Cambridgeshire DAAT. Adult Drug Treatment. Needs Assessment 2009/10

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1 Cambridgeshire DAAT Adult Drug Treatment Needs Assessment 2009/10 Louise Meats DAAT Information Officer December 2009

2 This Adult Drug Treatment Needs Assessment has been prepared for the Cambridgeshire Adult Treatment Commissioning Group to facilitate their development of the Adult Treatment Plan and or submission to the National Treatment Agency. This publication replaces the Adult Needs Assessment published in 2007/08. Whilst it has been possible to update most of the data, some tables remain unchanged because no new information has become available in the interim. With thanks to Susie Talbot, Paul Brand, Leigh Roberts, Owen Provost, Chris Mackett, Joe Keegan, Joan Kempster, Angela Carr, Clare Humphreys and all those involved in the collation of data for this document. For further details, please contact: Louise Meats, DAAT Information Officer Susie Talbot, DAAT Coordinator 2 of 73

3 CONTENTS Executive Summary 5 Introduction 9 Demography 11 Future Population Trends 12 Deprivation 13 Ethnicity 14 Service Provision in Cambridgeshire 15 Operational Structure 16 Problematic Drug Users 19 Crack Cocaine 21 Structured Drug Treatment Interventions 23 Treatment System Map 23 Referrals /09 Client Population 26 Age, Gender, Ethnicity and Duration of Contact with Services 26 Retention 27 Drug Use 28 Treatment Exits 29 Residential Rehabilitation & Inpatient Detoxification Service 30 Cambridgeshire Drug Intervention Programme (CDIP) 31 CDIP Clients 32 Referral Sources 33 Structured Support 34 CDIP Case Closures 34 Client Satisfaction 35 Crime Saving Analysis 36 Community Treatment Services 38 Needle Exchange Services 40 Blood Borne Virus (BBV) Interventions 42 3 of 73

4 Drug-Related Deaths 43 Connected Services 44 Probation Services 44 Hospital Episode Statistics 46 GP Registrations 50 Housing Support 51 Housing Support: Needs Analysis 52 Outcomes Information 52 Employment 53 Vulnerable Groups 55 Migrant Worker Registration 55 Sex Workers 57 Support for Parents /Families /Carers & Significant Others 58 Carer Support 58 Substance-Misusing Parents 58 Public Opinion 61 The Place Survey 61 Drug/Alcohol Survey for Community Beat Managers 61 National Drugs Week Client Satisfaction Survey 63 KISS FM Survey 64 Unmet needs analysis 65 Recommendations 66 References 68 Appendices 69 4 of 73

5 Executive Summary The Cambridgeshire DAAT commissions agencies to provide specialist treatment and targeted prevention work for substance misusing clients. All commissioning of adult drug treatment services, including for the Drug Intervention Programme, is delivered and monitored by the Adult Treatment Commissioning Group (ATCG), facilitated by the DAAT Treatment Coordinator, which reports directly to the DAAT Executive Board. The Adult Drug Treatment System was put out to tender in April 2007 and commissioned to Addaction from April Consequently, the 2008/09 Needs Assessment effectively examines two different forms of service provision, since it also examines March Adult treatment services are provided from four fixed sites across the county. There are also dedicated outreach teams, satellite surgeries and non-site-specific counselling sessions. Many services are offered to clients, ranging from focussed high-level treatment to more brief interventions, all of which are outlined in the assessment. Treatment Statistics In the financial year 2008/09, 318 problematic drug users (PDU) clients have been in treatment in Cambridgeshire. This is an increase of 72 clients from 2007/08. On examination of substance trends as measured by NDTMS, we find that in the 2008/09 period, 1122 PDUs were identified at triage. This is equivalent to 32% of all those triaged and 0.29% of Cambridgeshire s population aged This is an increase from 2007/08 and as a result continues with the gradually increasing numbers of PDUs since records began in 2004/05 (866 clients). Statistically, however the numbers of PDUs as a percentage of all cases triaged is actually decreasing, from 50% in 2004/05 to 35% in 2008/09. In 2008/09, according to the NDTMS, 1780 clients were in treatment, with 751 new referrals. Of the 1780 clients recorded in treatment, 461 have been in treatment for over two years - representing 25.9% of clients. 187 clients (11%) have been in treatment for over four years. This has improved from last year, when 35% of clients were in treatment for over two years, demonstrating that the reconfiguration of services has helped to streamline the treatment pathway. Just over 69% (1028) of clients presenting to treatment services in 2008/09 reported heroin as being their primary problem drug. 32% of clients referred in reported that they had never injected syringes were returned over the 200/09 financial year, and 1813 clients made use of the needle exchange services. It is now a current target of Addaction to have 50 Hep B tests completed over the year, and for 150 Hep C targets to be carried out, a target which is on course to be met Any interpretation of the Cambridgeshire treatment data is difficult due to both the changes outlined above and the poor quality of data recorded on NDTMS. One clear example of this comes with the bullseye client analysis, used to identify the numbers of substance misusers outside of treatment services. The bullseye tool tells us that 202 misusers are not known to the treatment system, and that only 20 remain unknown to both the treatment system and DIP. This suggests that treatment contact with clients in Cambridgeshire is extremely effective. However, it is more probable that this is due to a data inaccuracy, as it is extremely unlikely that the numbers unknown would be that low. It should also be noted that, as with the tables above, there is a 95% confidence interval for 5 of 73

6 the data. This means that the potential numbers not known to the treatment system ranges from -467 to 929 clients. Consequently, the bullseye analysis will be considered to be unreliable, and the needs assessment and treatment plan will focus on agency-specific data such as that examined within the treatment mapping process. Overall, crack, cocaine and opiate users accounted for 84.9% of all those presenting for treatment over 2008/09. This is similar to the substance profiles in other counties where opiates and crack cocaine are the main drugs for adults in treatment. Nationally, there are concerns about the increase in the use of crack cocaine across the country. Owing to the fact that only 6.9% of clients in treatment services report this as being their primary problem (lower than some other drugs, including cannabis 8.3%), it has been decided that cocaine-focussed clinics would currently be unsuitable for Cambridgeshire. Over 2008/09, 913 exits from various treatment modalities were made, with the majority of clients exiting via specialist prescribing. Over 2008/09, 407 clients left treatment, as indicated by the treatment map. Of these, 78% had an unplanned discharge. On treatment exit, of 407 clients only 37 have recorded Hepatitis C status as being tested 27 individuals were in Tier 4 treatment; 17 in Primary residential rehabilitation, 4 in Secondary stage residential rehabilitation and 13 in inpatient detoxification, with 2 receiving social care support. This balance has shifted since 2007/08, when out of 30 individuals in Tier 4 treatment, 77% were in residential rehabilitation. Take up continues to be predominantly 75% male. Peripheral Data The Annual Performance Summary for CDIP shows that 436 clients engaged with CDIP. The target is to have 75% of these clients in treatment. 88% of clients with CDIP during the last year stated that their main drug use was Class A (heroin, cocaine, crack or methadone). Some clients highlighted poly-drug use with Class A as a secondary use - and therefore still suitable for treatment and support from CDIP. Of the total CDIP caseload over the past 12 months, 86% received basic one-to-one support, with 54% being given rapid prescribing and 49% harm reduction support, which matches the trend from previous years. 31.7% of CDIP cases closed in 2008/09 due to client disengagement. We are able to estimate that 1007 potential acquisitive crimes may have been avoided within the CDIP client group over the past 12 months. In 2008/09, 80.5% of offenders on a DRR have also been assessed as having a potential alcohol need. With regards to health statistics, in Cambridgeshire, a lower percentage of those admitted to hospital with a drug-related diagnosis were receiving treatment to help them with their drug misuse problems than the percentage for the Eastern region. Between July and September 2009, Addaction conducted an audit of 30 case files where clients were recorded as being parents. The findings revealed that in 16 cases, the family was already known to social services, and there was social care involvement. In eight cases, a referral was made by Addaction, after an assessment, a discussion at team meeting, or after a particular incident that prompted a referral, e.g. disclosure of pregnancy or domestic violence. In the six other cases, a referral was considered but Addaction decided not to go ahead with it, on one occasion a referral was made to social 6 of 73

7 services by another agency, and in others a referral was made to a GP instead of social services. Public Opinion According to the most recent Place Survey, 24.2% of Cambridgeshire residents felt that drug use or drug dealing was a problem in their local area, which is well below the England average of 30.5%, and is an improvement on last year (42%). 41% of respondents felt that drug use or drug dealing was not a problem in their area, with a further 35% judging it to be a minor problem. Only 7% felt it was a major issue. 24% felt that the use or dealing of drugs was the biggest anti-social behaviour problem in the local area. /from the DAAT survey carried out in June, we found that respondents were least concerned about the treatment of drug users, with mixed views concerning the need to target drug dealing in communities. In October 2009 CDAAT carried out a confidential survey with 114 clients of substance misuse services within Cambridgeshire. 69 clients indicated an addiction to heroin, with crack cocaine and cannabis being the next most common (22 and 16 responses respectively). The service user survey indicated that 49% (58) of respondents were positive about the effect the substance misuse service they had accessed had had on their lives. 31% (36) were very positive. 9% (10) said it was negative or had no effect. 17 clients considered themselves to be clean, with periods of abstinence ranging from a number of weeks to 30 years. Retention: Additional evidence from the 114 service users that replied to the DAAT service user survey indicated that 32% (37) reported that they had been in contact with treatment services for between 1 5 years with 26% (30) service users reporting over 5 years in treatment. Other comments raised during the interviews included a concern about waiting times, either to enter the service, be referred into treatment, or when being moved into Tier 4 support. Harm reduction: The DAAT service user survey asked Do you think that you are provided with enough information regarding minimising the risk of harm? The overwhelming response was yes. However, many clients commented on the low availability of in-house detoxification provision. The DAAT service user survey asked for reasons respondents might have left or dropped out of service in the previous 12 months. Although there was a low response rate, reasons included moving areas, failing a treatment and returning to prison. 35% of respondents thought that services had improved in the last 12 months, 21% felt services had remained the same. 15% thought services had got worse. Concerns were raised during interviews about the degrees of support offered by caseworkers, including concerns about availability, ease of access and difficulties when being transferred to a new caseworker. Findings Following the services analysis conducted within this needs assessment, it has to be noted that one of the key challenges we face is around data accuracy. Whilst this is not a problem isolated to Cambridgeshire, it still requires attention. There is also a need to focus on those exiting treatment, to reduce the numbers of unplanned exits. The confidential questionnaires and interviews held with substance misusers both inside and outside the treatment system proved to be a great success. An analysis of the data alongside recommendation for the future is made at the end of this report. 7 of 73

