Project: Joint Strategic Needs Assessment

Profile Title: Substance Misuse

Author/Priority Lead: Ben Seale

Date of Submission: 01/02/12

Document Reference no: Version no: 0.4 Please ensure you complete the version control to ensure the most recent Document is presented.

Version Comments Author Date Issued Status 0.1 First Draft Ben Seale / Sarah

Fox / Nicola Grainger 09/09/2011 [Draft]

0.2 Second draft Sarah Fox/Nicola Grainger

12/9/2011 [Draft]

0.3 Third Draft Ben Seale / Sarah Fox / Nicola Grainger

22/11/2011 [Draft]

0.4 Fourth Draft (amends only)

Rachel Atkins 01/2/12 [Draft]

Introduction Substance misuse is the term used to describe the problematic use of licit substances such as alcohol and / or illegal substances such as cocaine or heroin. This can result in many adverse effects, ranging from attributable health problems such as alcoholic liver disease and blood borne viruses to associated social functioning issues such as worklessness, engagement in criminal activity and the breakdown of family relationships. Sunderland remains firmly fixed amongst the areas in England worst affected by substance misuse. In particular, directly alcohol related hospital admission rates in the city were ranked at 9th worst in the country during 2009/10. This equated to 1723 recorded admissions. During the same period, mortality rates due to alcohol were recorded as the 15th worst in England. This creates excessive burden not only on healthcare but also social care, the criminal justice system and communities. There is also strong evidence that this trend in increasing ill-health is likely to continue to develop over the coming years - confirmed increases have been recorded for both males and females every year since 2005. Most alarmingly, for males in 2009/10, a 39% increase was recorded. This provides a stark reminder of the scale of the issue, both as it is known at present and as it may reveal itself in the coming years. In terms of prevalence of problematic drug misuse, Sunderland is rather less unusual, though significant problems remain. The numbers of individuals engaged in structured treatment services peaked earlier this year at 1314 in January 2011. Whilst in recent years these numbers have continued to increase, the proportion attributable to opiate and crack cocaine use appears to have reached a comparative plateau. In general levels of drug related crime have reduced over recent years as a result of robust policing, improved management of offenders and increased availability of treatment pathways for drug misuse. For example, drug related offences reduced by 11.7% in Sunderland in 2009/2010. However, it remains important to maintain a robust response - notably in the first quarter of the 2010/11, an increase of 5.1% was recorded. Additionally, trends in drug misuse vary widely over time and require wide ranging and flexible responses. For example, substantial production of cannabis has been evidenced in Sunderland with 59 cannabis farms recovered during 2010. Also, Harm Reduction Services in Sunderland (and across the region) also report a large upsurge in activity relating to the use of performance enhancing substances such as steroids and growth hormones. So, although the misuse of heroin appears to have stabilised other risk taking behaviours are rapidly replacing it.

Key issues and gaps

Large scale national investment began in tackling drug misuse following the publication of the 1998 strategy ‘Tackling Drugs to Build a Better Britain’ with the introduction of a ring-fenced budget provided by the Department of Health to support the development of drug treatment systems. Over the subsequent years, this budget was adjusted as prevalence and demand became better known across the country. As such, Sunderland currently has a budget for tackling drug misuse which is consistent with levels provided across the rest of the country. As policy at the time and throughout most of the 2000 decade was concerned primarily with reduction of crime via the management of the use of opiates and crack cocaine, this investment and others like it (e.g. the Drug Intervention Programme) was not available for utilisation to tackle alcohol.

However, during 2008 NHS South of Tyne and Wear identified that the scale of alcohol related illness in its responsible areas (including Sunderland as well as South Tyneside and Gateshead) was sufficient to warrant substantial investment. As such, from that point Sunderland has had proportionally similar budgets for the management of both drug and alcohol misuse. This is not the case in many parts of the country, where generally alcohol budgets are dwarfed by nationally managed investments in drug treatment.

Based upon this, a more balanced and needs led system of delivery of services has been made possible. Additionally, more recent policy changes have begun to address the issue of substance misuse in a rather more holistic way. Notably, the 2010 Drug Strategy - ‘Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life' now refers to both the treatment of drug and alcohol misuse and looks to apply similar principles.

As a result of this story of development, large scale services that were introduced to work with alcohol misuse are still relatively young, whilst interventions for tackling drug misuse are moving into a rather later stage of development which requires a shift in emphasis. In both cases, it is clear that efficient, needs led pathways to recovery are required. Whilst the historic emphasis of demand emanating from drug misuse was premised around rapid access to services and retention within services this requires re-casting to ensure that the sufficient emphasis is placed upon successful discharge from treatment and sustained recovery. As treatment of alcohol misuse has not been focused on retention within services, emphasis on successful discharge and sustained recovery has been clearer from the outset; however, continuous improvement is required to ensure that positive outcomes are maximized and that Sunderland reverses the trend of increasing ill-health relating to alcohol.

