioning priorities, needs andopportunities to service providers; and is intended to offer a focus fordiscussion with service users and the local community, as well as anopportunity to open dialogues with potential providers.

The strategy belongs to the Safer Bristol Partnership. It is an overarching planand analysis outlining priorities and strategic direction for the next 3-5 years. Itwill work in conjunction with a number of complementary plans, and otherBristol City Council Strategies.

Update 26/09/12: This is the final version of the Commissioning Strategyfollowing a twelve-week consultation period. This consultation period hashelped to inform and develop the final recovery model outlined in this strategythat will be commissioned over the next year.


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2 Introduction

Over the last two decades a number of substance misuse services havedeveloped in Bristol. Since 2003 Safer Bristol, the Crime Drugs and AlcoholPartnership led by Bristol City Council, has commissioned many of these and

a number of other services as part of a citywide treatment system.

The treatment system in Bristol performs healthily but as well as our goal ofcontinual systemic improvement there are two key drivers behind SaferBristols current exercise in developing and implementing a newcommissioning strategy which will involve re-commissioning the majority ofBristols services.

Firstly, European procurement regulations dictate that many public servicesare regularly put out to competitive tender. This is an obligation underEuropean legislation and many of the services we currently commission are

now due to undergo this process.

Secondly, in the last few years national developments in the substancemisuse field including HM Governments 2010 Drug Strategy have put anemphasis on areas providing a recovery orientated treatment system with amore explicit focus on achieving successful, substance-free outcomes withservice users.

Safer Bristols Substance Misuse Team has responded to this by supportingproviders in the current system to make changes to the way they work. Weare now proposing a new treatment model and outcomes framework todeliver a Recovery Orientated Integrated System (ROIS).

Safer Bristol has adopted the UK Drug Policy Commission (UKDPC)definition of recovery which explains the process ofrecovery fromproblematic substance use is characterised by voluntarily-sustained controlover substance use which maximises health and wellbeing and participationin the rights, roles and responsibilities of society (UKDPC, 2008).

Following consultation, the model will be agreed by the Joint CommissioningGroup and procured through a competitive tendering process using the

Bristol City Council Procurement portal: Proactis- Provide to Bristol.

The target for awarding the contracts to deliver the new model is August 2013with an expected commencement date of November 2013. It is likely thatTUPE will apply if there is a change in service provider, which may lead to alonger implementation time, but it is expected that the new model will be fullyoperational by January 2014.

Throughout this strategy where the term substance is used, it is referring toboth drugs and alcohol.


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2.1 Key Demographics

With a population of 433,100, Bristol is the largest city in the South West andis one of the eight Core Cities in England (excluding London), covering112km

2of the local area. At present, it is estimated that 221,300 are males

and 220,000 females in the local area, with 32.3 as the median age in yearsfor males and 33.6 median age in years for females respectively. Figure 1below shows the Bristol Population Pyramid (2010)

1:

Figure 1: Bristol Population Pyramid (2010)

Since 2001, there has been a small decrease in the number of children by anestimated 1,800 children (2.4%) and also a decrease in the number of peopleaged 65 and over, by an estimated 2,800 people (4.8%). The population aged16-64 has risen by 48,000 people, an increase of 18.4.

Males

Females


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Figure 2: Bristol Population by Ethnicity Groups

Figure 2 above shows a breakdown of Bristol population by ethnicity. 19% ofthe population do not fall under White British category, and Other Whiteshows the highest number compared to other ethnicity. The Councilsintelligence suggests that since 2001 there has been a significant increase inthe number of international migrants coming to live in Bristol, particularlySomali communities and Polish residents coming to work in Bristol followingthe expansion of the EU.

Figure 3: Concentration of Bristol Population


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Figure 3 above shows the concentration of Bristol population by Lower SuperOutput Area (LSOAs). The top three LSOAs with the most condensedpopulation, as reflected in the dark purple shades above, are:

Old Market and the Dings LSOA 3981 people

City Centre and Harbourside LSOA 3875 people

University Halls LSOA 3433 people

In addition, about 25,600 full time students live within Bristol boundariesduring term time and 91,100 people are currently working in Bristol CityCentre. The number of Job Seeker Allowance (JSA) claimants for Bristol morethan doubled between July 2008 and July 2009 but has remained significantlylower than that of the recession of the early 1990s.

Other key facts of Bristol include the following:

Table 1: Other Key Facts of Bristol

Categories Bristol England andWales

Notes and source

Black andminority ethnicresidents (BME)

13.5% (OverallBME population)

14.8% (16 59(working age))

12.5%(England)

Data from Office for NationalStatistics (ONS) 2010 ExperimentalStatistics Crown Copyright 2011.

One personhouseholds

38% 34% Department for Communities andLocal Government (CLG) 2008-based Household Projections

Average earnings 27,100 26,400 Median gross annual pay of full timeworkers workplace analysis. Datafrom ONS 2011 Annual survey ofhours and earnings ONS Crowncopyright reserved (NOMIS)

Average houseprice

165,400 160,400 Average price of dwelling sold. Datafrom HM Land Registry MonthlyReport December 2011 Crown

CopyrightUnemploymentrate

7.30% 7.70% Data from ONS Annual PopulationSurvey (July 2010 - June 2011) andmodelled Bristol statistics ONSCrown Copyright Reserved(NOMIS)

Qualified to HNDor degree level

37.10% 31.00% Qualified to NVQ4 equivalent orabove. NVQ4 equivalent includesHND, degree and higher degreelevel qualifications. Data from ONSAnnual Population Survey (January- December 2010)


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2.2 Key Priorities

Based on the Bristol Substance Misuse Needs Assessment 2010/11 thefollowing key priorities were identified in 2012-13 by the Safer BristolPartnership:

Develop and consult on the Commissioning Strategy for a recovery-focussed drug and alcohol treatment system appropriate for service usersfrom all backgrounds in Bristol that will meet the performance indicators inthe Public Health Outcomes Framework.

Work with Bristol City Council Procurement and Commissioning Team tocompetitively tender services.

Increase the numbers of clients successfully completing, exiting the

treatment system and achieving sustained recovery.

Increase the numbers of opiate, non opiate and crack users identifiedwithin the criminal justice system accessing and successfully exitingstructured treatment services and not requiring further treatment (i.e. re-entering the treatment system).

Increase the numbers of clients in the Criminal Justice Intervention Team(CJIT) who access appropriate structured treatment and successfullycomplete, sustain recovery, reduce re-offending and subsequentrepresenting to the treatment system.

Work with Bristol Prison, Avon & Somerset Probation Trust, CJIT and theUser Feedback Organisation (UFO) to implement plans for gate pick upon release from prison, to ensure continuity of care between prison andthe community to support the clients recovery journey, and reduce re-offending rates.

Implement recommendations from the psychosocial audit conducted byPublic Health in the Primary Care Trust.

Increase move on, throughput and increased successful completions

from the treatment system.

To achieve 90% plus compliance for start, review and exit TOPS andensure providers utilise the TOP Quarterly Outcome Reports to monitorclients recovery journey.

Work with Housing and Job Centre Plus to increase substance misusersuptake of services that will support treatment and recovery.

Agree targets with all providers to decrease voids and improve

accommodation outcomes for services users in drug and alcohol services.


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Work with Troubled Families Coordinator (when appointed) to ensurepriority access to, and joint working with services for identified clients andfamilies.

Work with Bristol City Councils Children and Young Peoples Service

(CYPS) to implement the recommendations from the Serious CaseReviews.

With CYPS, implement the new joint safeguarding children protocolchildren and families living with substance misuse and associated jointpractice guidance.