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9 Introduction The Crime and Disorder Reduction Act 1998 placed a requirement on responsible authorities (local authorities, primary care trusts, police and probation) to undertake audits and development plans in relation to drug misuse. In many counties a Drug Action Team or other local group has been established to oversee this alongside wider local strategic needs assessment and planning processes. It is a national requirement that all DAATs carry out an annual Adult Needs Assessment to identify the needs of the local population requiring specialist treatment for substance misuse each year. With the involvement of partner agencies, this assessment should be able to outline key targets for the coming financial year and inform the 2010/11 treatment plan priorities. It has identified service user and potential service users needs, gaps and/or comparative differences in service provision and retention across the county, and the prevalence of substance misuse. Substance misuse treatment plans should be aligned with broader delivery plans for the county, across all relevant organisations. The Needs Assessment primarily interrogates treatment data but also uses statistics and information from partner services such as the Police, Health, Trading Standards and Probation. It seeks not only to identify the unmet needs of the substance misusing population, but also their carers and families, and can then inform decisions on how those needs can be best met within available resources. This report will present the review of the adult treatment system by examining the following: Demographics of Cambridgeshire Where are we now? Service provision in Cambridgeshire Housing support Vulnerable population groups Harm reduction services Treatment process mapping The prevalence of drug use in Cambridgeshire CDIP and Probation services Support for parents/carers What do we need to do to improve the treatment system? Unmet needs, and future targets Expert Groups An expert group was established and called upon at specific points during the needs assessment process. Stage 1: To assess the initial data available and to critically evaluate it. The initial stage assessed these data sources against local experiences, determined what other local databases could be used and tested the main analytical methods to be employed. The Adult treatment system maps were provided to the group. The outcome of stage 1 guided the 9 of 73

10 main questions to be tested within the needs assessment and potentially addressed within the treatment plan. At this meeting the DAAT agreed to undertake analysis and produce some detailed interim findings prior to the second meeting of the group. Stage 2: At this stage the expert group met to test the data and interim findings, and the attempts to link different data sources. Key findings were presented to the group, and a critical analysis similar to that within the first meeting was conducted. Discussions were held around the integration of the needs assessment and the treatment plan Stage 3: Draft versions of the document were circulated to relevant colleagues and key partners. Feedback was then given with regards to each section of the document, both specific to each service and on overall data validation Stage 4: Stage 4. DAAT Awayday. Presentation to ATCG 10 of 73

11 Demography The mid-2008 population estimates have been recently released, and indicate an increase in overall population of 8600 since Since 2001 the population of Cambridgeshire has increased by 7.8% to 595,500. The largest percentage increase has been in East Cambridgeshire where the population has increased by 12% to 79,400 since Huntingdonshire has had the smallest change since 2001 at only 3.8%: Cambridgeshire's settlement pattern is dominated by the city of Cambridge, which accounts for 19.8% of the County's population and 34.4% of the population in all parishes with more than 5,000 residents. Most settlements are small; only 20 of Cambridgeshire s 238 parishes (including Cambridge) have populations of over 5,000 and only 8 parishes have more than 10,000 people. Nevertheless, 58% of Cambridgeshire's population live in parishes with more than 5,000 people. Within Cambridge City, unlike the rest of the county, the lower age groups are fairly evenly balanced. 44% of Cambridgeshire s year old population resides in Cambridge City. This is partially due to the high concentration of students, with over 20,000 attending university within the City. During term time, students may account for around 20% of the Cambridge population. Experience suggests that many students are not entered on the electoral register, including some overseas students not eligible for registration. Figures from educational establishments help in recording the student population changes not fully covered by electoral roll change. The chart below examines the mid-2007 data with regards to district and age. It is necessary to use 2007 data when examining age breakdown because this has not yet been produced by the ONS for However, it is unlikely that the percentage breakdown have changed significantly between 2007 and One third of Cambridgeshire s overall population is aged between 40 and 64 years, and a further 24% of the population is aged less than 20 years. The highest numbers of adult population are in the 40 to 64 and 25 to 39 brackets years years years years years 75+ years Total population Cambridgeshire 139,500 44, , ,000 47,100 42, ,200 Cambridge City 24,500 19,300 28,600 29,000 6,700 7, ,200 East Cambridgeshire 18,900 3,900 14,700 27,400 6,700 6,300 77,900 Fenland 21,700 4,700 16,700 30,800 9,100 8,500 91,500 Huntingdonshire 40,100 9,000 31,100 58,500 13,000 10, ,000 South Cambridgeshire 34,200 7,200 26,600 50,300 11,600 10, ,500 Population estimates by district and age-band for Cambridgeshire: ONS Mid-2007 UK estimates 11 of 73

12 Future Population Trends In 2008 the Cambridgeshire County Council Research Group (CCCRG) forecast a 6% increase in the population of Cambridgeshire between 2007 and Cambridge City is expected to see the largest growth in that period with a forecast 14% increase, while the other 4 districts are expected to experience between 3-4% growth. In the longer term, Cambridgeshire s population is forecast to grow by 13% between 2007 and 2021, the majority of which is expected to occur in and around Cambridge City, and in new settlements and market towns across the county. As discussed in the section analysing Class A drug users, a 2007/08 Home Office report estimated that 2.4% of those aged 16-59years reported using Class A drugs. We should therefore expect a potential 13% increase in Class A drug users in Cambridge by Population change by ward, , Cambridgeshire County Council Research Group, of 73

13 Deprivation The following map uses data examined by the Cambridgeshire County Council Research Group on the Index of Multiple Deprivation (IMD) 2007 for Cambridgeshire and its constituent lower super output regions (LSOAs). The IMD allows for direct comparison between areas whilst also recognising the multidimensional nature of deprivation. Cambridgeshire is ranked within the 10% least deprived counties in England. However, despite this being the overall picture, there are some relatively large local variations in deprivation levels. The map below outlines the distinct differences across the county. There is a clear north-south divide, with deprivation concentrated in parts of rural northern Fenland and Wisbech, the Oxmoor Estate in Huntingdon and parts of north Cambridge City. The county of Cambridgeshire can be broken down into 73 Lower Super Output Areas (LSOAs), of which nine are within the most deprived quintile in terms of income deprivation. Whilst Cambridgeshire paints a positive national picture, high deprivation points are isolated to specific areas within the county, with four LSOAs within Fenland. Cambridgeshire Index of Multiple Deprivation of 73

14 Ethnicity The table below shows Cambridgeshire s population by ethnic group as derived from the 2001 national census. The figures are contrasted with the mid-2004 and mid-2007 estimates from the Office of National Statistics. The percentage of the population listed as White has decreased since 2001, most significantly so in the White: British category, with a notable increase in the numbers of Asian/Asian British and Chinese/Other residents. HIV and other sexually transmitted diseases are much more prevalent among Black and Minority Ethnic groups than the White population. In the East of England, the Black African group accounts for the largest proportion of patients seen for care for HIV more than half of all HIV patients in the region are from this group. Asian groups have low incidence of HIV, but Aspinall & Jackson (2004) caution that newly diagnosed cases of HIV in England and Wales are now commonly contracted in Asia. Other sexually transmitted diseases are found disproportionately in Black Caribbeans and those belonging to the Other Black ethnic group. In the case of gonorrhoea, 50% of cases nationally are found in the White groups and 30% in the Black Caribbean group. In the East of England the proportions are slightly higher for those in the White group and slightly lower for those in the Black Caribbean group. The ODPM count of gypsy caravans was last undertaken in 2005, showing the East of England to have the largest number of caravans of any region in England. A total of 3,980 caravans were recorded, an increase of 14.5% over two years, and around two thirds of these were on authorised sites. The largest numbers of caravans were located in Cambridgeshire and Essex, with more than 1,000 in each of these areas. The smallest numbers were in Southend-On-Sea where no caravans were recorded and Luton, where 51 caravans were located. The largest increases in caravan numbers in a two year period were in Bedfordshire and Luton, both of which saw increases of more than 80%, although the numbers involved were smaller. In 2008 it was estimated that 6,500-7,000 Gypsies and Travellers live in Cambridgeshire. 14 of 73