Specifically, the following issues and gaps are identified for Sunderland: • Rising levels of hospital activity relating to alcohol underline the need

to augment and improve upon services currently working within and into City Hospitals Sunderland – diversionary pathways should also be investigated to help reduce the burden of binge drinking on the hospital (particularly at peak times)

• Continued emphasis is required to ensure that the safeguarding of children and vulnerable adults is adequately considered and acted upon by substance misuse services

• Increased emphasis on management of substance misuse via a multi-agency Whole Family Approach is required

• Continued emphasis is necessary on workforce development in relation to recovery, safeguarding and family approaches, consistent assessment practice and recovery based care planning

• Stakeholders and national policy have indicated the need to pursue methods of better integration of services and simplified, needs-led pathways wherever possible

• Increased capacity within services offering structured psychosocial interventions is required to ensure that sufficient time may be spent with service users to ensure that sustainable gains can be made

• High numbers of drug users remain in treatment in Sunderland in excess of 2 years – concerted efforts should be made to ensure that these service users are supported on their journey to recovery

• An overall change in performance management is required to help better understand recovery outcomes and successful / sustainable discharge from treatment

• Whilst a peer support service for alcohol users is in place this is not the case for drug users – this service should be adapted to cover both areas

• Current commissioning guidelines from the National Treatment Agency require that partnerships must ensure that ‘Recovery Champions’ are in place at Strategic, Operational and Community Levels – commissioning plans should reflect arrangements to ensure this. Also they should ensure that commissioning work is meaningfully supported by input from service users

• Increased coordination of delivery is necessary throughout the treatment system to help facilitate smoother recovery pathways

• Though the emphasis is shifting from accessibility to sustainable discharge from treatment, all attempts must continue to be made to ensure that hard to reach or under-represented groups are engaged. Specifically, in Sunderland these tend to be females, users of stimulants (cocaine/amphetamine etc.) and BME communities. Better monitoring is also required of Disabilities and Sexual Orientation to allow greater understanding of equality of access

• All efforts should be made to ensure that those currently living in unacceptable hostel accommodation are encouraged to access treatment and other accommodation options

• Further work is required to greater engage General Practice in the delivery of services for those affected by substance misuse

• Criminal justice interventions require adjustments to ensure that they are responsive to the evident needs arising in relation to alcohol – particularly for those entering and exiting custody

• Greater use of residential placements should be explored as these are used in a comparatively limited number of cases at present

• Greater use of assertive outreach is required to help minimise drop-out and improve outcomes

• Recovery from substance misuse should be fully integrated into service delivery alongside offender managers to assure balanced service delivery for offenders

• Improvements are required to pathways for those with combined Mental Health and Substance Misuse issues (Dual Diagnosis)

• Performance in relation to delivery of screening and immunization for Blood Borne Viruses (e.g. Hepatitis B and C, HIV) should be improved – this should include interventions for those accessing services and using performance enhancing drugs

Recommendations for Commissioning

Current recommendations for commissioning are as follows:

• Prioritise full re-design of services to migrate from tier based model of

delivery to one based on a clear, coordinated recovery pathway which assures that all service users are being supported towards recovery and re-integration at all times – in line with emergent national guidance and progress of PBR Pilots

• Move contracting arrangements to PBR based models which reward long term outcomes

• Ensure that services are commissioned within available budgets and that effective delivery is assured into 2012 and beyond

• Continue to improve current provision of activities to reduce and manage alcohol related hospital activity. This will include increased use of outpatient delivery for procedures normally requiring admission, further exploration of diversionary pathways for binge drinkers (potentially using a mobile unit or SOS Bus) and ensuring targeted packages of care are in place for the top 30 hospital attenders at all times

• The Hidden Harm Strategy group should continue to assure the improvement of practice within substance misuse services around safeguarding of children and vulnerable adults

• Update performance management methodologies to better scrutinise achievement of recovery outcomes

• Improved and innovative ways of working will be tried to ensure that a Whole Family Approach utilized wherever necessary / possible – e.g. family placements, improved ‘team around the family’ working arrangement and ensuring that carers are engaged appropriately within care packages

• Training to be rolled out to all substance misuse practitioners in early 2012 to ensure that assessment skills are consistent across all services

• Implement Recovery Champion functions in line with national guidance to ensure that services and commissioners are regularly held to account in the light of service user and carer experiences – also that targeted outreach work can be carried out to help encourage under-represented groups to access services