Work with CYPS, the Youth Offending Team (YOT) and Young PeoplesOpening Doors services to ensure young people requiring Tier 3treatment are referred to the appropriate service, complete a care planincluding healthcare assessment and where appropriate are offered, andreceive Hep B vaccination. Targets will be agreed to increase thenumbers of young people successfully completing treatment and exitingthe treatment system drug free.


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2.3 Current governance structure

Safer Bristol Partnership co-ordinates Bristols response to issues of drugs,alcohol harm, crime and community safety and implements the GovernmentsNational Drug Strategy in Bristol.

The Joint Commissioning Group (JCG) acts on behalf of the SaferBristol Executive Board. The Service Director of Safer Bristol chairs theJCG and this group is responsible for commissioning services thatdeliver drug and alcohol treatment across Bristol.

The Treatment Task Group (TTG) contributes towards the development anddelivery of effective, efficient and evidence based substance misuse treatmentservices. The TTG consists of members from commissioned services, serviceusers and other relevant stakeholders.

The JCG are committed to ensuring that service users, carers and providersinform decisions. This is done by representatives of these groups sitting onvarious forums including the TTG, the Treatment Providers Forum, UFOService Users Forum.

From April 2013, Public Health will move in to the Local Authority and newHealth & Wellbeing Boards will be in place. Their role will be to improvehealth, social care and public health services. They will develop a joint Health& Wellbeing Strategy. Additionally there will be an elected Police & CrimeCommissioner for Avon & Somerset from November 2012. Both of thesechanges will impact on the level of funding, and commissioningaccountabilities, for drug and alcohol services. Safer Bristol is working with allrelevant partners during this transition period.

Figure 4: Current governance substance misuse meeting structure


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2.4 Values

This Commissioning Strategy is informed by some shared values, whichrecognise that, while action on drugs and alcohol is fundamentally health-led,

there is an equally important criminal justice focus. Our values and approachare therefore dependent on excellent collaboration between all stakeholders.This means that we will:

Approach the commissioning of drug and alcohol services in a transparentway.

Ensure service users feel able to influence and be involved in all stages ofthe commissioning cycle.

Work to ensure that drug and alcohol provision, relevant to need isavailable to all residents of Bristol, including homeless people.

Seek to enable people to move away from a culture of dependency.

Aim to offer choice and opportunity to service users with a range of harmreduction and recovery options.

Ensure best value for use of public money, seek to commission on thebasis of evidence based good practice, and meeting greatest needs.

Ensure that provision is high quality, and meets the needs of all equalitiesgroups across Bristol.

Move to an outcome based approach to commissioning and monitoring.

2.5 Commissioning Principles

Safer Bristol will be using Bristol City Councils Enabling CommissioningFramework. The objective of this framework is to create a standardisedapproach across the Council to commissioning. The commissioning processis broken down into the four stages with each stage being dealt with in turn

Analyse

Plan

DoReview


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Agreed framework for Bristol City Council - The 4 Stage Cycle

This is the agreed four stage commissioning cycle that has been adoptedfrom the IPC (Institute of Public Care) joint commissioning model for publiccare.

Figure 5: Four Stage Commissioning Cycle

In pursuit of these activities, the Commissioning Strategy conforms to somekey principles:

All four activities are sequential and equally important.

Commissioning and purchasing cycles are linked, and activities in one mustinform the ongoing development of the other.

The commissioning process must be equitable and transparent, and open toinfluence from all stakeholders through ongoing dialogue with service usersand providers.

There is a focus on needs identified by all agencies, ensuring a jointapproach.


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3 Legislation and other key drivers

The agenda of the present Government is clear, underlining considerablechange in the broader policy context, to be seen in conjunction with significant

reductions to public expenditure. A number of policy developments are driversfor change:

The National Drug Strategy: Reducing demand, restricting supply,building recovery: supporting people to live a drug-free life(2010)signalled a shift in emphasis from harm reduction to a focus on recovery.The goal is to increase the numbers successfully completing treatmentdrug free and reintegrating in to their communities.

The Governments Alcohol Strategy (2012) focuses on irresponsibledrinking, closer working with the drinks industry and support for

individuals to make informed choices about responsible drinking andreducing the numbers of people drinking to excess.

NTAs Medications in Recovery: Re-orientating Drug DependenceTreatment in July 2012 looked at delivering good practice for OST(Opiate Substitution Therapy) to maximise a persons recovery.

The Joint Strategic Needs Assessment (JSNA) Pack for Commissioners(2011) was published by the NTA. This informs the commissioning of arecovery-orientated system, in line with the 2010 Drug Strategy aim of

replacing the national service framework (set out in Models of Care 2002& 2006) with a stronger recovery focus and updated evidence base.

The publication in 2010 by the NTA of Commissioning for Recovery,which focuses on outcome-based commissioning for the drug treatment,re-integration and recovery system in drug partnership areas for drugusers. It sets out to highlight good practice in a recovery-based treatmentsystem. While it relates to the 2008 drug strategy, it clearly anticipates thechange of emphasis set out in the 2010 strategy.

A consultation paper titled Building Recovery in the Community was

published by the NTA in 2011 to gather views on how to develop arecovery orientated framework to replace the current Models ofCare(originally published in 2002 and updated in 2006). The NTApublished a summary of the responses to this consultation on 18 May.The key messages from the consultation were that an integrated recoverysystem should focus on the following:

Collaborative working between all partners to commission servicesbased on outcomes.

Prompt access to appropriate interventions for drug-dependent people,including offenders.

High-quality treatment that prepares service users for recovery whileprotecting communities.

Encouraging service users to successfully complete treatment withoutputting them at risk.


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Links to support networks to sustain long-term recovery and reintegratepeople back into society.

Putting Full Recovery First a cross governmental paper was published inMarch 2012. The document outlines the Governments roadmap for

building a new treatment system based on recovery, guided by threeoverarching principles- wellbeing, citizenship and freedom fromdependence.

The Ministry of Justice (MOJ) Green Paper, Breaking the Cycle EffectivePunishment ,Rehabilitation and Sentencing of Offenders focused onrehabilitating offenders to reduce crime. Offenders on communitysentences or on release from prison will face a tough and coordinatedresponse from the police, probation and other services. Offenders will berequired to tackle the problems which underlie their criminal activity , thisincludes getting drug and alcohol dependent offenders off drugs andalcohol via effective treatment programmes in prison and the community.

The Substance Misuse Skills Consortium launched as an independentnetwork in 2010. The Skills Consortium have developed a framework ofdrug treatment that constitutes a consensus on effective treatment- knownas the Skills Hub- and is used as an online resource for commissioners,managers and practitioners.

In the Open Public Services (2012) paper the Government outline theirdesire to make sure that everyone has access to the best possible public

services. To improve the effectiveness of public services the Governmenthave looked at rolling out new commissioning regimes based on paymentby results. There are currently 8 pilots taking place across the countrythat are aiming to achieve better outcomes for drug and alcohol users,their families and communities utilising different payment by resultsmodels.

The Healthy Lives, Healthy People-Update & Way Forward White Paper(2011) proposes a new public health system for England in which:

Local authorities take new responsibilities for public health. They will besupported by a new integrated public health service, Public Health

England.The functions of the National Treatment Agency (NTA) will besubsumed within Public Health England from April 2013.

There will be a stronger focus on the outcomes that need to beachieved across the system. In terms of drug and alcohol treatment,the public health outcomes we will be responsible for are listed below:

Domain 2.15 (Health Improvement): Successful completion of drugtreatment.

Domain 2.16 (Health Improvement): People entering prison withsubstance dependence issues who are previously not known tocommunity treatment.

Domain 2.18 (Health Improvement): Alcohol-related admissions tohospital.