15 Service Provision in Cambridgeshire The Cambridgeshire Drug and Alcohol Action Team (CDAAT) resides within Cambridgeshire County Council. Its strategic direction is laid out by the DAAT Executive Board, whose members include senior leads from the County Council, health services including Cambridgeshire PCT, constabulary and probation services, housing services, community safety teams, and the NTA. Adult Services All commissioning of adult drug treatment services, including that for the Drug Intervention Programme, is delivered and monitored by the Adult Treatment Commissioning Group (ATCG) and facilitated by the DAAT Treatment Coordinator, which reports directly to the DAAT Executive Board. The ATCG is a multi-agency partnership comprising of highranking leads from partnership organisations. Wider stakeholders are involved in the review and planning process, including service providers, service users, community groups and other members of the public affected by substance misuse issues. This serves as a formalised approach to the inclusion of all strands of the general public, to work alongside the use of parent/carer and service user forums, various other meetings and the regular circulation of questionnaires. Children and Young People s Services Treatment for children and young people is also coordinated through the DAAT, with services being commissioned through the Young People s Commissioning Group (YPCG). The YPCG decisions are reported to and monitored by the ATCG and DAAT Executive Board. Cambridgeshire Drug Intervention Programme (CDIP) CDIP has an operational project group which monitors performance and activity. This group reports directly to the ATCG, with responsibility for the commissioning and development of services being delegated to the ATCG. DIP planning is integrated within the adult treatment planning programme. Alcohol Services The CDAAT have formed a multi-agency strategic Adult Alcohol Commissioning Group (AACG), which works with partners to address the need for evidence-based alcohol treatment services. It aims to reduce the physical and psychological health-related troubles caused by problematic alcohol misuse, and to reduce the harm caused by alcohol to individuals, families and society by providing a timely and appropriate access to alcohol treatment. The AACG supports the implementation of the Alcohol Harm Reduction Strategy. Outcomes include reducing harm to health, addressing alcohol related crime and disorder, lowering alcohol related hospital admissions, and reducing the harm to children, young people and families caused by alcohol misuse, improving social integration. 15 of 73

16 Operational Structure CDAAT commissions agencies to provide specialist treatment and targeted prevention work for substance misusing clients. The NTA defines specialist substance misuse as a range of interventions that are intended to remedy an identified drug-related problem or condition relating to a person s physical, psychological or social (including legal) wellbeing. Structured drug treatment follows assessment and is delivered according to a care plan, with clear goals, which is regularly reviewed with the client. A wide range of support and treatment services exist across Cambridgeshire. Current provision is equitable across the county. The Adult Drug Treatment System was put out to tender in April 2007 and commissioned to Addaction in April The PCT drug treatment process and the County Council s pooled treatment budget were then pulled together to jointly commission adult treatment services as one. A motivation for this amalgamation of resources at this point was the opportunity to commission drug treatment services with a mid-term planning model, by extending the awarded contract from a 1-year tendering cycle to a 3-year contract. This enabled adult treatment services to become more streamlined and stable across Cambridgeshire. The treatment structure was reconfigured to ensure all models of care were aligned, thereby offering Cambridgeshire residents equal access to the full range of interventions and services available. From the start of the 2008/09 financial year, the drug treatment system consisted of a 3-step recovery process with the following key phases: The Induction Phase - This is the first point of contact for the client. Making use of the single point of contact model, individuals can either self-refer or be referred by professionals (with consent) into a service. - This phase also includes basic services such as needle exchanges, guidance on safer injecting, harm reduction interventions and risk assessments as necessary. - Advice and information is offered in addition to a triage assessment. The client is then referred on into other elements of treatment as required. - An initial care plan is drawn up and a key worker is identified. Clients are then placed into an appropriate primary treatment modality. The Intensive Phase - Once referred, the client will begin a structured treatment modality. - A full assessment of the modality will commence. The clients care plan will be reviewed regularly to reflect the interventions undertaken. Joint planning efforts will facilitate referrals onwards into the Move On phase. - This includes, but is not limited to, specialist prescribing, structured psychological interventions, GP-shared care and structured day programmes. Service users also have further access to more intensive BBV and harm reduction interventions. 16 of 73

17 The Move On Phase - This phase enables clients to successfully return to the wider community with a lower level of support. - This may include GP-shared care, relapse-prevention group work, housing support, and help developing educational skills with a view to employment (facilitated by ETE workers through NACRO). - In exceptional cases for clients with complex needs, continuation prescribing can be provided within the specialist prescribing process. Adult treatment services are provided from four fixed sites across the county. There are also dedicated outreach teams, satellite surgeries and non-site-specific counselling sessions. The four fixed sites are: Cambridge (covering Cambridge City, South and East Cambridgeshire) Wisbech (covering Fenland) Huntingdon St Neots A number of satellite sessions are provided across the county including those provided weekly in Ely. The new services include: A single point of entry through assessment and open access services; Harm reduction services such as needle exchange (including fixed-site and pharmacy-based) and an integrated blood-borne virus service; Specialist prescribing services; Delivery and development of the GP Shared Care Scheme; Structured psychosocial Interventions including counselling support; Structured day and group work programmes. 17 of 73

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19 Problematic Drug Users Nationally, Class A drug use costs an estimated 15.4 billion to crime and health services each year, of which 99% is accounted for by heroin and crack use. Between a third and a half of acquisitive crime is estimated to be drug-related. Therefore, for every 1 spent on drug treatment there is a saving of 9.50 to society as a whole. According to the Home Office report entitled Drug Misuse Declared: Findings from the 2007/08 British Crime Survey England and Wales 1, the proportion of year olds reporting the use of Class A drugs in the last year in the East of England was 2.4 %. When this is applied to the local population aged years old at the time (387,700), we have an estimated number of 9,300 people in Cambridgeshire who have used Class A drugs in the last year. A problematic drug user (PDU) is identified as being an opiate and/or crack cocaine user. As we can see from the estimated population increase of 6% by 2011, this number of PDUs could increase by 563 to 9,863, which should be considered when examining future capacity planning for services. The 2008/09 British Crime Survey is awaiting analysis and will therefore be of benefit for future analysis during There are several drug misuse prevalence measures available, however any conclusions drawn from these must be taken with caution due to data limitations. As a result, estimated numbers of PDUs in the county has a significant margin of error, with a confidence interval of 95%. The treatment bullseye is an illustrative tool that helps to define and better understand the level of PDU engagement with structured treatment. Clients aged from 15 are included in the data. Since no estimates of Class A users were made last year, an average of the data recorded from 2004/05 to 2007/08, as given below, is used. The distinct difference between 2004/05 and 2005/06 data of 740 clients means that the validity of the 2007/08 average of 1654 should be treated with caution. Glasgow PDU estimates 2004/ / / The table below summarises the estimated number of PDUs within Cambridgeshire in 2007/08. The treatment bullseye breaks down the 1654 Class A clients identified above to allow us to identify the degree of unmet need in the region. As with last year, there is a significant overlap between crack and opiate populations, with a minority only taking one of the two substances. Category Estimate 95% CI Lower 95% CI Upper Opiate and Crack Crack Opiates Injecting Estimated prevalence of opiate and/or crack cocaine use, Glasgow smoothed estimates 2 1 British Crime Survey 2 Glasgow smoothed estimates are an average of the figures produced 2004/ / of 73

20 On examination of substance trends as measured by NDTMS, we find that in the 2008/09 period, 1122 PDUs were identified at triage. This is equivalent to 32% of all those triaged and 0.29% of Cambridgeshire s population aged This is an increase from 2007/08 and as a result continues with the gradually increasing numbers of PDUs since records began in 2004/05 (866 clients). However, statistically, the numbers of PDUs as a percentage of all cases triaged is actually decreasing, from 50% in 2004/05 to 35% in 2008/09. The bullseye tool tells us that of these clients, 202 are not known to the treatment system, and that, across the entire county, only 20 substance misusers are not known to either treatment or to DIP. This suggests that treatment contact with clients in Cambridgeshire is extremely effective. However, it is significantly more likely that this is a data inaccuracy, as it is particularly implausible that the numbers unknown would be that low. It should also be noted that, as with the tables above, there is a 95% confidence interval for the data. This means that the potential numbers not known to the treatment system ranges from -467 to 929 clients. Consequentially, the bullseye analysis will be considered to be unreliable, and the needs assessment and treatment plan will focus on agency-specific data such as that examined within the treatment mapping process, and on the assumption that we have a wider range of unknown substance misusers in the county. In the financial year 2008/09, 318 PDU clients have been in treatment in Cambridgeshire. This is an increase of 72 clients from 2007/ clients are recorded as not being in contact with treatment services but still being in contact with CDIP. Treatment Bullseye: Opiate and/or Crack Cocaine users, 2008/09 20 of 73

21 Crack Cocaine Nationally, there are concerns about the increase in the use of crack cocaine across the country. The Eastern Region in the last five years has seen numbers reporting problematic crack use doubling since 2004/05. This equates to 31% of all crack uses in Cambridgeshire being in treatment in 2008/09 whereas 83% of primary drug opiate users are in treatment. This data suggests that 20% of opiate users in the county do not access treatment but with crack users this rises to 70%. More crack users report crack as a secondary or tertiary drug but figures for primary drug crack users suggest that only 3.1% of the total crack population access services. Numbers in treatment with a primary problem substance of crack, 2004/ /09 The number of clients in treatment with crack identified as a secondary or tertiary problem substance has notably increased. Over the same 5-year period secondary crack use by those in treatment has increased by over 140% - from 1700 in 2004/05 to 4100 in 2008/09. It is possible that this might be partly attributable to improved reporting of additional problem substances. Combining all clients reporting crack use either as the primary or an additional problem substance indicates that the total number of individuals reporting any problematic crack use has more than doubled over the 5 year period from under 2400 to The proportion of females within that total has remained fairly stable at around 30%, which is roughly the same at the proportion of females in treatment for opiates and other drugs. The following graph shows the gender breakdown of the total numbers reporting any problematic crack use. 21 of 73

22 Total numbers reporting any problematic crack use by gender, 2004/ /09 In some counties, crack cocaine-focussed clinics have been set up. As a result, we have looked into the data available within Cambridgeshire to identify whether this county has increasing substance misuse issues regarding this drug. Cambridgeshire shows very low growth rates in primary crack treatment, but a doubling or trebling once secondary and tertiary problem substances are included. The low numbers of clients registering the use of crack cocaine may therefore prove indicative of the relative unavailability of appropriate crack treatment. The use of cocaine amongst young people has increased slightly, with an increase from 5.1% to 6.6% between 2007/08 to 2008/09. This therefore implies there may be an increase in the numbers of young adults using cocaine over the forthcoming years. However, owing to the fact that only 6.9% of clients in treatment services report this as being their primary problem (lower than some other drugs, including cannabis 8.3%), it has been decided that cocaine-focussed clinics would currently be unsuitable for Cambridgeshire. Within Q1 of 2009/2010, there has been an estimated 3% improved engagement of crack users, and 0.4% improvement access for crack users. However, when taking into account the potential rise in clients, this will be an area for future consideration in the forthcoming year, and will be re-examined in the 2009/2010 needs assessment. 22 of 73

