London: boom or bust

Transcription

1 Treatment systems at a city level Planning, implementing and evaluating London: boom or bust Annette Dale-Perera Strategic Director of Addiction & Offender Care Effective treatment, changing lives

2 London 33 area s population 8 million

3 Top down treatment planning in England National drug strategy with targets Government departments with targets National Treatment Agency (NTA) Regional Offices Very data driven planning Local planning partnerships & Drug Action Teams commission Treatment Drug treatment providers Drug Service users

4 London: a planning nightmare Population Population 8 million: High rate of population change, mobility, temp workers & tourism Very culturally and ethnically diverse: 30% non-white London Drug Trends relatively high levels of drug use 23% heroin & crack users in England Increase in crack and cocaine use Higher levels of IDU, HIV, Hep C Drug and drug treatment tourism Huge club scene: designer drugs Planning Co-ordination difficult across city 33 local areas each with a local Drug Action Teams (DATs) ,000 residents each 150+ drug services NTA Regional Team performance manages each DAT individually

5 Massive (planned) growth in numbers in drug treatment in London in 10 years numbers in drug treatment in london 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5, numbers in drug treatment in london Numbers in structured drug treatment increased from 10,900 to 36,361 (not counting those in prison treatment) Thousands more in contact with open access & NEX services Plus real achievement in treatment outcomes..more on this later How did we do this?

6 How we got planned expansion Govt PRIORITISED drug treatment with national targets A) to double numbers in drug treatment ( ) B) Increase numbers of heroin and crack users in effective treatment a) retained at least 3 months and b) planned discharge having addressed their dependency C) Schemes to target drug-using offenders and pull into treatment SIGNIFICANT government investment: increase in 10 yrs 95 to 581 million (2008/9) with special ring-fenced allocations for each DAT. Significant performance management of each DAT by NTA Data driven national system: with monthly `real time data on: numbers in treatment, detailed client profiles & treatment journey, waiting times, type of treatment received, retention (3 months), how discharged, and now client outcome data by service and DAT.

7 Every DAT area has to provide same menu of evidence-based drug treatment services Tiers of drug treatment services: Open-access eg NEX; Care planned community treatments eg substitute prescribing & keywork; and In-patient & residential rehab based on national clinical guidelines

8 DAT level: Annual planning and review cycle Annual DAT needs assessment : data on prevalence provided (Hay et al) Annual allocated (ring-fenced) based on need and performance Annual plan for each DAT area agreed via Partnership (health, social care, criminal justice, housing, education & employment) Annual targets agreed locally (heroin & crack users prioritised). Treatment penetration: % need met Numbers in effective treatment Numbers in treatment % retained 3 months or more or with a planned discharge (where dependency has been addressed Others targets eg waiting times, BBV testing & vaccination etc DAT SCRUNITISED EVERY 3 MONTHS BY NTA ON PERFORMANCE AGAINST PLAN Moving to evaluate treatment OUTCOMES: Treatment Outcome Profile (TOP)

9 What measurable impact: did it work? Increased no s in treatment from 10,900 (1997) to 36,361 (2008) Increased 3 month retention: increased from 52% to 78% Treatment `penetration heroin and crack users around 65% of need Low waiting times: 95% of people wait less than 3 weeks Treatment systems cover communities and prisons BUT We havent yet got treatment exits right: systems `managed on unplanned discharge rate of 50% Highly performance managed systems huge level scrutiny Methadone backlash accusations of `parking people on methadone and not enough abstinence But drug related deaths high

10 Great national local & regional data on Types of treatment Flow through treatment systems provided how someone was discharged 2008/9

11 From process measures to client outcomes TOP Validated outcome tool 20 questions in 4 domains Done with every client at treatment start, 6 mth review and exit for all in drug treatment 207,000 Getting results on first cohort Performance manage and manage our services based on outcomes in the future

12 Treatment Outcome Profile TOP findings National cohort study 14,656 heroin and/or crack misusers clients. In community drug treatment :opioid prescribing or psychosocial to May 09 Compared drug use at treatment start and 6 month review or exit if completed Heroin use after 6 mths 37% were abstinent from Heroin Overall heroin use reduced 14.5 days Of those who had used only heroin 42% were abstinent Of heroin + crack users 33% were abstinent Crack use after 6 mths 52% were abstinent from Crack Overall crack use reduced 7.7 days Of those who had used only crack 57% were abstinent Of those who had use crack and heroin 51% were abstinent Published The Lancet Effectiveness of community treatments for heron and crack cocaine addiction in England: a prospective, in-treatment cohort study J Marsden, B Eastwood, C Bradbury, A Dale-Perera, M Farrell, P Hammond, J Knight, K Randhawa, C Wright. 2 Oct 2009

13 CNWL Drug services: outcomes CNWL Addiction services covering 7 DATS and 3 prisons ,00 drug and alcohol users First TOP outcome data Community drug services : Graph shows change in heroin use (heroin users who don t use crack) in the first 5 months of treatment. 73% clients improved ie heroin use reduced at least 13 days: 43% abstinent, 30% improved Able to show differences in services & use this to manage my services Opioid users (no crack) change in illegal opioid use at review Westminster K&C Hounslow % Abstinant Hillingdon H&F Ealing % reliably improved % unchanged % deteriorated Brent All 0% 20% 40% 60% 80% 100% Sample size N = 776

14 London (and all cities in England) Very driven & performance managed system Advantages Boom: achieved rapid expansion of no s in treatment Crime fallen (acquisitive) Treating most heroin and crack users who want treatment Excellent data on local systems TOP outcome system embedded and producing data Disadvantages One city: 33 different local drug treatment systems System driven very hard and fast: Huge emphasis on (`process ) data immense pressure on providers Is data a good thing? The outcomes are not `good enough for politicians `improvement is not enough: `anti methadone & greater call for abstinence Is the BUST coming.