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In addition to this the drug and alcohol field will contribute to numberof wider PH outcomes (see Outcome Framework on pg 19).

The abolition of PCTs from April 2013 and the introduction of GPCommissioning and Health & Wellbeing Boards.

Public Health England and local authorities will play a key role in tackling

the harms caused by alcohol and drugs. Local authorities will beresponsible for commissioning treatment, harm reduction and preventionservices for their local population, providing an opportunity to morecomprehensively join up the commissioning of drug and alcoholintervention and recovery services locally.

The Police Reform and Social Responsibility Bill - September2011,introduces major changes to the way policing locally. It includesprovisions for:

Making the Police service more accountable to local people byreplacing Police authorities with directly elected Police and CrimeCommissioners to be introduced from November 2012. TheseCommissioners will have local control of both the Home Office part ofthe DIP funding and the Safer & Stronger Communities funding. Anintegrated working approach will be required with Police And CrimeCommissioners to ensure effective treatment for drug and alcoholusers locally.

Overhauling the Licensing Act to give more powers to local authoritiesand police to tackle any premises that are causing problems, doublingthe maximum fine for persistent underage sales and permitting localauthorities to charge more for late-night licences to contribute towards

the cost of policing the late-night economy.Introducing a system of temporary bans for new psychoactivesubstances, so-called 'legal highs', whilst the health issues areconsidered by independent experts, to ensure our legislative processcan respond quickly to emerging harmful substances.

The Think Local, Act Personal agreement, which recommends howcouncils, health bodies and providers need to work more efficiently topersonalise and integrate service delivery across health and adult socialcare. The proposal sets out what needs to be done to ensure furthertransformation of adult social care. It reiterates the need for integration of

health and social care, in particular, around outcome basedcommissioning and procurement and effectively engaging with localmarkets to deliver on the choices and outcomes people require. To targetsupply effectively requires commissioners to develop stronger and morecollaborative relationships to develop new models of provision and reducecost; to work with providers to diversify their services and commissionersto develop better ways of gathering and utilising market intelligence.Whilst the personalisation agenda is moving forward for many clientgroups there has been limited progress regarding widespreadimplementation of personalised budgets for clients with drug and alcoholproblems. However this may be a feature in the future.

On 8 March 2012 the Welfare Reform Act 2012 received Royal Ascent.The main elements of the Act are:


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Introduction of Universal Credit, replacing the current complex range ofbenefits including Jobseekers' Allowance by 2013.

Replacing Disability Living Allowance with the Personal IndependencePayment, where the focus will be on supporting claimants to work.Everyone on DLA currently will be reassessed and moved onto the new

relevant benefit.New powers to tackle fraud, which costs the Government 5.2bnannually, and tougher sanctions including "three strike" rule for theunemployed who do not seek work.

A cap, linked to average weekly earnings, which will limit the amount ofbenefits one household can receive.

Employment Support Allowance will be limited to 12 months' supportfor those able to prepare for work.

These changes will have a significant impact on residents locally,especially those who are already marginalised such as drug and alcoholusers.

Aside from the overall context for public expenditure, and the aforementionedproposals impacting directly on drugs and alcohol, health, crime and policing,there are a number of broader policy developments which will haveimplications for the business of the Substance Misuse Team and how itapproaches its commissioning responsibilities.

Of particular significance are:

The momentum for localism, and a likely focus on place-based budgeting,moving the Total Place approach on to another stage. There will be animperative to achieve greater value for money through collaboration, andin turn this will require service transformation.

Tackling social problems around families with complex needs. Thisapproach will be rolled out nationally by 2013-14.

The Localism Bill was introduced to Parliament in December 2010, andincluded proposals for community empowerment, greater accountability tolocal people, and, of huge significance for commissioning activity,diversifying the supply of public services, aimed at increasing choice, best

value for public money and achieving a better standard of public services.

The Big Society agenda, supported by a Commissioning GreenPaper13, which sets out the Governments intention to create anenhanced role in public service delivery for voluntary and communitysector organisations.. This will clearly have implications for the role ofcommissioners, not least in developing broader provider markets.


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4 Needs assessments

4.1 Substance Misuse Needs Assessment 2010/11 Key Findings

Safer Bristol completes and publishes an annual needs assessment. The

following section summarises the latest Substance Misuse NeedsAssessment (2010/11) for Bristol.

Prevalence of Opiate and Crack Users: National Treatment Agency (NTA)prevalence data suggests that there are 4777 Opiate and Crack Users(OCUs) in Bristol. 74% of the OCUs (3512 users in treatment / 4777prevalence) have had contact with structured treatment services in 2010/2011compared to 68% (3572 users in treatment / 5285 prevalence) in 2009/2010.Based on this prevalence data, it is estimated that there are 15 OCUs per1,000 Bristol population. Bristol ranks the highest rate of OCUs among thesimilar cities,( NTA complexity cluster) of Birmingham, Doncaster, Leeds,

Leicester, Liverpool, Manchester, Nottingham, Sheffield and Stoke-on-Trent.

Other Drug Use: In line with national trends and work in Bristol to encouragepeople who misuse drugs other than opiates into treatment the numbers ofcocaine, cannabis, amphetamine and benzodiazepine users in treatment haveincreased .In 2011/12 there was a 69% increase in the numbers in effectivetreatment compared to 2010/11.

Engagement: The level of penetration in Bristol is 74%, compared to 68%last year for heroin and crack users. Whilst this looks like an improvement inpenetration rates it must be remembered that the baseline figures have beenchanged from 5,285 in 2009/10 to 4,777in 2010/11. Bristol is ranked sixth outof the ten DAATs in the same complexity cluster for penetration rates.

The number of arrests for trigger offences has been consistently lowerthroughout 2010-11. The proportion of offenders testing positive for class Adrugs has remained static at approximately 40% of those tested. There is adecrease in the number of offenders testing positive for sole opiate use and adecrease in combined opiate and crack use. There was an increase in thenumber of offenders testing positive for cocaine.The number of cocaine, cannabis, amphetamine and benzodiazepine users

who accessed treatment services during 2010/11 has increased compared to2009/10.

Clients Exiting the Treatment System: Work with all agencies to increasethe numbers of planned exits has resulted in an increase of the exits from thetreatment system. In 2011/12 there was a 35% increase in successfulcompletions, with a 109% growth in Non Opiate clients successful completingtreatment in January-March 2012. The percentage of Criminal Justice clientswho successfully complete treatment has increased to 16% of all criminaljustice clients in treatment. Positive outcomes for criminal justice clientsleaving the treatment system has increased by 3%.


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On the negative side, data for the rolling year that ended March 2012 showedrepresentations (clients re-entering the treatment system having leftsuccessfully), was higher than the national figures .17% of opiate users havereturned to treatment within six months of having been successfullydischarged. For non-opiate users, 4% of clients have returned to treatment

within six months of having been successfully discharged. Improvement inperformance is required to reach the best performing DATs in our complexitycluster. However, whilst we would aspire to reduce the number ofrepresentations, we would also want to ensure that if clients relapse they canquickly re-engage rather than waiting until their offending and drug useescalates.

Treatment System Map: The total referrals in 2010/2011 reduced by 25%,from 1294 to 1034. The ratio of exits to entries increased from 57% (739 /1294) to 74% (822 / 1115) whilst the ratio of exits to clients in treatment(turnover of clients) has increased from 18% (739 / 4149) to 20% (822 /

4192). Similarly, the total number of agency transfers has decreased during2010/2011. For tier 4 treatment, there had been a 19% increase for thenumber in treatment in 2010/11.In 2011/12 the average length of time clients had been in the system was 2.3years, 14% had been in treatment between 1-2 years, 28% 2-4 years and13% 6 years and over.