23 Structured Drug Treatment Interventions Treatment System Map A treatment map is a graphical representation of the treatment pathways available to clients. The purpose of mapping the pathway is to identify the numbers and types of clients that are flowing into, out of, and between services. This can then be used to identify areas for improvement within the system, be they to reduce barriers into treatment, maximise efficiency, or to incorporate new services to ensure more effective treatment. The model described in this document is constructed from data collected by the NDTMS on all Tier 3 and Tier 4 clients. A restructure of the treatment system took place in 2008, where responsibilities were moved to lie within Addaction as opposed to each single service. As a result, one month of the data recorded for this year incorporates the previous system, thus explaining the lack of referrals to the services listed in the two left treatment boxes in the chart overleaf. All open client records, irrespective of agency, were transferred across to new agency codes in accordance with NTA procedures, enabling Addaction to take on clients without the need to reassess, and ensuring that and effect the changes in the treatment pathway might have on Cambridgeshire s performance metrics were kept to a minimum. Any interpretation of Cambridgeshire treatment data is difficult due to both the changes outlined above and the poor quality of data recorded on NDTMS. Therefore any conclusions based on the data must be taken with due care. However, it should be noted that there has been a significant improvement in data recording from the previous year. The drug treatment service delivery map in Cambridgeshire is illustrated overleaf. Please be aware that due to the fact that clients may access services from more than one agency (e.g. the Access Surgery and Addaction), they may be counted twice. The new drug treatment system and pathway is illustrated in appendix 1 The data recorded in the other box has to be viewed with caution as some of the services listed (Detox 5HQ, SMS West and Stevenage Drugsline) are not services within Cambridgeshire DAAT area, unless clients have been referred to them as they have left the county. 23 of 73

24 24 of 73 Treatment system map, Cambridgeshire, 2008/09

25 Treatment Referrals Referrals into adult treatment services come from various sources, as highlighted in the Treatment Map diagram. Following the service changes in May 2008, clients from the existing agencies were referred into Addaction. Those in treatment prior to April were still recorded within their original services, and as a result we see that whilst no referrals have been made into these services, there were still some clients connected to them in March. In 2008/09 we see a dramatic increase in the numbers of referrals into treatment being made, with there being almost double the number made in 2007/08This increase can be explained by the migration of client from old systems into Addaction. During this process, cases had to be closed and then reopened under the new service. As with 2007/08, selfreferrals make up nearly half of client referrals within Cambridgeshire (52%). This is higher than the regional (40%) and national percentages (41%). The majority of referrals made went to Addaction s Cambridge City offices. 24 clients were referred in from DIP services. The Cambridge service referred out 20 cases 12 to the Access Surgery, and the remaining 8 into the DIP. The Addaction offices in Huntingdon and Wisbech received 154 and 203 referrals respectively, with the St Neots office receiving only 45 and making no agency transfers. Of those referred into DIP, 28 were transferred into mainstream services (6 to the Access Surgery, 13 to Addaction Wisbech, and 9 to Addaction Huntingdon). 23% of client referrals are recording as having come from other sources. This group comprises of a variety of services and people, including: A&E Hospitals Social Services Community Care Assessments Psychiatry Psychological Services Employment Service Connexions Relative Concerned others From 2007/08 to 2008/09, the percentage of referrals coming from defined sources has for the most part remained unchanged. However, the number of referrals coming under the category other is notably higher, with 174 clients (23.2%) falling under this area. This is a large increase from 2007/08, where 33 clients came from other sources, and is very high in comparison to regional figures, where only 8.6% fall under this category. This clearly needs to be addressed over the coming year. Referrals from Social Services still remain a significant problem, with only one episode being referred throughout 2008/09. The numbers of those referred from an arrest or from the DIP has fallen 74 to 39. However, when examining the CDIP in more detail, we see they are greatly exceeding their targets. 25 of 73

26 2008/09 Client Population Age, Gender, Ethnicity and Duration of Contact with Services Each agency records the number of clients it is in contact with, which can therefore mean that some clients are recorded more than once according to the number of services they are in contact with. As a result, by adding the records from each agency from the treatment map above, we identify 1780 client records in 2008/09. However, the actual number of clients may be slightly lower than that. In 2008/09, according to the NDTMS, 1780 clients were in treatment, with 751 new referrals. This figure differs from the NTA s 2008/09 Green Report that indicates there were 1341 clients in treatment. The difference is possibly due to the way the data has been captured. The NTA Green Report looks at clients that have been in effective treatment and the NDTMS looks at all clients recorded in treatment No. Clients within the Treatment System The chart to the left demonstrates the increase in client numbers in treatment since This includes those sent out of county for treatment for example, those sent to detoxification services and those in services just outside of the Cambridgeshire border. We expect that client numbers will increase further this year with the opening of new satellite centres and shifts in the focus of treatment. This can be evidenced by the examination of the 2008/09 Quarter 4 data which indicates that more clients started a new treatment journey that in the same period in 2007/08. Of the 1780 clients recorded in Client Duration in Treatment treatment, 461 have been in treatment 16 for over two years - representing 25.9% 14 of the client population. 187 clients 12 (11%) have been in treatment for over years four years. This has improved from last 8 4+ years year, when 35% of clients registered as 6 being in treatment for over two years, 4 2 demonstrating that the reconfiguration of 0 services has helped to streamline the Local Regional National treatment pathway. It should also be noted that these numbers, whilst concerning, are in par with both regional and national pictures. However this is still a significant part of the treatment population, and steps should continue to be taken to improve this. Overall, 70.5% of those in treatment were male. This balance remains the same for those in treatment over 2-4 and 4+ years. This means that there were approximately 2.4 males / / /09 26 of 73

27 to every female in treatment. This is higher than the estimated national gender balance, but is in line with local data from previous years. There has been a marked improvement in the recording of client ethnicity, with a 99.9% completion rate in 2008/09. The vast majority of clients are White (97%), with 0.5% recorded as Asian/Asian British, a further 0.5% being Black/Black British, and the remaining 2% being categorised as an other ethnicity. As with the gender breakdown, this balance remains similar when examining those in treatment for longer periods of time. These proportions are in line with the 2001 Census ethnicity data from Cambridgeshire. Client age breakdown remains similar to previous years. As highlighted in the chart to the right, the majority are aged between 25 and 44 years. Only three were aged over 65. This division remains similar for those in treatment over longer periods. The main drop is in those aged years, whilst the percentage aged over 45 years actually increases (from 11.8% to 25.1%). 34% Clients in Treatment: Ages 12% 13% % Numbers in treatment by age group, Cambridgeshire, 2008/09 Age recorded on 30 th September 2008 Retention By examining the NDTMS Information Reports, more commonly described as Green Reports, we see that in 2008, 85% of PDU clients and 81% of all clients had been retained in treatment for over 12 weeks. This is an improvement on previous figures, most likely demonstrating an improvement in treatment pathways and stronger data recording methods Total starting new treatment journey Retained > 12 weeks Completed with care planned discharge PDUs (85%) 6 (1%) 80 (14%) Not in effective treatment All Clients (Over 18s) (81%) 15 (2%) 128 (17%) Effective Engagement of New Treatment Journeys 01/01/ /12/ of 73

28 Drug Use The NDTMS Green Reports have been used to analyse the following data. Just over 69% (1028) of clients presenting to treatment services in 2008/09 reported heroin as being their primary problem substance. This is an increase from last year s figure of 830 (65%). This difference may be due to the changes in data recording styles by NDTMS, and therefore should not necessarily be considered comparable. 784 clients had a secondary drug issue recorded, with 291 recording a third drug. The most common second drug was crack, closely followed by alcohol. Methadone is used by 4% of the drug misusing population. 80% of drug clients did not have a tertiary drug problem recorded. Secondary or tertiary alcohol misuse was recorded for approximately 10% of all drug clients. Of the 1028 heroin clients, 48% (493) came forward as having secondary (and possibly tertiary) drug problems. Within this group, the most common secondary drug was crack (37.3%), followed by cannabis (13.6%) and alcohol (10.8%). Overall, crack, cocaine and opiate users accounted for 84.9% of all those presenting for treatment over 2008/09. This is similar to the substance profiles in other counties where opiates and crack cocaine are the main drugs for adults in treatment. Primary Drug Use Within Client Population 2% 5% 4% 8% 1% 2% 78% Opiates Crack Cocaine Amphetamines Cannabis Benzodiazepines Other Main drug used, Cambridgeshire, 2008/09 28 of 73

29 Treatment Exits Over 2008/09, 913 exits from various treatment modalities were made. The graph below outlines the numbers leaving each modality over the year. As you can see, the majority of clients exit via specialist prescribing as any other intervention type. This is likely to be a result of the degree and commonality of the intervention for example, when examining residential rehabilitation, inpatient treatment and structured day programmes, a significantly smaller number of clients will enter the intervention, and therefore there will be fewer exits from the treatment system. Treatment Modality Exits Inpatient drug treatment Residential rehabilitation Specialist prescribing 122 GP prescribing 18 Structured day programmes 177 Structured psychosocial interventions 213 Other structured treatments The above graph analyses each treatment modality, and therefore the overarching numbers of exits will not reflect the number of adult clients leaving the system due to dual recording. Over 2008/09, 407 clients left treatment, as indicated by the treatment map. Of these, 78% had an unplanned discharge. Addaction have developed a Performance Management Plan focussing on Planned Discharge issues, and CDAAT have set services an aim to increase the numbers of planned discharge rates to 40% by the end of 2009/ of 73