• Improve balance of service delivery to ensure that adequate capacity is assured within delivery of structured psychosocial interventions

• Implement programmes for active encouragement of service users that have been in treatment in excess of 2 years to pursue recovery and increase planned discharge / recovery outcomes

• Explore re-allocation of funding to allow increased access to residential placements during 2012/13 and beyond

• Continue to support Integrated Offender Management work to ensure that recovery from substance misuse is included in packages of care for offenders

• Work alongside emerging Clinical Commissioning Groups (CCGs) to ensure that alterations to delivery are consistent with their understanding / requirements as representatives of General Practice

• Continue to roll-out the NHS South of Tyne and Wear Dual Diagnosis Strategy to improve pathways for those with co-existing mental health and substance misuse issues

• Adjust delivery to ensure delivery of assertive outreach and peer support services across the treatment system as a whole

1) Who is at risk and why? Substance misuse can be a factor in a wide range of harms which affect the whole of society. Firstly, it can commonly cause harm to the health of the user in the form of:

• Associated chronic diseases such as Alcoholic cirrhosis of the liver or alcoholic gastritis

• Blood borne viruses such as hepatitis B and C • Alcohol related injuries resulting from falls, assaults and other

accidents Secondly, it can cause risk for families, carers and communities in the form of:

• Drug and alcohol related crime • Anti-social behaviour • Domestic violence • Neglect

It is also known to be one of the 3 main contributory factors identified within Serious Case Reviews (Ofsted 2010). In terms of the breadth of the issue, Alcohol is now identified as the second biggest risk factor for cancer after smoking and is the biggest cause of liver disease, which is the fifth most common cause of death in England. There is very clear correlation between deprivation and prevalence of both drug and alcohol misuse. For example, within Sunderland both Hendon and Southwick wards demonstrate the highest levels of alcohol related admissions with respective admission rates of 1368 and 1000 per 100,000 of population during Q2 2011/12. Also, The Advisory Council for the Misuse of Drugs report ‘Drug Misuse and the Environment’ (1998) stressed the following points: • Deprivation is linked most strongly with the extremes of problematic

use and least with casual, recreational or intermittent use of drugs. • Poor areas with high unemployment levels can provide an

environment where drug dealing becomes an established way of earning money. Deprived people living in over-crowded and sub-standard accommodation are more likely to share injecting equipment and more likely to get hepatitis, HIV and Tuberculosis.

• The chances of overcoming drug problems are less among people who are disadvantaged. They have fewer positive alternatives and less access to meaningful employment, housing etc.

As such, those affected by substance misuse are often very far from the job market. They are also often affected by issues with access to travel within areas, given the costs associated with public transport. However, there is also emerging evidence of differing areas of substance misuse where worklessness is less of an issue. For example, those presenting to services that are using performance enhancing drugs such as steroids are often employed. Similarly, cocaine misuse often manifests itself within the mainstream night time economy alongside use of alcohol. Local voluntary organisations have identified emerging alcohol issues for older people. This is often a ‘hidden problem’, given that the majority of older people, drink within their own home and it is therefore not always recognised as an issue. This is thought in some cases to be linked to social isolation or major transitions in life such as retirement or bereavement. National research has also shown that illicit drug misuse is more prevalent within LGBT groups than among their heterosexual counterparts (UK Drug Policy Commission 2010). It is also reported that this drug misuse may be associated with risky behaviours including exposure to HIV infection. Those suffering from mental health issues are also very likely to have concurrent substance misuse issues (dual diagnosis) with emerging evidence suggesting that as many as 30-50% of people in touch with either mental health or substance misuse services will have a dual diagnosis (NHS South of Tyne & Wear: Commissioning Plan For Dual Diagnosis – 2010). It is also anticipated that demand for services from ex-military personnel may increase in coming years – especially in the light of demobilisation and potential re-settlement and / or unemployment.

2) The level of need in the population Alcohol High levels of need in relation to alcohol are clear from a range of indicators that are maintained and updated by the North West Public Health Observatory. These allow comparisons with the rest of England. Admissions to hospital with alcohol specific conditions:

Males, all ages, Direct Standardised Rate (DRS) per 100,000 population during 2009/10 - Sunderland was the 9th worst nationally (from 151 PCT’s) and 2nd worst regionally (from the12 PCT’s in the North East region). During 2009/10 the admission rate per 100,000 was 828. This equated to 1180 male admissions.

Historical Male Admissions 2005-6 = 458 2006-7 = 508 (11% increase) 2007-8 = 537 (06% increase) 2008-9 = 596 (11% increase) 2009-10 = 828 (39% increase)

Females, all ages, DSR per 100,000 population during 2009/10 - Sunderland was the 12th worst nationally and 5th worst regionally, (this is a slightly better picture than the male figures but is still in the worst national quartile). During 09/10 the admission rate per 100,000 was 378 and this equated to: 543 female admissions.