Treatment Outcomes Data (TOPs): The information from the NTA for theNeeds Assessment included Start and Review TOPS data. Exit TOP datawas not provided to any Drug Action Team. In 2010-11, Bristol achieved 85%completion of start TOPS but only (54%) of review TOPS (between 5 52weeks). Substance use as declared in TOPS shows that Bristol hassignificantly higher use of opiate and crack throughout baseline and reviewTOPS against the national rate. There have been significantly fewer peopledeclaring cocaine use in TOP than the national picture.

Bristol has more injecting users (23% of clients at start TOP); injecting ratedeclines in the first year of treatment (10% at review TOPS). Sharing atbaseline is also higher than the national average (20%). Sharing declinesduring the course of engagement after one year it is reported as 6.9%.

Bristol is much less likely to have people in paid employment throughout theirtreatment - the baseline of 11.5%. This is also higher than the Bristolunemployment rate of 7.30%. 2011/12 Data for exit TOPs shows only 6% ofopiate clients were employed , this compares very poorly with the nationalfigure of 21%.For nonopiate clients the local figure is 17% compared to thenational figure of 28%. Analysis of the TOPs data for housing shows that18% recorded an acute housing problem at the start TOP, which dropped to2.8% after one year. Clients successfully completing treatment with noreported housing need was 77% Physical health, psychosocial health andquality of life are in line with national trends.


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Key Demographic Issues for Bristol

Age: The decrease in drug users aged 15 24 accessing services that washighlighted in 2009 has continued. However, the exception is amphetamineuse, increasing by 2%. Within the 25 34 age group accessing services,

cocaine and cannabis use rose by 2% and all other drugs decreased.

In contrast, those aged 35 64 showed a notable increase in the use of mostdrugs particularly cocaine (+11%) and other drugs (+13%). These findingsshow that drug use varies with age and that there is an ageing cohort of polydrug users.

Gender: There has not been much variation between genders in 2009/2010and 2010/2011. 70% and 30% - 2009-10 compared with 71% and 29% in2010-11.

However, the choice of drug has changed, for male users in treatment, thelargest variation is amphetamine (+4%) and other drugs (-4%), this may bedue to recording practices. A similar trend is identified for women in treatmentwhere the largest variation is amphetamine (-4%) and other drug use (+5%).

Ethnicity: Within the treatment system in 2010-11 clients identified theirethnicity as 91% White and 9% of BME drug users. As we do not know aboutthe prevalence of drug use in the BME community it might not be appropriateto use the percentage of adult BME in Bristol, which is 14.8%, as acomparator. Looking at drug use in the BME Opiate & Crack Users, 14% ofcocaine users are from BME. For DIP clients, 14% of the clients are fromBME background.

Bristol is home to a diverse community and this impacts on the services weprovide. We are resolute about understanding more about the diverse groupswithin our community and safeguarding equality of access for all groups. Wewill work hard towards ensuring that our services are as accessible aspossible for all whilst ensuring individual needs are met.

Bristol City Council has achieved Excellence Standard of the EqualityFramework for Local Government the work within the Substance MisuseTeam to tackle inequalities contributed to the submission of evidence tosupport the award.

4.2 The Drug Intervention Programme (DIP)

The DIP programme continues to be a key component of Bristols treatmentsystem. It aims to engage drug and alcohol misusing offenders in structuredtreatment, thereby reducing offending behaviour. Bristol is an Intensive DIParea.


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Bristols data from Home Office DIP Dashboard and DIP Quarterly Reports for2011/12 shows:

1059 clients tested positive on arrest and had an initial requiredassessment imposed.

678 clients attended an initial required assessment.

476 clients taken onto the DIP caseload.566 clients were referred to treatment.

Of these, 352 clients were already in contact with treatment services whilst214 clients were treatment nave.

14% of clients in the treatment system are DIP clients.

128 DIP clients successfully completed treatment.

Further to these 128, 43 clients successfully completed but re-presentedwithin the year.

HMP Bristol Prison

HMP Bristol is part of the Ministry of Justice pilot projects for Drug RecoveryWings and Drug Free Wings. The Integrated Drug Treatment Programme isjointly commissioned with NHS Bristol and is part of Bristols overall treatmentsystem.

Based on data from quarter 3 2011/12:

There were 425 individuals starting a treatment episode in prison.

Of these 390 were opiate users whilst 35 were non opiate users.

187 of individuals were currently injecting and 123 were previously injecting

41% were drinking above six units a day.For individuals completing treatment in prison, 12% required no furthertreatment whilst 78% were transferred with an onward treatment referral.

For individuals leaving prison, 22% were transferred to CJIT and 25% weretransferred to another prison.

50% of those in treatment were aged between 25 34.

In terms of ethnicity, 84% were White British, 1% were White Irish, 3%were Other White whilst the BME population totalled 11% with 1% notbeing stated.

4.3 Alcohol Needs

Alcohol is now generally recognised as a major national concern across theUnited Kingdom. Some of the main issues are as follows:

Alcohol related harm is estimated to cost society 21 billion annually.

25% of hospital admissions are related to alcohol.

There are almost a million alcohol-related violent crimes each year inEngland & Wales.

40% of domestic violence incidents are alcohol related.

One third of cases of child abuse are associated with alcohol consumption.11 people are killed each week in road traffic accidents due to drinking.


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33,000 people die each year from alcohol related causes.

19% of men and 5% of women in Britain report having had some sort ofalcohol related problem.

The North West Public Health Observatory, which profiles alcohol harm, has

found that Bristol performs significantly worse than the national average onthese measures:

Male alcohol specific mortality.

Male mortality from chronic lever disease.

Male and female alcohol specific hospital admissions.

Male and female alcohol attributable hospital admissions.

Alcohol related recorded crime.

Alcohol attributable violent crimes.

Alcohol attributable sexual offences.

Claimants of incapacity benefits working age.Binge drinking.

The Observatory provides estimates of alcohol use in Bristol. It estimates thatthere are 19,591 people drinking at higher risk levels in Bristol; drinking atthese levels can cause clear harm to the drinker and/ or to others. Of thisgroup, 16,256 are dependent drinkers. In addition there are over 69,000 whoare drinking at increasing risk levels. This means they are drinking more thanthe national low risk guidelines and may well develop alcohol relatedconditions in the future; they are currently at risk of injury, accidents andalcohol poisoning.

Dependent Drinkers: Evidence tells us that dependent drinkers cost the NHStwice as much as other drinkers. The Department of Health alcoholcommissioning guidelines, Signs of Improvement (2006), states that providingtreatment services for 15% of the population of dependent drinkers each yearwill produce the largest and most immediate reduction in alcohol-relatedadmissions.

Dependent drinkers fall into 3 broad categories:

Severely dependent drinkers who need intensive specialist treatment andmedical supervision when they detoxify. They may experience withdrawalfits (for instance confusion or hallucinations) and may drink to escape fromor to avoid these symptoms.

Moderately dependent drinkers many of whom will experience the bestoutcome if they take a harm reduction approach. If they do decide to gothrough detoxification they will need a medically assisted detoxification asthey can suffer withdrawal symptoms. They need specialist treatment in ageneralist or specialist setting.

Mildly dependent drinkers who will have the best outcome if they take aharm reduction approach.


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NICE identifies additional groups of drinkers that, though not necessarilyseverely dependent, need specialist treatment, and possibly an inpatientdetoxification. These groups include vulnerable adults such as:

Older people.

Homeless people.

Pregnant women.People with a history of epilepsy or experience of withdrawal symptoms orDTs during a previous assisted detoxification programme.

Concurrent withdrawal from alcohol and benzodiazepines.