30 Residential Rehabilitation & Inpatient Detoxification Service Residential rehabilitation placements and inpatient detoxification services can be an effecting treatment process for substance misusers, especially for those wishing to recover after prolonged and strong use of substances, and for those who have more complex needs. Drug users can be supported into moving towards longer term abstinence, with services assessing and stabilizing chaotic clients. Early intervention techniques can service to progress clients away from longer-term substance misuse In 2008/09, 27 individuals were in Tier 4 treatment; 17 in primary stage residential rehabilitation, 4 in secondary stage residential rehabilitation 13 in inpatient detoxification with 2 receiving social care support. This balance has shifted since 2007/08, when out of 30 individuals in Tier 4 treatment, 77% were in residential rehabilitation. Take up continues to be predominantly 75% male. The following data is extracted from NDTMS and does not correlate with our records which indicate a far higher number of clients connected to these services. This information is listed in Appendix 4. The difference in numbers is mostly likely due to data recording inaccuracies which we endeavour to address in the coming year. 23 clients are recorded as being in Tier 4 treatment in 2008/09, divided between 10 services as listed below: Agency No. in Treatment Salvation Army Greig House Alcohol Detoxification 1 Trust The Process Counselling 1 Phoenix Futures Alpha Residential Services 1 Mill House Drug and Alcohol Service 1 Diana Princess of Wales Treatment Centre 3 CDT Fenland 1 Cambridge MHT DIP 2 ADAPT BARLEY WOOD 2 ACTION ON ADDICTION - CLOUDS HOUSE 1 Detox 5 HG 10 This is a low proportion of the total number of clients in treatment during the year (1.3%). 10 of these clients were pre-existing in Tier 4 services as the year began. 10 clients left Tier 4 treatment services. No exits were unplanned, as highlighted below: Agency Planned Unplanned Referred On Salvation Army Greig House Alcohol Detoxification Diana Princess of Wales Treatment Centre CDT Fenland Cambridge MHT DIP Detox 5 HG of 73

31 Cambridgeshire Drug Intervention Programme (CDIP) The CDIP has been in operation since April 2005 and is a critical part of the Government s strategy for tackling drugs in Cambridgeshire. The programme involves criminal justice and treatment agencies working together with other services to provide a tailored solution for adults who commit crime to fund drug misuse. The programme aims to provide rapid prescribing and wrap-around support to Class A drug users. Cambridgeshire is a non-intensive area with two teams: DIP Southern, based in Cambridge City (covering City, East and South Cambridgeshire), and DIP Central, based in Huntingdon (covering Huntingdon and Fenland). Both are teams with staff from various agencies, including the CDAAT, Cambridgeshire Constabulary, Probation, Cambridgeshire and Peterborough Foundation Trust (NHS), Prolific and Priority Offender Scheme, and Luminus Housing Association. CDIP Referral Pathway CDIP clients include voluntary referrals, prison referrals, Prolific and other Priority Offenders (PPO s) and probation clients who have been given a Drug Rehabilitation Requirement (DRR) as part of their sentence. By successfully engaging with clients and supporting them through treatment, the CDIP can positively impact on acquisitive crime rates within Cambridgeshire. It is well-documented that a crime of choice for this group is shop theft; however many clients have been involved in more serious acquisitive crimes such as burglary, robbery and vehicle crime. CDIP clients are engaged through several referral routes: Police Custody: - Voluntary Drug testing On Detention (VDOD) at Cambridge, Parkside Police Station Self referral: - Voluntary referrals by individuals aware of the services offered by DIP. Prisons: - CARAT referrals for prisoners sentenced or on remand. Probation: - Mostly clients who receive a Drug Rehabilitation Requirement order through the courts. Other Agencies: - Referrals from other drug treatment agencies where clients would benefit from specific DIP interventions. Last year, the DIP set a target of introducing a minimum of 14 new clients (excluding DRRs). Due to revised NTA expectations, the target has now been raised to 25 clients per calendar month as from August The monthly average caseload between April and August 2009 was 163, and is set to rise. The current caseload for August 2009 was 177 cases. 75% of new clients will be referred into one or more structured treatment modalities including Specialist Prescribing or Psychosocial Interventions such as CBT. 31 of 73

32 CDIP Clients The target for CDIP is to have 75% of clients in treatment. The following data is collated from the CDIP database, which holds all client information for both the central and southern regions of Cambridgeshire. The data is mainly derived from the Drug Interventions Record (DIR) forms which are completed by Case Managers/Key workers alongside the clients. The records used were those of clients that were known to DIP that were case managed between April 2007 and March The CDIP client caseload has remained at a consistent level during the past 12 months, peaking at 173 case managed clients in November The number of new clients assessed has been consistently above the local target of 14 a month, and the cumulative total of new clients for the year is 40 above the cumulative target level. The DIP has made significant improvements in its engagement with and retention of clients within treatment. Feedback from the recent CDAAT service user events held throughout the county placed great emphasis on both the accessibility of the DIP to clients and the quality of treatment and key working whilst engaged with the service. It is rewarding to note that the qualitative feedback on DIP treatment provides a positive endorsement of the service over and above the quantitative performance measures. Whilst a certain number of clients who do not require prescribing are still entered onto the NDTMS system there are also a large number who are not as they do not require any clinical input or they are only engaged with CDIP for a very short time before being closed or signposted onto another service. Such examples are CARAT referral client who are initially assessed and then do not attend any further appointments and people seen in the 32 of 73

33 custody block for whom CDIP makes an initial assessment but will close if not suitable for further assistance. There is also the possibility of data input error for clients who come in and out of treatment several times within the same year and the NDTMS system not being closed between the two episodes. CDIP data will include multiple entries for clients who come through the service more than once within the year. Taking all these factors into account it is reasonable to expect such a disparity between the CDIP and NDTMS data as highlighted in this case. Referral Sources All clients are recorded on an access database and the Annual Performance Summary shows that 436 clients engaged with CDIP. This includes those clients already on the caseload prior to April 2008 and also all of the new referrals into treatment that have been received by both teams during the last 12 months. As highlighted in the graph above, DRR orders account for the highest percentage of new clients across both teams. As part of the agreement with probation, CDIP undertakes the initial assessment of offenders who are put forward for a DRR as part of their sentencing. Of the overall caseload at the end of March 2009, 54 CDIP clients (36%) had a DRR order. CARAT (Prison) referrals are the second main referral source and reflect the close links between DIP and CARAT services to ensure the continuity of care and treatment for Class A drug users within the criminal justice system. Gender statistics for CDIP clients remain unchanged from the previous year s figures with a prominent 81% male client base. This is in line with Home Office research stating that in the past year, men aged between 16 and 59 years were twice as likely as women to have used any drug and specifically any Class A drug (4.2% compared with 1.7%). 33 of 73

34 The age range of clients, as demonstrated in the chart to the right, is also in line with national figures, showing that clients in the age ranges of and 34+ being significantly more prevalent than clients in the age range. In line with the criteria for acceptance as a CDIP client 88% of clients in treatment during the last year stated that their main drug use was Class A (heroin, cocaine, crack or methadone). Some clients stated poly-drug use with Class A as a secondary use therefore still making them suitable for treatment and support from CDIP. CDIP client data, 2008/09 Structured Support Every client on the programme is eligible for input from both a criminal justice and clinical perspective. Levels of intervention depend upon the individual needs of the client at the time of their referral to CDIP and during their progress whilst they remain case-managed. Of the total caseload over the past 12 months, 86% received basic one-to-one support, with 54% being given rapid prescribing and 49% harm reduction support, which matches the trend from previous years. The chart below outlines the breakdown of treatment and/or support offered based upon the data submitted to the Home Office. CDIP Case Closures As highlighted in the graph and pie chart below, the highest proportion of cases closed in 2008/09 was due to client disengagement (31.7%), with 15.7% reaching successful 34 of 73

35 completion of their treatment approximately half the number disengaging. This is a decrease from 2007/08, where 23% of cases were closed following successful completion. Reason for Closure Total % CDIP Closure Client Disengaged Client in Prison Sign Posted to Other Agency Successful Completion of Treatment Transferred to other DIP Totals Client Satisfaction CDIP conduct an annual survey with clients, examining various details about their substance misuse habits and their perception of the DIP overall. The most recent results, published in July 2009, questioned 28 clients and found that all were happy with the services delivered. This time 11 of the clients (39%) surveyed are on statutory orders (Probation clients). The previous survey showed 5 (19%) in this group. It was found that following engagement with the DIP, total drug spend for the group fell by 82%, with over three quarters of the group spending under 50. The current self-admitted drug usage data suggests that 25 (89%) of the clients have either a lower frequency of use of their main drug or have reduced the classification of that drug i.e. switched from Heroin to Cannabis for example. However 3 (11%) are showing as the same or worse. 35 of 73

36 The main influences behind drug use came across as being internal, such as boredom, depression, a general desire to rebel, or as a form of escapism. CDIP is seen to act as both a treatment mechanism and as a support service, raising people s self-confidence and offering regular support. All the clients surveyed cited treatment as a main factor that engagement with CDIP. Well-being, accommodation and food are identified as the other most important areas of support. Most of the clients acknowledge that CDIP has had an impact upon their offending. This endorses the major aim of the DIP to direct clients away from crime and into treatment. Crime Saving Analysis By monitoring the offending history of CDIP clients and using a recognised multiplier theory analysis devised by the Cambridge University Professor of Criminology, we are able to estimate that 1007 potential acquisitive crimes may have been avoided within the CDIP client group over the past 12 months. Whilst this is only an estimate, it still reflects the positive effect of the CDIP in terms of client engagement and re-offending behaviour. The chart below breaks down the numbers of crimes potentially saved each month over the last 12 months. Estimated Numbers of Crimes Saved Apr 08 - Mar Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Client Numbers Crime Saved The following graph charts a significant drop on the levels of re-offending during the first year of engagement with CDIP. Nationally, the DIP is recognised as being a key contributor in the government s crime reduction initiative. The Police National Computer (PNC) records for a 50% sample of CDIP clients engaged over the last 12 months shows a total of 108 recorded convictions during the first year of engagement, as opposed to 282 convictions in the year prior to joining the programme. This equated to an average of 1.5 convictions per current clients. Prior to engagement, the same client group shows a 5.2 conviction rate per client. 36 of 73