Historical Female Admissions 2005-6 = 309 2006-7 = 328 (06% increase) 2007-8 = 351 (07% increase) 2008-9 = 341 (03% decrease) 2009-10 = 378 (11% increase)

Clearly the most concerning factor from above chart is the 39% increase in male admissions during 2009-10. Also overall there is a year on year increase for all years except 08-09 for females. Nationally Sunderland is in the highest national quartile for admissions for both genders.

Admissions to hospital with alcohol attributable conditions (previously NI39) based on a DSR per 100,000 population:

With 2380 admissions per 100,000 during 2009-10 (8310 in actual numbers) Sunderland was ranked as the 13th worst nationally (in the highest national quartile) and 4th worst regionally, and shows a growing year on year increase since 2005.

Alcohol-Specific Mortality: Males, all ages, DSR per 100,000 population (2007-2009) shows 23 mortalities per 100,000 this equates to a real figure of 100 (in the highest national quartile) and sees Sunderland ranked at 15th worst nationally and 3rd worst regionally.

Females, all ages, DSR per 100,000 population (2007-2009) shows 8 mortalities per 100,000 equating to 37 in real figures and sees Sunderland ranked at 42nd worst nationally and 9th worst regionally.

Incapacity Benefit (IB) Claimants Claimants of IB whose main medical reason is alcoholism - persons, crude rate per 100,000, working-age population (Aug 2010) was 175 per 100,000. This equates to 310 in real figures and sees Sunderland ranked 24th worst nationally (in the highest national quartile) and 2nd worst regionally.

Binge Drinking Synthetic estimates of the percentage of the population aged 16 years and over who report engaging in binge drinking (2007-2008) was a very high at 29% and is the 11th worst nationally (in the highest national quartile) and 8th worst regionally). Notably from the highest 12 binge drinking estimates, the North East appears 9 times - clearly indicating a major problem with binge drinking in the North East.

Chronic Liver Disease Males - Mortality from Chronic Liver Disease: all ages, DSR per 100,000 population (2007-2009) was 21 this equates to 94 deaths in real figures and sees Sunderland ranked 25th worst nationally (in the highest national quartile) and 6th worst regionally.

Females - Mortality from Chronic Liver Disease: all ages, DSR per 100,000 population (2007-2009) was 9 this equates to 45 in real figures and sees Sunderland ranked 51st worst nationally and 8th worst regionally.

Drug Misuse The Glasgow Smoothed Estimate for Problematic Drug Users - The most recent estimates of problematic drug use (PDU) are the published figures on the National Drug Treatment Monitoring System (NDTMS) website for Needs Assessment 2010/11, produced by Glasgow University on behalf of the Home Office.

There is an estimated 1386 problematic drug users in Sunderland, with a confidence interval of 1296 – 1510. Problematic drug use PDU) is defined as those individuals using opiates and/or crack cocaine.

This figure was provided by the Centre for Drug Misuse Research (CDMR) at Glasgow University. The data sources used for this were:

• National Drug Treatment Monitoring System needs assessment data • Information held by local Harm Reduction Services on injecting drug

users • Testing data derived from mandatory drug tests carried out in custody

As an intensive DIP area, all individuals arrested for offences associated with drug misuse are subject to mandatory testing for Heroin or Crack/Cocaine.

All data processed locally concerned individuals that had demonstrated problem drug use in the 2010/11 period for example: by collecting injecting equipment for use with intoxicants, being subject to a Drug Rehabilitation Requirement (DRR) Drug testing for acquisitive crime, and for being in treatment for problem drug use. Opiate and/or Crack An estimated 254 opiate and/or crack users were unknown to treatment. Expressed as a percentage of the overall PDU estimate: 18% were unknown to treatment. Based on historical data, the estimated penetration rate for opiate and/or crack users was 82% over the past 2 years.

Opiates There is an estimated 328 ‘treatment naïve’ opiate clients. Expressed as a percentage of the opiate cohort, 24% were unknown to treatment. Based on the historical data contained in the bull’s eye, the estimated penetration rate for opiate users was 76% over the past 2 years.

Crack The estimated treatment naïve cohort for crack problem drug users is 135, Expressed as a percentage of the crack cohort, 23% were unknown to treatment. There were 251 crack clients known to treatment at 31/03/11. This represents a penetration rate of 77%.

Drug Intervention Programme (DIP) 88 PDU clients were in contact with DIP either from community (18) or prisons (70) but these were not engaged in structured treatment in 2010/11.