Significant physical or psychiatric comorbidities (for instance chronic severedepression, psychosis, malnutrition, congestive heart failure, unstableangina, chronic liver disease or significant learning difficulties or cognitiveimpairment.

Higher risk drinkers who do not actually fall into the dependency category,

can benefit from brief alcohol advice or longer interventions addressinglifestyle choices.

Increasing risk drinkers can benefit from brief alcohol advice. This is mainlydelivered in primary care.

The Safer Bristol Alcohol Strategic Needs Assessment 2012 describes thecurrent situation in Bristol and the numbers in treatment:

696 clients were referred to the specialist service in 10-11, of these 318attended appointments, and 83 went on to be detoxified in the communityand 36 had an inpatient detoxification.

729 clients were treated by the community alcohol service in 2010-11. Theyreceived support, advice and information.


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5 Initial consultations and developing the market

5.1 Mapping and gap analysis

The mapping and gap exercise was carried out in the following way:

A series of consultations were undertaken with the following groups:Treatment Task Group, Shared Care Monitoring Group, UFO, PracticeGovernance, Young Peoples Managers Meeting, Safer BristolCommunities Team, Safer Bristol Crime & Substance Misuse Managermeeting and thematic lead groups (e.g. Employment). (Approximately 130participated).

An online survey was designed and circulated to all relevant stakeholders.(191 participated).

UFO representatives carried out face to face interviews with current serviceusers from commissioned services. (64 participated).

The Substance Misuse Team contacted other DAATs (Drug & AlcoholAction Team) in the complexity cluster to gather information on theirservices and future commissioning intentions.

Through these consultations a number of common themes emerged:

Priority areas to look at:

Addressing and improving the balance of the treatment system by lookingat:

Abstinence vs Harm Reduction.Opiates vs Non Opiates.Drugs vs Alcohol Provision.

Developing a fully integrated system that is flexible and can change toreflect emerging patterns of substance use.

Improve joined up working across agencies by incorporating a systemwide-care co-ordination model.

Improve the access in to and out of the recovery system for our most

complex clients (e.g. serious mental health issues, sex workers) etc bystrengthening links across different strategies.

Improve and expand aftercare/wrap around services to promote therecovery culture. Central to this is service users taking ownership of theirrecovery. There needs to be an increased focus on the recovery capital ofclients: families, employment, housing etc.

Many of the services are located centrally - Not many services in the Northor South of city (e.g. group work).

Need to look at how community day programmes are delivered in Bristol. Ahigh demand but also a need to reduce waiting times for clients.


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Improve information sharing in regards to recovery and housing. HSR(Housing Support Register) process is not explained clearly enough toclients.

What is good about the treatment system:

We have a very diverse set of services and service users have a range ofoptions:

An accessible and mobile needle exchange service that can ofteninitiate the start of a clients recovery.

The accessibility of shared care is also good. We have a spread ofservices across the city with a large number of GP surgeries involved.

The quality and choice of community day programmes are impressive

It is easy to access Tier 4 provision in Bristol.

Communication has improved between different parts of the system.

The prison drug and alcohol service has improved their relationship withcommunity drug and alcohol services over the past couple of years.

We have good Jobcentre+ links in prison.

Consultant psychiatrists are available for drug and alcohol clients with dualdiagnosis.

The development of more non opiate provision is encouraging.

Womens provision is strong in the community.

Our system keeps people safe and effectively reduces drug related deaths.

There is a strong focus on service user involvement that helps shape thetreatment system.

What needs to be improved in the treatment system:

Joined up working across agencies needs to be improved. There is a lackof a system wide approach with care pathways being unclear. Some clientsalways end up going to the same agencies with not enough movementbetween the agencies. There can sometimes be an unhelpful ownership ofclients, e.g. my client.

Multi-agency working can produce variable quality. It is difficult tostandardise (e.g. One GP surgery can perform well whilst another one

doesnt).The balance of spend in the treatment system needs be addressed with toomuch being spent on prescribing. There remains a risk of parking serviceusers on scripts.

The Bristol treatment system is currently very opiate-based. More non-opiate provision needs to be offered in a more flexible treatment system toallow for any potential changes in drug trends.

There are still blocks in the system, especially around community dayprogrammes, due to waiting times and inconsistent referral systems, thatimpact on a clients recovery.

There needs to be more provision offered to primary alcohol clients.

We need to look at how we jointly commission with mental health servicesin order to offer more effective services to clients with dual diagnosis.


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There needs to be more of a link in with aftercare and mutual aid when aclient exits Tier 4 treatment.

A better geographical spread of services across the city would be helpful.

We need to more effectively challenge the stigma encountered by those inrecovery.

More work needs to be done around housing. In particular the HousingSupport Register process needs to be explained more clearly to clients.

More tailored provision is required for mothers and baby as 12 weekprogrammes are not long enough for this group.

Need more accessibility for clients to employment and training provision. Inparticular we need to develop clearer links with the Work Programme.

Messages about positive changes to system are not promoted to serviceusers enough (i.e. police not routinely coming to those who overdose).

Gaps and needs in the provision of alcohol treatment services according tothe Alcohol Strategic Needs Assessment 2012:

In order to reach the commissioning target of service provision for 15% ofdependent drinkers every year we need to work towards increasingprovision by 1,096 places.

Improve links between mental health and general practice health forcomplex and chaotic alcohol patients.

Develop pathways for people with alcohol related brain disease.

There is a perceived lack of community base services.

There is no entry group dealing with motivational enhancement in the

specialist services to boost engagement in treatment.There is no dual diagnosis service this would enhance service for thiscohort of clients.

There is a lack of capacity for community assessment for complex andchaotic or vulnerable clients.

Consideration needs to be given to a single point of assess to allcommissioned substance misuse services.

There needs to be a harm reduction inpatient facility for chaotic drinkers.

5.2 ROIS Survey

There were 255 questionnaire responses over the course of the informationgathering process with both service users and providers completingquestionnaires, with input also coming from professionals in the field and fromthe wider Partnership.

Analyses of the many responses show that a number of current treatmentoptions are working well and helping with recovery. By the same token, thereare also areas in which current service delivery has been challenged and itscontribution to recovery questioned.


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The most commonly identified issue has been around the poor integration ofservices within the Bristol treatment system. Respondents felt that the currenttreatment system works well in areas but that the services work in silo, oftenin competition with one another. Referral pathways between agencies werecriticised as being too inflexible with multiple assessments being cited as a

barrier to engaging with more than one agency.

Individuals felt that the ease of accessing treatment was very muchdependant on where you live and the complexity of your need. Treatmentprovision outside of the city centre was felt to be minimal and the access toalcohol and non-opiate treatment was said to be difficult due to the focus onopiate services.

Many contributors felt that current provision did not really include or have anysignificant focus on the roles of family and concerned others in a serviceusers treatment journey.

Analysis of the replies suggests that respondents felt there is not currentlyenough funding made available to currently commissioned community basedservices and that locally available community rooted organisations are underused.

Looking forward to recommissioning, concerns were raised about those fromspecific communities, especially Black & Minority Ethnic and also British SignLanguage and disabled clients being able to access treatment if the alreadyminimal outreach service were to be withdrawn.

5.3 Market Development

The drug and alcohol field is a relatively well developed market with a numberof different providers of varying size (including NHS and 3

rdsector VCS

services) delivering services locally. In addition to these local providers thereare a significant number of other providers delivering substance misuseservices in other comparable areas and nationally.

The Substance Misuse Outcome Focus Fund (SMOFF) has been identified as

a potential method by which to test the market and identify new ways ofworking in areas where gaps in services have been identified through theNeeds analysis process. Through a competitive tendering process applicantswill be evaluated on their ability to achieve outcomes through the delivery ofevidence based services. Lessons will be learned with regard to anoutcomes based approach to purchasing services in addition to any impact ofthe new services.