37 An analysis of all case-managed clients from the last 12 months shows that shoplifting was the most common offence committed by clients prior to engagement with the CDIP. Shoplifting accounted for 27% of all reported crime. Further analysis of the offending history for CDIP clients also shows that many have been involved in more serious acquisitive crimes such as burglary, robbery and vehicle crime. 37 of 73

38 Community Treatment Services A variety of treatment services are offered throughout Cambridgeshire, including appointment-based support, outreach interventions and direct open access facilities. Holistic therapies are also available, such as acupuncture and shiatsu. These are available in the following locations: Cambridge Wisbech Huntingdon St. Neots March Chatteris Appointment-based services are offered in all of the above locations as well as in Ramsey, St. Ives and in GP surgeries across county surgeries. Open Access services also provide telephone advice and information to drug misusers, their family, carers and professionals. The Cambridge Access Surgery offers a dedicated GP service for people in Cambridge who are homeless, living in sheltered accommodation or at risk of homelessness, which guarantees that if a client turn up at the surgery between 9.00 and am a doctor or nurse will see them. Two Joint Cambridge Access Surgery/Addaction Clinics are run at the surgery on Tuesday and Thursday afternoons. Attendance is strictly by appointment only and restricted to CAS patients with complex health needs. There is a Joint Waiting List for Addaction Services and some of our patients access them at Addaction s Mill House premises. Addaction Addaction Cambridgeshire provides support and treatment for individuals aged 18 and over with substance misuse issues. There are four permanent sites, located in Cambridge City, Wisbech, St Neots and Huntingdon. Addaction are also finalising plans to open a new site in Ely, with a view to its opening in early The county-wide service provides the following: Advice and Information to individuals and to their families / concerned others Complementary therapies including auricular acupuncture Harm Reduction Services - Needle Exchange Services - Co-ordination of the Pharmacy Based Needle Exchange Scheme - Integrated Blood Borne Virus Service (pre and post-test counselling, screening and vaccination) Group work including relapse prevention, stimulant group and personal development programmes Prescribing Services Specialist Prescribing and GP Shared Care Structured Counselling Support Structured Psychosocial Interventions Homelessness link / co-ordination service 38 of 73

39 Employment, Training and Education support services (via a contract with NACRO) County-wide volunteer scheme County-wide outreach team Support for Concerned Others In addition to this, Friends and Family Support Groups now run in Chatteris, Ely, Cambridge and Huntingdon. The groups are monthly in each location, but occur on separate weeks throughout the month enabling friends and family to travel to meetings and attend weekly if needed. Each permanent and satellite site across the county offers set types of interventions, as outlined in appendix of 73

40 Needle Exchange Services Needle exchange services are an important element of adult treatment services. A range of sites across Cambridgeshire offer these services, with locations identified according to local need and preference on service users. Needle exchange combined treatment centres are based in Wisbech, Huntingdon. Cambridge and St Neots. Satellite centres also exist in Ely, March, Chatteris, Ramsey and St. Ives. Treatment services are also available from various GP surgeries however these do not offer needle exchange services. Needle collection and disposal points, monitored prescription services and harm reduction advice are also widely available, both within support sites and external locations such as pharmacies. All needle exchange service locations are widely promoted, as are needle disposal points. Localised leaflets have been developed and are regularly updated to reflect these locations. Data from NDTMS shows that, of clients who were referred into services, 32% reported that they had never injected in 2008/09. This is a decrease of 8% from the previous year. One quarter of clients were recorded as having never injected, with a further 27% stating they not longer injected but had done so previously. These numbers are roughly the same as those recorded for the previous year. In 2007/08, 424 cases were recorded in comparison to 751 in 2008/09. This could be accounted for by clients choosing to not disclose their status. The graph below outlines the percentages of those entering treatment against their injecting status. Based on information taken from ERPHO, 25th Sept 2009 Injecting Status 07/08 07/08 08/09 08/09 Current Previous Never Missing Total syringes were returned over the 200/09 financial year, and 1813 clients made use of the needle exchange services. This is probably due to clients in treatment not admitting to 40 of 73

41 using needle exchange facilities as this would imply that they were using street drugs whilst receiving scripted treatment. The district breakdown is shown below. Of these 1813 clients, it is estimated that none were in structured treatment. The chart below shows that 42.7% of syringe returns are within Cambridge City, however, the majority of clients actually come from the Wisbech area, with there being a gap of roughly 20% in numbers in Cambridge. This therefore implies that those injecting in Cambridge do so more regularly than, for example, in St Neots, with an average of 10 ¼ needles being used by each client in the former, and those in the latter using 1/6th of a needle each. Cambridge City Huntingdon St Neots Wisbech Total Number of syringes returned % % % % % Number of clients using the service % % % % % Last year, client feedback indicated that people felt that only 17% of pharmacy clients felt the appropriate equipment was supplied. Addaction have now changed suppliers, and have developed service level agreements with pharmacies which includes a request to identify a champion from each pharmacy to be responsibly for the needle exchange services. In return, Addaction offer relevant training on issues around safer injecting, BBVs and general drug awareness. Needle packs being supplied at NEX points have also been changed, offering items such as vitamin C, and being made to be more discreet in packaging size. This is set to be a significant part of the 2010 programme, where the services will be re-examined through a new survey, which can in turn feed into the 2010/11 treatment plan. Figures updated in March 2009 shows that there were 30 needle exchange pharmacies in the county, 8 in Cambridge City, 9 in Fenland, 5 in East Cambs, 9 in Huntingdon and none in South Cambs. 41 of 73

42 Blood Borne Virus (BBV) Interventions Through the tendering process in 2008/09 it was agreed that Addaction would have a team that specialised in BBV interventions. This newly formed team is working towards addressing gaps in BBV intervention and support. The Cambridge Access Surgery is currently being used as a location for testing and vaccinations. We therefore anticipate that over the coming year there will be significant improvements in numbers being recorded due to the stabilised service on offer through the Access Surgery; however due to the initial difficulties encountered, current numbers are not impressive. It is now a current target of Addaction to have 50 Hep B tests completed over the year, and for 150 Hep C targets to be carried out, a target which is on course to be met. A BBV Performance Management Plan has been developed to address issues regarding the BBV Service, which includes goals to supply 1 practice nurse in the Cambridge Access Surgery, to run fortnightly BBV clinics at Mill House from 2-4pm in Wednesdays by the end of July All districts in Cambridgeshire will provide pre- and post- counselling for clients, to be conducted by Addaction staff. Harm reduction pocket-sized leaflets have been developed outlining risk around needle use, disposal and exchange points, and guidance on drug overdosing. Social workers are also receiving training on drug awareness, safer injecting and BBV interventions. This includes raising awareness of NARCAN 3, an opioid antagonist, and the possibility of training substance misusing clients on its use is also being considered. With regards to Hepatitis B, 295 clients exiting the system have no record of their status (72.5%). In 2008/09, 39% of those who entered treatment were offered a Hepatitis B vaccination. For the first quarter of 2009/10, this has risen to 53%. It is an ongoing target to ensure all drug users that present as a current of previous injector should be offered a personal test for Hepatitis C if they do not know their Hepatitis C status. However, in many cases it is not recorded on a client s file whether or not they have been offered a vaccination, which has resulted in a lower percentage recorded. This needs to be addressed. The percentage of clients that had a Hepatitis C test has significantly increased from 2007/08, from 18% to 37%. For the first quarter of 2009/10, this percentage has again increased to 42%. This demonstrates a significant improvement in the promotion of BBV services. Hepatitis C screening takes place through Addaction, and further measures are ongoing to improve recording of screening by staff, through additional training and support. Through NDTMS data we see that, on treatment exit, of 407 clients only 37 have recorded Hepatitis C status as being tested. This amounts to 9.1% of those leaving treatment. Only 1 of those 82 clients having a planned exit has been tested for Hepatitis C. This is alarmingly low, but is partly due to issues around data recording, which is to be addressed in the forthcoming year. It is estimated that 27.6% of those in treatment inject and were offered a Hepatitis C injection. The above data suggests that clients in Cambridgeshire would benefit from continued improvements in Hepatitis B and Hepatitis C interventions. The expansion of the open access service would improve the accessibility and availability of this service to more clients. 3 NARCAN 42 of 73

43 Drug-Related Deaths Since 2003 the Office for National Statistics (ONS) has produced reports on the numbers of drug-related deaths across England. The most recent report produced enabled the development of the graph below (Fig.20). This shows the numbers of drug-related deaths between 2001 and 2007 for each area within the eastern region Drug-related Deaths, Southend-on-Sea Peterborough Norfolk Luton Cambridgeshire Thurrock Bedfordshire Essex Hertfordshire Suffolk 0 DRDs 2001 DRDs 2002 DRDs 2003 DRDs 2004 DRDs 2005 DRDs 2006 DRDs 2007 Cambridgeshire Drug related deaths, St George s Hospital Medical School, 2008 Within Cambridgeshire, the numbers of drug-related deaths in 2007 have fallen from those recorded in However, as is the case for the region as a whole, numbers have been on the rise since 2004, and the 39 deaths in Cambridgeshire over the seven year period is higher than projected (37.3). Compared with other DAATs in the region, Cambridgeshire s mortality rate per 100,000 population is 2.66, which is slightly higher than the regional average of Information recorded regarding drug related deaths across the region is limited and therefore impedes in-depth analysis. An improvement in data collection and analysis would benefit the CDAAT, enabling a more efficient review of processes and potential prevention methods. 43 of 73