Non PDU Non PDU clients accessing structured treatment remain high in Sunderland. They account for 30% of the total number of drug users entering structured treatment measured at 31/03/11, compared to only 15% nationally. National evidence identifies strong links between substance misuse and homelessness, with drug users seven times more likely of becoming homeless. Research also suggests a large proportion of those individuals report increased problems with substance misuse, after becoming homeless and subsequently face a number of issues/barriers in accessing the support needed to address their substance misuse (homeless link). Recent consultations with service users, carers and other stakeholders have identified the following needs/ issues for consideration / rectification within commissioning plans:

• Greater coordination of care required to assure that the client is assisted on a needs led recovery journey from point of access to the system

• Locality based delivery would be helpful • Minimised complexity in pathways • Duplication of delivery should be removed to help reduce

complexity / improve value for money • Increased alignment with other elements of holistic delivery, such

as Jobcentre plus and Housing

• Unified information systems and clearly governed information sharing arrangements are required

• Ideally, delivery of service should be via multi-disciplinary / integrated teams providing access to all necessary core treatment modalities - namely:

– Collaborative care/Care navigation for all clients

– Substitute prescribing / clinically assisted detoxification

– Education, Training and Employment

– Therapeutic/Psychosocial interventions

– Residential rehabilitation/detoxification

– Harm reduction/Needle Exchange

– Peer support/Mutual aid

– Specialist family interventions

– Outcome/Recovery monitoring methodologies used throughout

3) Current services in relation to need

Substance Misuse Services in Sunderland are currently based on a four tiered model, as described in the Models of Care guidance documents for drugs and alcohol. Broadly, the interventions offered within the tiers increase in intensity from Tier 1 (universal services) to Tier 4 (inpatient detoxification and rehabilitation). These tiers are described below:

Tier 1 Interventions delivered via generic services, such as General Practice, Police, Housing or Social Care alongside other interventions. Comprising substance misuse related information and advice, screening, assessment and referral into specialist substance misuse treatment services. Funding contributions are currently made to the Housing Options Team and the Probation Service to provide support to those affected by substance misuse within their host agencies, though in general, Tier 1 is not funded directly.

Tier 2 Interventions delivered via specialist services – these are open access, non-care planned and substance misuse specific. They comprise substance misuse related information and advice, screening, assessment and referral into structured substance misuse treatment. They will also offer any brief motivational interventions and aftercare following completion of structured treatment. In terms of drug treatment services, this Tier also includes harm reduction service which provide interventions such as needle exchange and Blood Borne Virus screening and immunisations. Provider services are:

• Lifeline - Harm Reduction • North East Council on Addictions (NECA) - Community Integration

Team • Turning Point - Hospital liaison, Arrest Referral and Community

Engagement • North East Regional Alcohol Forum (NERAF) – peer mentoring and

support • General Practice Local Enhanced Service for the delivery of brief

interventions for alcohol

Tier 3 Interventions also delivered via specialist services – these are accessed by self referral or referral via another professional, relative or carer, are community based and care planned. Some services provide both Tier 2 and Tier 3 interventions. Provider services are:

• Counted4 Community Interest Company – stabilisation, maintenance and detoxification for drug misuse, stabilisation and detoxification for alcohol misuse

• Developing Initiatives Supporting Communities (DISC) – Throughcare and aftercare within the Drug Intervention Programme. Structured Day Care provision for offenders on statutory drug or alcohol treatment orders

• NECA core services – structured psychosocial interventions such as Cognitive Behavioural Therapy and Motivational Enhancement Therapy

• Health Housing and Adult Service Drug and Alcohol Team – social work ream providing case management of complex cases as well as coordination of packages of care around rehabilitation (either in the community or residential)

• City Hospitals Sunderland Hospital Liaison Team – clinical support for those presenting at hospital primarily with chronic alcohol related illness and facilitating pathways to community services

Tier Tier 4 interventions comprise inpatient / residential specialist treatment for drug and/or alcohol misuse. These interventions are provided as part of a larger community based care plan which is co-ordinated to ensure continuity of care and aftercare. Services funded are:

• Four Seasons Healthcare – The Huntercombe Centre – block

purchased inpatient detoxification for alcohol and drug misuse • Residential Rehabilitation – accessed via spot purchase arrangements

as part of a care plan organised through the Health Housing and Adult Service Drug and Alcohol Team.

4) Projected service use and outcomes in 3-5 years and 5-10 years

It is clear from the evidence presented above that our current understanding of problematic alcohol misuse and its harmful effects is evolving year on year. However, it is also clear from past trend information in relation to alcohol related hospital admissions that demand for services will continue to rise. Between April 2010 and March 2011, 1090 individuals accessed structured treatment services in Sunderland. As at September 2011, 727 individuals had accessed services in the 2010/11 year, indicating that a likely rise will be seen by the end of 2011/12 compared to 2010/11. This is in line with expectations and we hope to see further rises in subsequent years. However, we will also expect to see increasing volumes of service users exiting structured treatment and moving into recovery.