The Substance misuse team are always on the lookout for new and innovativetreatment options. This is achieved by keeping up to date with new trends andregional and national contacts. Nationwide advertising will be carried out

when issuing the tenders.


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6 Formal Consultation Stage

6.1 Consultation Methods

The formal consultation on the draft model and strategy was carried out in the

following way over the period of Friday 18th

May Friday 17th

August 2012:

There were over 400 attendees (although some representatives attendedmore than 1 meeting) at the various consultation events held by SaferBristol.

There were 6 main events open to a range of stakeholders.

There were 8 specific service user events. Including targeted equalitiescommunities and agency service user groups.

Presentations were also given to a number of other standing groups e.g.Alcohol High Impact Users group and the Mental Health Partnership.

Presentations and workshops were also given at trustees and staffmeetings in a number of agencies.

An online survey was designed and included in the Bristol ConsultationFinder to gather a wider range of views from individuals and organisations.There were 173 responses to the online questionnaire.

Following the completion of the consultation events and onlinequestionnaire a number of common themes emerged that was thenconsidered within Safer Bristol.

A rationale for each of the decisions was recorded and will be included inthe We asked, you said, we did document.

6.2 Quantitative analysis of the online survey

The quantitative results from the online survey validate the proposedapproach with nearly 75% agreeing with the statement that the keycomponents of the treatment system were aligned with the correct clusters.

45% of respondents agreed or strongly agreed that the proposed modelimproved access to services whilst 43% neither agreed nor disagreed.

40% of respondents agreed or strongly agreed that the proposed modelimproves involvement and support for 'concerned others & families' whilst46% neither agreed nor disagreed.

47% of respondents agreed or strongly agreed that the proposed modelfostersincreased integration between and within serviceswhilst 33%neither agreed nor disagreed.

48% of respondents agreed or strongly agreed that the proposed modelfacilitates movement through and within the treatment systemwhilst 36%neither agreed nor disagreed.

39% of respondents agreed or strongly agreed that the proposed modelenables sustained recovery from substances of dependence whilst 37%neither agreed nor disagreed.


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6.3 Analysis of qualitative feedback

The following key themes emerged from the events and the onlinequestionnaire:

Housing support to be put into own cluster separate from Support clusterand to contain both accommodation based support and floating support.

Concerned/significant others to be added to the support for carers sectionin the Support cluster.

Change the name of the Intake cluster to Engagement.

Change the name of Recovery cluster to Completion.

Move peer support opportunities from Completion to Support cluster.

Create family support component and add it to Change cluster.

Add relapse prevention/aftercare provision to Completion cluster.

Recovery Support interventions to be brought in to line with the

forthcoming NDTMS Data Set J (November 2012).Remove residential rehabilitation from model and create CCA for accessto residential rehabilitation row in Change cluster.

Include residential rehabilitation as a framework agreement rather than asingle provider or consortia agreement.

Add a paragraph clearly explaining that Substance Misuse refers to both

Drugs and Alcohol throughout the strategy.

Provide a definition of Recovery in strategy. UKPDC (UK Drug Policy

Commission) definition of recovery to be used.

There are a number of points that will be removed from the model and addedto the commissioning intentions document as a core requirement for all

clusters. These include but are not limited to:

We will expect all providers to create strong pathways to work together

enable appropriate movement between clusters

Deliver harm reduction and healthcare interventions

Maximising the skills of the workforce and ensure staff are in accordancewith the Skills Consortium

All providers to promote, encourage and support referrals to mutual aid

e.g. SMART, 12 Step Fellowship

All providers to use our current case management system- Theseus.

We will be seeking to commission only evidence based interventions.

All providers to work with other DAATs for clients who move to different

local authorities.

All potential providers to be culturally competent.

Out of hours provision to be provided for those clients wishing to access

services outside 9-5 hours Monday to Friday.

Suggestions that were not included in the final strategy will be detailed in theforthcoming We asked, you said, we did document.


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7 Recovery Orientated Integrated System

To comply with legal obligations, Bristol City Council (BCC) ProcurementGuidance and evidence collected from the consultation exercises, SaferBristol will re-commission the majority of adult drug and alcohol treatment

services, including Supporting People drug and alcohol accommodation andfloating support services, with a new recovery orientated treatment modelexpected to become operational in November 2013.

The contracts are expected to be awarded in August 2013, with the targetcommencement date of November 2013 at which time all current services willbe decommissioned. Those services that are out of scope will be integratedwithin the proposed model, contracts will be renegotiated with new levels offunding and outcome focused performance targets. It is likely that TUPE willapply if there is a change in service provider, which may lead to a longerimplementation time, but it is expected that the new model will be fully

operational by January 2014.

7.1 Recovery Model

The model that we are implementing is driven from various national and localstrategic priorities. This structure has drawn on the feedback we have gainedfrom stakeholders in both the pre-consultation and formal consultation stage.All clusters will contribute to the outcomes set out in the outcomes framework.

In the new model, clients new to the treatment system or those re-presentingfor treatment will be expected to enter via the engagement cluster and movethrough change to completion and into community based support networks.During and throughout a clients treatment journey, they will receive ongoingintegrated assistance from both the support and housing support clusters ifrequired. When the new model is operationally embedded, those clientsalready in treatment will have their needs reassessed and goals revisited tobetter align their care with the new services.


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Figure 6: Recovery Model

The Bristol recovery system will comprise of five integrated clusters:

1) Engagement: During the engagement phase clients will begin to get helpwith their substance misuse. At this stage of a clients journey they willhave access to a triage, comprehensive assessment and recovery planningservice. This will enable them to access appropriate recovery-focusedtreatment and support.

We envisage key components of this cluster to be:

Triage, comprehensive assessment and recovery planning.

Low threshold and brief interventions.

Needle and syringe provision.Harm reduction and healthcare interventions.

Transition from YP services.

2) Change: During the change phase of a clients journey they will haveaccess to a fully integrated treatment service enabling clients to stabiliseand reduce their drug/alcohol use, facilitate recovery and promote healthand wellbeing.


Care coordination and recovery planning.

Specialist treatment provision.


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GP substance misuse liaison workers.

Inpatient/community detox and stabilisation.

Structured psychosocial interventions.

Family support.

CCA for access to residential rehab.*

*There will be a residential rehab framework for approved providers that willbe procured separately.

3) Completion: The completion phase of a clientsjourney will deliverinterventions to enable people to become drug or alcohol free andrecover. This will include promoting and supporting reintegration to otherservices such as training and employment. As recovery involves areas ofwork that treatment services are not able to provide directly this will involvea high level of partnership working with agencies that can provide theseservices.


Access to training, education and employment.

Relapse prevention/Aftercare.

4) Support: These services will enhance and develop the support that isoffered to clients through the engagement, change and completion clusters

in order to help aid their recovery.


Tackling discrimination and stigma in the community.

Advocacy.

Support for carers and concerned/significant others.

Peer support opportunities.

5) Housing Support: Clients will be able to access housing, via Bristol CityCouncils Housing Support Register, during any stage of moving through

the recovery model.


Accommodation based support.

Floating support.


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7.2 Substance Misuse Recovery System Outcome Framework

Safer Bristol will be using an outcome based commissioning process. Anoutcome-focused approach is not overtly prescriptive in the specification

about the services being commissioned. The service specifications will detailthe outcomes being sought and the target cohort of clients identified in theneeds assessment and consultation exercises.