44 Connected Services Probation Services The key roles of the Cambridgeshire Probation Areas (CPA) are to assess the risk that offenders pose to the local community, and to supervise and rigorously monitor their progress. The CPA supervises offenders on community orders and on licence on release from custody. It operates highly effective programmes 4 which aim to tackle the roots of offending, delivered by specially trained personnel. An Offender Substance Abuse Programme helps offenders to move away from the abuse of drugs and alcohol through group exercises, discussion sessions, problem solving techniques and self-assessment. In partnership with other agencies, CPA manages Prolific and other Priority Offenders (PPOs), in particular those on the 'Resettle and Rehabilitate' strand. Given the prevalence of drug misuse amongst this group, CPA ensures that relevant offenders are referred to the Drugs Intervention Programme. The service works closely with partner organisations to ensure a more integrated move away from offending, for instance in helping offenders develop employment-related skills or in finding and sustaining accommodation. CPA has recently entered into a partnership, funded by the Ministry of Justice, with the Women's Centres in Cambridge and Peterborough to develop programmes and interventions that address the specific needs of women offenders and those at risk of offending. Over the past ten years there has been a notable shift in the ways that substance misusing offenders are treated, from a focus on the health perspective to one that recognises involvement in the criminal justice system as a legitimate catalyst for treatment 5. The widespread use of drug treatment as a requirement of a community order for offenders has increased. In order to fund the additional costs of delivering Drug Rehabilitation Requirements (DRRs), compared to the delivery to other drug misusers, the Ministry of Justice makes a financial contribution to the Pooled Treatment Budget. In contrast, there are fewer treatment services available to address alcohol misuse. Main Drug Count % Total Heroin % Cannabis % Crack/Cocaine % Cocaine Hydrochloride % Amphetamines % Methadone % Benzodiazepines % Other % Misused Prescribed Drugs % Other Opiates % Steroids % Total % 4 5 Probation Inspectorate Report On Substance Misuse Work With Offenders - 'Half Full And Half Empty' Home Office of 73

45 About a quarter of offenders starting supervision are identified as having a drug problem associated with their offending. In 2008/09, 80.5% (29 of 36 clients) of offenders on a DRR have also been assessed as having a potential alcohol need. The above information gives outcomes of the drug needs analysis made where the offender was on an active DRR in the 2008/09 period. The data only records those offenders that could be matched to CDRPs using supplied postcodes. A small number of offenders, therefore, are not recorded here, either due to an unmatched postcode or those with no fixed abode. Within this group of 375 offenders, further questions were asked around the frequency of drug use, measured by each drug type, and therefore enabling an analysis of those who took substances beyond those listed as their primary drug. This included those who listed other as being their main drug used over the last 6 months. The following pie charts demonstrate the frequency of use for heroin, cannabis, and crack/cocaine. Frequency of Drug Use: Heroin 29% 38% 2% 7% 9% 15% Daily Monthly Occassional Weekly Not Specified Not Used Frequency of Drug Use: Crack/Cocaine Frequency of Drug Use: Cannabis 7% 2% 9% 11% 18% 1% 1% 53% 13% 70% 1% 14% Daily Monthly Occassional Weekly Not Specified Not Used Daily Monthly Occassional Weekly Not Specified Not Used 45 of 73

46 Drug Treatment System Data and Hospital Episode Statistics In November 2008, the Regional Drug Health Information Unit carried out the data matching exercise to analyse the demographic profiles of those individuals who are known to both to the drug treatment system (as recorded by the NDTMS) and Hospital Episode Statistics (HES) as having a drug-related condition. This group was then compared with those individuals who appear in HES, but who are not currently engaged within the drug treatment system (NDTMS). This comparison is not due to be carried out in 2009, but the 2008 information still paints a relevant picture of the current position. Two matches are examined: 1. Exact Match Individuals who have identical date of birth, sex, and postcode (using full outcode and first digit of in-code, i.e. NR30 1). 2. Fuzzy Match Matched on sex and postcode, allowing for an error in one of the units of the day, month or year of the date of birth or transposition of the days and months (i.e. these rules considered 12/03/64 and 13/03/64 to be a match, equally 02/03/65 and 03/02/65 were considered to be a match). Matched on postcode and date of birth allowing sex to be different. Combination errors will not be considered to be matches. Fuzzy match results are shown below: Age Male Female Total Total % < % % % % % % Total % Total % 64% 36% 100% d e 120 a tch 100 m 80 a ls u id 60 iv d in Cambridgeshire Female Male under Age band (years) Matched cases: Known to both HES and NDTMS 46 of 73

47 Age Male Female Total Total % < % % % % % % Total , % Total % 49% 51% 100% Cambridgeshire Female d e 250 Male a tch m u 200 a ls u 150 id iv d 100 In 50 0 under Age band (years) Unmatched cases: Known to HES but not matched to NDTMS In Cambridgeshire, 24% of HES cases (385 out of 1,631) could be matched with an NDTMS case. This is slightly lower than the East of England average of 28%. This demonstrates that in Cambridgeshire a lower percentage of those admitted to hospital with a drug-related diagnosis were receiving treatment to help them with their drug misuse problems than the percentage for the Eastern region. The age:sex distribution of matched cases in Cambridgeshire is typical of the region as a whole, with a peak at ages 25-34; whereas in the unmatched cases there are similar numbers in ages 18-24, 25-34, and A high number of cases are male (64%), which again contrasts against numbers recorded in unmatched cases, where there is an even balance of males and females. This is atypical of the regional picture. There are very few hospital admissions for those aged under 15, and it is likely that a large proportion of these cases are a result of accidental rather than regular use of drugs. The numbers of cases occurring in individuals aged over 45 is also small and decreases rapidly, suggesting that at this stage of their lives more individuals have stopped misusing drugs. Recent examination of drug-related admissions to hospitals show there has been a drop in the numbers aged 9-17 years being admitted. However there has been little change for those aged years hence, whilst there is an overall improvement in numbers, we still need to address adult admissions. Annual rate (crude) per 100,000 population 9-17 yrs yrs 9-74 yrs 2006/ / / / / / / / / By examining data at a local level, we see that the numbers of adult admissions within Fenland are of the most significant concern, with numbers rising from 95.4 to per 100,000 between 2006/07 and 2008/09. Huntingdonshire demonstrates the most significant reduction in numbers, from 77.8 to 53.2 per 100,000 population. The map overleaf shows place of residence for those individuals who were admitted to hospital with a drug-related condition and whether they were known to the drug treatment system. Similar to other DAATs in the region, Cambridgeshire sees 74% of matched and 76% of unmatched postcodes were within 5 miles of a drug treatment agency which 47 of 73

48 suggests that an individual is no more likely to be known to the treatment system if they live closer to a treatment agency. Cambridgeshire Addenbrookes is the main hospital in Cambridgeshire, serving Cambridge City, South Cambridgeshire and many other surrounding areas. Addenbrookes recently conducted research into the drinking behaviours of people admitted to A&E, funded by GO-East. It should be noted that this was not a survey of under 18s, as ethical approval was only gained for a study of over 18 year olds. The scope of the project was based on what is known as the Cardiff model, which addressed how information sharing between hospitals and CDRPs could help prevent alcohol related hospital admissions. It was originally 48 of 73

49 piloted to try and address the effects of pre-loading 6 on binge drinking, and to then examine the incidents that binge drinking can be connected to. This information could then be used to inform and educate licensed premises on the effects of underage drinking. An anonymous cross-sectional survey was conducted, interviewing all self-referred adults arriving at the emergency department of Addenbrookes hospital. Interviews took place between 22:00 and 02:00 (night) and 10:00 and 14:00 (day) at the weekend over eight weeks in the autumn of Those who were too ill to consent, unable to speak English or unwilling to be interviewed privately were not included. 58% of respondents were male, with the average age being 32 years, and 98% being White-British. 9% of daytime admissions and 42% of night-time attendances were alcohol related eligible patients 49 declined consent 992 non-eligible 10 were too ill 8 unable to consent 22 incomplete data 245 alcohol related attendances in study 161 had drunk alcohol away from a private residence 245 people were included in the study, and the main findings were that 40% of attendances were due to accidents, 27% due to assault, other 16%, 9% were incapable and 8% were for self-harm. These were the lowest ever recorded alcohol related A&E attendances in the UK. However, the study had limitations, in that Cambridge can only be directly compared with Liverpool, and only one site was studied. It did not gather any accurate data about the precise amount of alcohol consumed by people, and therefore, there are issues with reliability and usefulness of the data. However, the study did inform us that: 34% of patients developed the alcohol related problem at the site where they had done most of their drinking Pre-loading was not higher in any age group or patient category The proportion of pre-loaders was lower than the Liverpool study. Pre-loading is not a particular risk for alcohol-related A&E attendance. Pre-loading is consistently higher in women than men. Due to the low instance of pre-loading, efforts to control alcohol-related harms should continue to be directed at licensed premises. The industry has a duty of care to patrons who are injured as a result of alcohol consumption on their premises. The industry also needs to be aware that harms usually occur away from licensed premises where the majority of alcohol has been consumed. 6 Preloading : A phenomenon where people drink cheaper alcohol at a private residence before going out to clubs and/or pubs. 49 of 73