In addition to this, emergent Payment By Results commissioning models look to ensure that re-presentation rates are reduced. Whilst this is a relatively new method of measurement for the sector, demonstrable outcomes in this area will affect levels of payment for providers in coming years.

Within the next 3-5 years, evidence suggests that continued rises in alcohol related hospital activity are likely. However, given that there is now a considerable body evidence based investment in services in place to tackle this we must aspire to halt this rise within the next 3 years and subsequently begin to see the trend reduce.

In terms of drug misuse, evidence suggests that around 82% of the opiate and/or crack using population is either currently accessing treatment or has done so in the past and moved on to recovery. In the coming 3 years, Sunderland must aspire to ensure that its successful discharge rates become comparable with other areas identified as having similar populations in treatment – currently this a regularly demonstrable discharge rate of at least 12% of overall caseload per year. Sunderland currently exhibits an overall planned discharge rate of 6%.

However, it is clear also that new forms of drug misuse continue to arise over time. At present, increased use of Cocaine, performance enhancing drugs and synthetic highs is evident and services must be well positioned to manage the changing demands that these trends bring about in future years.

The Welfare Reform, legislates for the biggest change to the welfare system for over 60 years. Locally, the impact of this change will be felt by many residents of Sunderland, and will present significant challenges for both individuals and the City as a whole. Given the identified links between worklessness, deprivation and substance use, the introduction of this bill, could have a significant impact on the numbers of people within the City who misuse substances.

5) Evidence of what works There is now a wide range of evidence based practice that can be applied to the field of substance misuse – however, 2012/13 represents a time of great change across the country. The core commissioning guides for substance misuse services came in the form of the Models of Care for Alcohol and Drug misuse documents and their subsequent revisions - these are now being fully revised and replaced by the upcoming Building Recovery in Communities (BRiC) – consultation on this document was completed in May 2011 and publication is anticipated in early 2012.

Indications are that BRiC will advocate a move away from ‘tier based’ delivery of services and a tendency to focus on the delivery of specialist interventions to pathway based delivery – this endeavours to ensure that recovery outcomes are maintained at all times.

Additionally, Payment By Results pilots are being carried out across England. These are focusing on commissioning models which will move the financial emphasis of current systems to better reward planned discharges and sustained recovery outcomes. Whilst these are still in their infancy, progress is reported at http://www.nta.nhs.uk/.

The 2010 Drug Strategy Reducing Demand, Restricting Supply, Building Recovery forms the main policy document at present in relation to substance misuse. Key points are quoted from the strategy as follows:

• A fundamental difference between this strategy and those that have

gone before is that instead of focusing primarily on reducing the harms caused by substance misuse, it goes further and offers support for people to choose recovery as an achievable way out of dependency. It recognises that the causes and drivers of drug and alcohol dependence are complex and personal and as such the solutions need to be holistic and centred around each individual, with the expectation that full recovery is possible and desirable. The Drug Strategy 2010 is structured around three main themes:

• Reducing demand – creating an environment where the vast majority of people who have never taken drugs continue to resist any pressures to do so, and making it easier for those that do to stop. This is key to reducing the huge societal costs, particularly the lost ambition and potential of young drug users.

• Restricting Supply - drugs cost the UK £15.4 billion each year. We must make the UK an unattractive destination for drug traffickers by attacking their profits and driving up their risks.

• Building Recovery in communities - the Government will work with people who want to take the necessary steps to tackle their dependency on drugs and alcohol, and will offer a route out of dependence by putting the goal of recovery at the heart of all that they do. It will build on the huge investment that has been made in treatment to ensure more people are tackling their dependency and recovering fully. Approximately 400,000 benefit claimants (around 8% of all working age benefit claimants) in England are dependent on drugs or alcohol and generate benefit expenditure costs of approximately £1.6 billion per year. If these individuals are supported to recover and contribute to society, the change could be huge.

Key best practice outcomes for commissioners to consider are:

• Freedom from dependence on drugs or alcohol • Prevention of drug related deaths and blood borne viruses; • A reduction in crime and re-offending; • Sustained employment; • The ability to access and sustain suitable accommodation; • Improvement in mental and physical health and wellbeing; • Improved relationships with family members, partners and friends; and • The capacity to be an effective and caring parent.