The outcomes framework is set out below. The outcomes in the Green(bottom) box are the nationally set Public Health Outcomes being sought forservice users. It will be the achievement of these outcomes that will determinethe funding available for Bristol and used as a comparison of Bristolsperformance nationally. With the exception of 2.15 Successful Completion ofDrug Treatment, service providers will not be expected to individuallyevidence these outcomes as part of their reporting requirements as they are

achieved within the context of integrated working.

Service providers will be required to evidence the achievement of the bestpractice outcomes in the Yellow (middle) box. This will be evidenced throughvarious performance measures including, but not restricted to, National DrugTreatment Monitoring System (NDTMS) measures, Treatment OutcomeProfile (TOP) forms and Outcomes Stars.


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Figure 7: Outcome Framework


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7.3 Monitoring and review arrangements

The Safer Bristol Partnership will use a set of indicators to measure theimpact of the strategy against the outcomes, and will also develop measuresto gauge the impact of the proposed service developments and changes. We

will use a balanced approach that relies on a range and mix of measures.These will include, but not be restricted to:

System wide performance scorecard.

Treatment Outcome Performance (TOPs) forms.

Individual agency scorecard.

Risk management scorecard.

Service user feedback.

NTA DOMES reports.

Quarterly progress reports will be presented to the JCG based on theperformance of these measures.

Providers will be expected to use the agreed case management data systemTheseus to collect data and submit agreed required data systems (e.g.National Drug Treatment Management SystemNDTMS).

7.4 In scope services

The following current services are in the scope of this re-commissioningexercise:

Name of the SLA (ServiceLevel Agreement)

Short Description of Service Name ofCurrent

Provider /Agency

Preparation & Detox Stage 1 -Non residential

Prepare for and enter inpatientdetoxification programme.

Salvation Army

Substance misuse in-patientpreparation detox andstabilisation

Inpatient stabilisation, preparation anddetoxification (drugs)

Avon & WiltshirePartnership Trust(AWPT)

Substance misuse in-patientpreparation detox and

stabilisation

Inpatient stabilisation, preparation anddetoxification (alcohol)

AWPT

Residential; Rehabilitation Drug treatment provided in a communalsetting. The client would need to be drugfree on entry.

Salvation Army &WalsinghamHouse

Various spot purchasedtreatment

Drug treatment provided in a communalsetting. The client must be drug free onentry.

As agreed withcommissioners.

Structured Day Programme Community based treatment serviceabstinence based (includes alcohol).

ARA

Structured Day Programme Community based treatment service harmreduction based

BDP

Structured Day Programme Community based treatment servicestimulant based

Nilaari


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Structured Day Programme(Currently funded throughplacements budget)

Community based treatment serviceabstinence based

Serenity House

Integrated Drug and AlcoholSpecialist Treatment Service

(BSDAS)

Rapid prescribing, prescribing for peoplewith complex needs including maternity,

prescribing for detox, referrals in toresidential rehab (includes alcohol)

AWPT

BSDAS Alcohol Colston Fort 1-to-1s, groupwork and prescribing foralcohol users

AWPT

BSDAS Inpatient detox alcohol Inpatient detox alcohol AWPT

BSDAS Enhanced AlcoholService

Works with GPs and primary care AWPT

BSDAS Inner City CommunityDetox

Works with GPs and primary care AWPT

BSDAS HIU Nurses Works in hospitals AWPT

GP Prescribing / Shared Care Drug worker component of partnershipwith Primary Care GPs to provide SharedCare to manage a client's substituteprescribing needs.

BDP

Tier 2/3 Community BasedDrug Treatment Service

BOOST, family support, counselling,criminal justice, drop-ins, outreach tohostels and sex workers.

BDP

Bristol Needle Exchange andHarm Reduction Service

Bristol Needle Exchange and HarmReduction Service

BDP

ARA AMS Service Alcohol service Tier 2/3 service ARA

Transitions Service Service for young adults transferring fromYP services and needing ongoing support

AWPT

Hidden Harm Primary SchoolWorker

Service to support primary school childrenin S2 & S4

HAWKS

Advocacy Service for ClientsUsing Drugs Services in Bristol

Provide advocacy and support for clientsaccessing Bristol drug and services

The Care Forum

Bristol Citywide Service forCarer's of Drug Users

This service is for friends and familymembers who are concerned aboutsomeone elses drug use

KWADS

Jobcentre+ SPOC Service for JC+ clients with drug or

alcohol problems

BDP

Family service Supports substance user with a focus onwider family

NHS Bristol(HAWKSProvider)

Accommodation Supporting People Accommodation Chandos House

Accommodation Supporting People Accommodation St James

Accommodation Supporting People Accommodation Junction

Accommodation & FloatingSupport

Supporting People Accommodation People Can

Accommodation & Floating

Support

Supporting People Accommodation ARA


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Floating Support Supporting People Accommodation BDP

Table 2: In scope services

7.5 Out of scope services

The following services will not be part of the tendering exercise. They will beintegrated within the proposed model, contracts will be renegotiated with newlevels of funding and outcome focused performance targets being set.

Name of the SLA(Service Level

Agreement)

Short Description ofService

Name of CurrentProvider / Agency

Rationale forexclusion

Drug NurseSpecialists

Drug nurse specialistswithin the BRI - linkservice users tocommunity treatment ondischarge

Bristol RoyalInfirmary

Must be provided byqualified nurses basedin hospital

Alcohol: UHB ward-based and A&E nurse

Alcohol nurse specialists UHB Must be provided byqualified nurses basedin hospital

CJIT contract The managing of CJITclients care coordinationand further treatmentneeds. (Includes ARAalcohol arrest referral)Rapid access prescribing& detox

AWPT Recentlyrecommissioned andmajor changesexpected in 2013/14with new custodyarrangements.

Multi-agencySubstance MisuseMaternity Service(Maternity DrugService)

This part of the service iscomprised of midwivesand social workers whowork as part of a multi-agency team providing

support to drug usingpregnant women.

University HospitalsBristol NHSFoundation Trust &CYPS

Must be provided bymidwives and socialworkers. Additionalspecialist workersemployed within

mainstream services

Harm ReductionNurse

Service for homelessinjecting drug users.Participate in HSSoutreach clinics.

NHS Bristol Must be provided byqualified nurses.Provided as part ofwider homeless healthservice commissionedby PCT

The Provision of IDTSHMP Bristol

NHS Bristol, HMPBristol, Safer Bristol withBristol CommunityHealth

Bristol CommunityHealth and AWPT

Currently beingrecommissioned byNHS Bristol


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Provision of DRRs Drug rehabilitationorders, drug testing etc

Avon & SomersetProbation (NOMS)

Must be provided byProbation Officers

Theseus Case management

system for allcommissioned treatmentservices

Cyber Media Recently

recommissioned

GP Prescribingshared care scheme

GPs and pharmacycomponent of SharedCare, providing a client'ssubstitute prescribingneeds. Commissionedby NHS Bristol

NHS Bristol Must be provided byGPs and pharmacists.

Consideration shouldbe given to negotiatingchange in currentmodel of service.

Early InterventionService

Young people's targetedservice

BDP and ARA. Part of Youth Linksrecommissioning

Homelessness HealthService

Harm Reduction Service NHS Bristol Commissioned by NHSBristol

Police Drug Co-ordinator

Liasion between PoliceDrug Strategy and BCC

Avon & SomersetProbation (NOMS)

Must be provided byPolice

Alcohol: LocalEnhanced Service

(GPs)

Brief interventions NHS Bristol Must be provided byGPs

Alcohol: HomelessService wet clinic

Primary care services forcurrently drinkinghomeless people

Lawrence HillHealth Centre

Must be provided aspart of a GP service forthe homeless.Commissioned by PCT

Young People inCYPS/SocialServices

Service dealing withchildren at risk andchildren in need

Drugs & YoungPeople's Project

Must be provided bysocial workers

Young People withcomplex needs

Specialist YP servicewith links to CAMHS

Young PeoplesSubstance Misuse

Service

Recentlyrecommissioned

Young Peopleinvolved in the CJsystem

Young People in the CJsystem

YOT Must be provided byYOT workers

SMOFF Outcome Focussed worksupporting Non OpiateUsers and Safeguardingwork

Yet to be awarded non-recurring annualfund


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Supporting RecoveryGrant

Increasing recovery andreducing stigma in thecommunity

People Can, ARA,Windmill Hill CityFarm, Barton HillSettlement, SevernProject

non-recurring annualfund

Table 3: Out of scope services

7.6 Harm reduction work

Harm reduction, in its broadest definition, encapsulates all policies,programmes, services and actions that work to reduce the health, social andeconomic harms to individuals, communities and society that are associatedwith the use of drugs and alcohol.

The new drug strategy calls for a rebalancing of the treatment system and as

such it remains vital to ensure that harm reduction plays its role within allareas of treatment provision.

Reducing the transmission of blood borne viruss (BBVs) will remain a priorityfocus for all commissioned providers, particularly as Hepatitis C (HCV)prevalence within Bristol remains high. Whilst treatment system responseshave led to a reduction in new cases of HCV a greater effort must be made infacilitating access to testing and treatment for HCV and for improvements tobe made in enabling access to Hepatitis B vaccinations.

The Government Drug Strategy states substitute prescribing continues to

have a role to play in the treatment of heroin dependence, both in stabilisingdrug use and supporting detoxification. Medically-assisted recovery can, anddoes, happen.

As such the guidance set out in Drug Misuse and Dependence- UKGuidelines on Clinical Management; Medications In Recovery- Re-orientatingDrug Dependence Treatment; and NICE Psychosocial Interventionsguidelines, the treatment system shall have all evidenced treatment options atits disposal to best meet the needs of individuals and communities.

Effort will however need to be taken to ensure that for people currently on a

substitute prescription, what should be the first step on the journey to recoverydoes not risk ending there. Greater importance will be put on supportingpeople to successfully complete drug treatment and move on to engage inrecovery activities.

Strategically a broadening of the focus of harm reduction work to link withexisting strategies (including alcohol and sexual health) and respond toemerging trends within substance misuse in Bristol will be necessary.

A more broadly based approach will call for close links with the reorganisedhealth care commissioning structure expected to take shape over the next 12months to link in with established strategies already in place.


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7.7 Workforce Development and Equality & Diversity

Safer Bristol Substance Misuse Use Team is committed to ensuring that Bristolhas a skilled workforce to deliver the services we commission. We want tobuild the right culture, developing the paid and voluntary workforce to deliver

services that achieve the agreed outcomes, and support service users on theirrecovery journey. This approach is captured well within the Skills Consortiumand its evidence matrix.

The Skills Consortium and the The Skills Hub with its vast library of resourceson substance misuse treatment interventions, will play a key role in achievingan effective, competent and capable workforce that is able to activelycontribute to a clients recovery.

The model compliments the Skills Hub and together with development of theSMT Workforce Development Strategy and Equality Good Practice Guide we

are confident that good practice will achieve quality outcomes. Training,development and equalities will be embedded within the proposed model.

Equality means quality and equality in provision is not about treatingeverybody the same, it is about individual assessments of everyonesindividuals needs.

The Substance Misuse Team has a duty to ensure that its commissionedservices are accessible to and appropriate for everyone. To support this,providers will need to work towards ensuring that their workforce isrepresentative of the diverse communities of Bristol, culturally competent andable to respond to the needs of all communities.

Under the Equality Act 2010 and the Public Sector Equality Duty, Safer Bristolhas a responsibility to promote equality of opportunity, foster good relationsbetween different groups and work to ensure that nobody is discriminatedagainst because of age, gender (sex), gender reassignment, disability, race,religion and belief, pregnancy and maternity, marriage and civil partnership orsexual orientation. All contracts will require providers to comply with theEquality Act 2010.

Equality is built into commissioning and procurement and therefore into servicedelivery and a key consideration for everyone involved at all stages of thisprocess. As part of the tendering process, service providers will be asked todemonstrate how their services will meet the needs of those from equalitiescommunities. Equalities monitoring and workforce audits will continue to takeplace and providers will be expected to actively engage in these processes.

The model and the commissioning strategy have undergone an equalityimpact assessment (EQIA). This document is included in the consultation onthe proposed model and strategy. We welcome any comments andsuggestion on how improvements can be made and how any impacts can be

mitigated were possible.


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8 Resource analysis

The table below summarised the position for last year and the current year.

Budget 2011/12 2012/13

DIP 2,201,605 2,136,655

PTB 5,915,892 6,115,091

Partnership 2,224,885 2,138,466

Supporting People 1,595,904 1,339,035

BCC revenueoverheads

0 321,416

Placement (BCC

revenue)

724,547 724,547

Total 12,662833 12,775,210Table 4: 2011/12 & 2012/13 Budgets

Given the major structural changes that will take place from April 2013 it isdifficult to predict future levels of funding. We know that there are reductionsin the following budgets:

DIP, Home Office element: 2012/13 800,000 will move to the Police &Crime Commissioner.

Supporting People: 400,000 savings need to be made in 2013/14.

Young Peoples Prevention Fund: 86,000 discontinued from 2013/14.

With the abolition of the NTA, the pooled treatment budget and DIP treatmentallocations will become the responsibility of the Director of Public Health.However it is unclear if these budgets will continue to be ring fenced. Thispresents a risk to future levels of finance available.

Given these uncertainties it is not possible to finalise the likely commissioningbudget available for 2013/14 onwards. Therefore we are working on theunderstanding that the budget is likely to be reduced by at least 10%.

It is recognised that this presents a challenge to Safer Bristol Partnership, theJoint Commissioning Group, service providers and service users and we willendeavour to work with our partners to maximise the funding available forBristol.

It is essential that during the re-commissioning period, Bristol continues toperform well and continues to achieve the numbers of people successfullycompleting treatment drug free, reduce re-offending and sustaining recoveryin the community.


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9 Risk Assessment

The Substance Misuse Team conducted a PESTLE (Political, Economic,Social, Technology, Legal, Environment) analysis when conducting the riskassessment:

Political

Concerns about access to recovery capital e.g. welfare and housing benefitreforms.

The new agenda arguably offers great opportunities to commissionservices most appropriate to a locality, but in practice there may beconflicting agendas from the different localities that this impacts on.

Political changes to the structure of Bristol City Council (e.g. Mayor andPolice & Crime Commissioner).

Economic

The risk of disinvestment in drug and alcohol treatment.

The risk that competition on cost could compromise sustainability andinvestment in capacity building, research and workforce development;

Potential implementation of Payment By Results (PBR).

Risk of a shrinking market due to providers closing because they haventwon contracts.

Social

Shift in demographics of drug trends (e.g. aging cohort of heroin users,wider range of substances being used by younger cohort).

Rise in unemployment rates and housing needs due to benefit changescould lead to increased substance use.

Technology

First time of outcome focussed commissioning being used to purchasesubstance misuse services.

Ability of data collection tools (Theseus) to respond to required changes in

data collection.Lack of evidenced based practice for treatments for `new` substances.

Legal

Risk of challenge from providers as a result of procurement processes.

Implications of TUPE.

The importance of supporting Health and Wellbeing Boards and other localstructures to bring services together and to join up local strategies (forexample Police and Crime Plans).

The potential impact of

commissioning a recovery orientated substance misuse treatment system for bristol commissioning...

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