Specifically in terms of tackling alcohol misuse, an updated national strategy is still awaited at the time of writing this document. The much earlier 2004 Alcohol Harm Reduction Strategy for England identified the following work streams:

• Better education and communication • Improving health and treatment services • Combating alcohol-related crime and disorder • Working with the alcohol industry

As with the treatment of drug misuse the strategy anticipated that treatment of alcohol misuse will contribute to these work streams either directly or indirectly. The 2004 strategy was updated in 2007 with Safe. Sensible. Social - The next steps in the National Alcohol Strategy which sought to augment these work streams with:

• Sharpened criminal justice for drunken behaviour • A review of NHS alcohol spending • More help for people who want to drink less • Toughened enforcement of underage sales • Trusted guidance for parents and young people • Public information campaigns to promote a new ‘sensible drinking

culture’ • Public consultation on alcohol pricing and promotion; and • Local alcohol strategies

Evidence provided within both documents suggests the close association of alcohol misuse with: • Poor health/illness • Crime • Anti-social behaviour • Social harms • Economic harms • Accidents

As mentioned above, under their current configuration, treatment services for drug and alcohol misuse are commissioned against the Models of Care guidance documents provided by the Department of Health and National Treatment Agency. In line with the Department of Health and National Institute of Clinical Excellence guidelines, services are required to work toward the following core guidance documents (though this list is not exhaustive):

• Drug strategy 2010: Reducing Demand, Restricting Supply, Building

Recovery • Alcohol Harm Reduction Strategy for England (2004) • Safe, Sensible, Social: The next steps in the National Alcohol Strategy

(2007) • Reaching Out: Think Family (2008) • Choosing Health: Making Healthy Choices Easier (2004) • Dual Diagnosis Good Practice Guide (DOH 2002) • Every Child Matters, 2003 • NHS Operating Framework, 2009/10 • Our Health, Our Care, Our Say, 2006 • Choosing Health, 2004 • World Class Commissioning, 2009 • Commissioning Framework for Health and Wellbeing, 2007 • NICE UK Guidelines on Clinical Management (Orange Book), 2007 • Models of Care for Treatment of Adult Drugs Misusers 2002 and

Update 2006

• Treating Drug Misuse Problems: Evidence of Effectiveness (NTA, 2006)

• Safer Sunderland Partnership Drug and Alcohol Treatment Plans • NICE Guidelines Alcohol dependence and harmful alcohol use 2011 • NICE Guidelines alcohol use: disorders and clinical management 2010

6) User Views Feedback is sought from carers throughout the year. Currently, as the substance misuse commissioning team does not have an internal function for consultation however, this has been facilitated via a range of different sources. These include:

• Alcohol evaluation carried out by Joint Commissioning Officer in 2011 to look at efficacy and outcomes from investment in alcohol services – including focus groups with carers and service users

• 2 x workshops with providers, service users and commissioners to derive input to potential re-design plans (what currently works / does not work / characteristics of an improved system / potential delivery models)

• Rapid Process Improvement Workshops – used to engage providers and service users to help improve working process and pathways (specifically looking at alcohol related hospital activity)

Currently, a Recovery Champion Function is being put in place to ensure that a regular flow of meaningful input is derived from service users and carers – in particular throughout processes of re-design of service but also in future to inform performance management of services. This will be in place from December 2011. Carers representatives are also enabled to participate in all relevant commissioning and steering groups. Through these consultations a number of issues were identified (outlined in needs section) for and will be considered / rectified within future commissioning plans.

7) Equality Impact Assessments This needs assessment has been Equality Impact Assessed. Whilst it is felt that its contents and commissioning priorities address and advocate positive impacts for the following characteristics:

• Marriage and Civil Partnership (re – Whole Family Approach) • Pregnancy and maternity (re – Whole Family Approach) • Race/Ethnicity (re – Recovery Champion Initiative) • Religion/belief (re – Recovery Champion Initiative) • Sexual Orientation (re – Recovery Champion Initiative) • Trans-gender/gender identity (re – Recovery Champion Initiative) • Worklessness / poverty (re – Community Integration / system re-

design) NB – it is clear that our knowledge of demand for services characterised by Sexual Orientation and Trans-gender/gender identity is limited though the Recovery Champion initiative is aimed to improve this.

Equality Impact assessments have highlighted an under representation amongst a number of groups of individuals, specifically;

• BME communities • Women • LGBT communities • Those with a disability

• Ex-service personnel

Moving forward there is a need to ensure that there is increased engagement and take up of services within these identified groups. Further specific actions must be added to ensure that inequalities around:

• Age • Disability • Gender / Sex

NB – with the exception of Disability, information is robust in relation to these areas. However, it is clear that service uptake remains skewed towards younger males. ·

Additional actions required:

• Identify clear actions to ensure that gender specific access to services is currently possible / under development

• Review all services to ensure compliance with relevant disability legislation

8) Unmet needs and service gaps

Sunderland hosts a broad range of targeted substance misuse services which have been developed to meet the specific needs of Sunderland’s residents. All recommended interventions for substance misuse can be made available as required, though at present further coordination of services is necessary to ensure that this is the case within the system in its entirety.

Additionally, it remains the case that these services were originally commissioned to primarily meet the needs of opiate users - in line with national strategic directives and performance indicators. The high prevalence of drug users accessing treatment for extended periods of time indication that there is further work required to ensure that their needs are met and their recovery journeys are actively facilitated.

Continued work is required to ensure that under-represented groups (as identified within the equality impact assessment) are enabled and encouraged to access services.

In order to ensure that meaningful recovery is actively facilitated, services will also be required to ensure that operate outside standard working hours. Whilst this is currently in place in some areas of service, more flexibility is required.

Feedback received from a voluntary and community sector event, highlighted a number of unmet needs;

• In order to ensure services are inclusive there is a need to gain a better understanding of the use of substances across a number of different groups such as BME and LGBT communities, older people and young people, the issues, needs and preferences will not necessarily be the same;

• Services should be adequately equipped to meet the needs of the increasingly diverse population within the City. This includes improving engagement with under represented groups, for example making leaflets/information available in other languages and promoting services in a wider range of publications in order to raise the profile of services amongst specific groups;

• Better targeting of services, tailored to the needs of individuals;

• There is a need for services to work with employers, in order to educate them in recognising employees with potential substance use issues, increase awareness of the services available and signposting to those services and how employees can be supported during this engagement;

• There is a need to raise the awareness of the usage of prescription drugs and ensure there are regular reviews and services in place that can offer support to people around medicine management and for those who have used these drugs for extensive periods of time and require help in order to reduce or stop this usage;

• Carers are the providers of the majority of care to people with long-term illnesses and disabilities, including substance misuse, in Sunderland. 11% of the population are carers. The cost of replacing this care is estimated at £706.9 million p.a. (Circle at University of Leeds/Carers UK). There is a need for more recognition and support services for the carers of people who abuse substances to ensure they are given all of the opportunities of other carers.

Finally, it is clear that demand for services for alcohol is set to rise in coming years – this will almost inevitably lead to capacity problems given that the scale of the problem appears to be increasing rather than reducing at present.

9) Recommendations for Commissioning Current recommendations for commissioning are as follows:

• Prioritise full re-design of services to migrate from tier based model of

delivery to one based on a clear, coordinated recovery pathway which assures that all service users are being supported towards recovery and re-integration at all times – in line with emergent national guidance and progress of PBR Pilots

• Move contracting arrangements to PBR based models which reward long term outcomes

• Ensure that services are commissioned within available budgets and that effective delivery is assured into 2012 and beyond

• Continue to improve current provision of activities to reduce and manage alcohol related hospital activity. This will include increased use of outpatient delivery for procedures normally requiring admission, further exploration of diversionary pathways for binge drinkers (potentially using a mobile unit or SOS Bus) and ensuring targeted packages of care are in place for the top 30 hospital attenders at all times

• The Hidden Harm Strategy group should continue to assure the improvement of practice within substance misuse services around safeguarding of children and vulnerable adults

• Update performance management methodologies to better scrutinise achievement of recovery outcomes

• Improved and innovative ways of working will be tried to ensure that a Wh l F il A h tili d h / ibl

• Continue to support Integrated Offender Management work to ensure that recovery from substance misuse is included in packages of care for offenders

• Work alongside emerging Clinical Commissioning Groups (CCGs) to ensure that alterations to delivery are consistent with their understanding / requirements as representatives of General Practice

• Continue to roll-out the NHS South of Tyne and Wear Dual Diagnosis Strategy to improve pathways for those with co-existing mental health and substance misuse issues

• Adjust delivery to ensure delivery of assertive outreach and peer support services across the treatment system as a whole

10) Recommendations for needs assessment work

A Needs Assessment is carried out annually in relation to drug and alcohol misuse as required by NTA. This will be refreshed in January/February 2012. Further improvements are required in the collection and analysis of data relating to underserved groups. It is also anticipated that via the commissioning of the Recovery Champion Function, commissioners will be enabled to receive more rigorous and timely information from service users.

Key contacts

Ben Seale – Joint Commissioning Manager (ben.seale@sotw.nhs.uk)

Gillian Gibson – Public Health Consultant (Gillian.gibson@sotw.nhs.uk)

Leanne Davis – Associate Policy Lead for Community Safety (leanne.davis@sunderland.gov.uk)

Nicola Grainger – Drug and Alcohol Commissioning Officer (grainger.nicola@sotw.nhs.uk)