50 GP Registrations In June 2007, the number of people registered with a GP practice located within Cambridgeshire was 594,000. However, only 574,000 of these people were resident in Cambridgeshire. Similarly, some Cambridgeshire residents are registered with practices outside the county. The table below outlines the age structure of those registered with Cambridgeshire GP practises in October We can see that the majority of those registered are of working age. It should be noted that not all the population of Cambridgeshire will be registered with a GP, and this is more the case with migrant workers, as explained later in this report. Numbers registered with Cambs GP Practices October Ageband Female q Male GP registered populations, Oct 2009: Source: ASP Exeter 50 of 73

51 Housing Support Stable accommodation can be crucial to a successful treatment journey and a client s reintegration into mainstream services. It is especially important for a client to have a stable environment when exiting the treatment system. Homelessness can also act as a barrier to clients accessing some treatment services. For example, if a client is identified as being homeless, supervised consumption services will often be offered in place of a general prescription. Many clients are therefore not inclined to disclose housing problems, especially when engaging with prescribing services. Equally, it can be difficult to acquire housing support if a client has substance misuse issues. Whilst a client would not be banned from homelessness accommodation services, providers will have rules and policies in place which would ban substance misuse on the premises and encourage the applicant into the treatment system. Most have particular criteria that a potential resident must meet before they are assessed on suitability and need. In Cambridgeshire, the following accommodation-based services are available to people with substance misuse problems through the English Churches Housing Group: 222 Victoria Road 74 places Move-on House (Cambridge) 27 places Willow Walk 22 places Additional accommodation-based services are available to vulnerable adult groups such as the single homeless. However none of these specialise in people with drug problems, even though a number of their clients may very well have drug problems as well. One example is the Ferry Project 7 in Wisbech and March, which maintains 86 beds, providing shelter, support and guidance to the homeless. All people who access Supporting People (SP) services are sorted into client groups (e.g. homeless, alcohol or drug problems). Each person has a primary client group and according to need they can also be assigned a secondary client group. In 2008/09, 67 clients were classed as people with drug problems as their primary group. 80 clients were classed as people with alcohol problems as their primary client group. An additional 146 people with drug problems not picked up through primary client group. 237 clients were classed as people with alcohol problems as secondary client group, 6 of these also having drug problems as primary client group. People who fall in the primary client group People with Drug Problems are generally younger (25-39) than people in the primary client group People with Alcohol Problems (35 44). 7 Ferry Project. Luminus report, page of 73

52 Housing Support: Needs Analysis In November 2008 CIVIS Consultants were commissioned by the SP Team in Cambridgeshire to develop a model to project the housing support needs for each vulnerable client group within the SP programme. The model looks at populations at risk of needing housing support, and then examines those within this group who will be in need of housing support, taking into account future population fluctuations. It should be noted that this type of needs mapping is not an exact science but a method of bring together different sources of data to develop a hypothetical picture of need. Overall, the analysis indicated that demand exceeded supply for people with drug and alcohol problems. This will be examined and addresses through future commissioning in There is a potential need for an additional 55 units for those with drug problems. It also showed a low level of theoretical supply of floating support for this client group, where there is a potential need for an additional 107 units. Assessing isolated client groups can give a very narrow perception of need as, for example, one cannot assess those with both offending and substance misuse needs. It is therefore more useful to look at supergroups to give a broader understanding of need by bringing together a range of client groups. If the client supergroup definitions of Drug Problems and Alcohol Problems are combined with the client groups Single homeless, Rough sleepers and Offenders, analysis shows a low level of theoretical supply of accommodation-based support. There is a potential need for an additional 83 units. However there is also a high level of theoretical supply of floating support. This means taking the groups together we probably have enough if not slightly too much floating support. Outcomes Information All SP providers are required to report on the outcomes achieved for each service user once they leave the service. This provides a picture of the needs of the clients. 32 outcomes forms were completed for people with drug issues in 2008/09. The most common needs people presented with were: Support to better manage substance misuse 29 Support to comply with a statutory order 20 Support to maintain accommodation 17 Support to maximise income outcomes forms were completed for people with alcohol issues in 2008/09. The most common needs people presented with were: Support to better manage substance misuse 41 Support to maximise income 35 Support to better manage physical health 35 Support to maintain accommodation 28 Addaction has two Accommodation officers and CDIP has two part-time housing workers and one resettlement worker employed by Luminus working on-site. However, accommodation needs will still remain one of the most difficult task that requires a multiagency approach. 52 of 73

53 Employment The national strategy Drugs: Protecting Families and Communities 8, identifies the primary focus for drug treatment services as being as helping individuals overcome drug dependency, enhance their life experiences, improve the contribution they can make to the community, and minimise the risks they pose to themselves and others. Training, skills and employment opportunities are central to the achievement of these ambitions, and jobcentres have a significant role to play in this. It is therefore important that strong links are maintained between Jobcentre Plus, the services it provides, and the key agencies involved in drug treatment and support within Cambridgeshire. Prevalence estimates developed by the Home Office suggest that of the 19,174 problem drug users in the East of England approximately 15,340 (80%) are unemployed, and that of those 7,670 (50%) are not currently engaged in treatment. Jobcentre Plus has an important part to play in identifying potential service users and helping them in on the road to overcoming addiction, thus leading healthier and safer lives and supporting their social reintegration. Studies show that 80% of people on court orders with drug rehabilitation requirements have unmet skills and employment needs 9 and one in five of those who responded to the NTA s service user survey requested help with education and employment 10. As part of the Department of Works and Pensions (DWP) Drugs Strategy, problem drug users in Cambridgeshire are able to access a number of mainstream and specialist services designed to help them access treatment and incorporate their education, skills and employment aspirations into their drug treatment care plans. Appendix 2 lists the services available to problem drug users in receipt of welfare benefits via a referral from their local Jobcentre. To encourage those who voluntarily declare themselves to be a PDU, a Jobcentre Plus personal adviser 11 can refer them to a drug treatment provider for an initial assessment to discuss their treatment options. To support this process in Cambridgeshire, Jobcentre Plus has also: Introduced District Drug Co-ordinators to work with the drug treatment community to increase the number of problem drug users entering treatment and or accessing Jobcentre Plus services; and Arranged training to ensure that personal advisers can identify suitable customers and refer them into treatment using the agreed referral route way; 8 HM Government (2008), Drugs: protecting families, and communities 9 NTA (2007), Needs assessment guidance for adult drug treatment 10 NTA (2007), 2005/6 survey of user satisfaction in England 11 Jobcentre Plus personal advisers support those in receipt of Jobseekers Allowance. Pathways to Work personal advisers support those in receipt of Employment and Support Allowance which replaced Incapacity Benefit last year. 53 of 73

54 The role of the District Drugs Coordinator includes establishing a clear set of relationships within the drug treatment community; gaining a commitment to the importance of employment in drugs treatment; strengthening referral pathways into treatment, and from treatment into education, employment and training; and establishing single points of contact between Jobcentre Plus and local drug treatment providers. The role of the Personal Adviser will be to establish whether drug misuse is a barrier to employment for the individual. I.e. where a customer identifies problematic drug use as a barrier to their return to work, their personal adviser will assess whether or not they are already in treatment. In instances where the customer has not already engaged with a drug treatment provider they will be offered the opportunity to attend an appointment with Addaction Cambridgeshire. Customers under the age of 18 will also be referred to Addaction Cambridgeshire who will ensure that an appointment is made with the appropriate Young People s Service. Customers who voluntarily agree to attend an appointment will be asked to provide consent for Jobcentre Plus to share details with the treatment provider, namely: their name, national insurance number, date of birth and contact details. In addition, personal adviser in Cambridgeshire have been allocated, where appropriate, time to work with the problem drug user and a relevant colleague from the drug treatment services to examine a client s casework in order to developing a streamlined approach to offering cross-agency support. Whilst the numbers of substance misusers known to Jobcentre Plus is recorded, the quantity and quality of data can be questionable since many clients are unlikely to highlight a substance misuse problem under the concern that it may impede their employment opportunities. Locally, the majority of PDUs brought to the attention of Jobcentre Plus are single female parents on income support. The need to focus on improved partnership working to improve this data will be focussed on in the forthcoming year. The Cambridgeshire Treatment Plan will encourage treatment providers to routinely work with Jobcentre Plus to help meet service users training, skills and employment aspirations. Within Jobcentre Plus, District Drugs Coordinator will work with Addaction Cambridgeshire to develop a route way from treatment into Jobcentre Plus, and will develop a more robust data gathering system in order to develop a baseline against which to measure improvements and contribute to future drug treatment needs assessments. Improved communications with treatment agencies such as Addaction will enable both services to identify areas of focus that will help to improve the level of service offered to problem drug users. SEE APPENDIX 2 54 of 73

55 Vulnerable Groups Migrant Worker Registration There are a number of categories of migrants and they are not a homogeneous group. These categories include temporary labour migrants, highly skilled migrants, irregular or undocumented/illegal migrants, family reunion or reunification migrants, return migrants and forced migrants, which includes refugees and asylum seekers. In 2008 the CCCRG published its report, The Demographic Impact of International Migration in Cambridgeshire, which examined the past and future impacts of international migration on Cambridgeshire s population. Drawing on National Insurance Number Registrations (NINo) and data from the Worker Registration Scheme (WRS), amongst other data sources, the report concluded that the number of migrant workers within Cambridgeshire is amongst the highest in the East of England region. Similarly, the East of England ranks third in the country, after London and the South East. The information headlined below is extracted from that report. The 2001 Census showed that 9% of Cambridgeshire s population were born outside the UK, of which 34% were born in Western Europe, 24% were born in Asia and 20% were born in America. NINo figures indicate that approximately 30,000 people not born within the UK have registered to work since The graph below outlines the numbers of NINos within Cambridgeshire from by continent of origin, and shows an upward trend in the number of migrants arriving since 2002, with a significant spike in numbers of Eastern Europeans from 2005 onwards. This generally indicates the new status in the EU of the A8 Accession States (Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia). The Cambridgeshire County Council Research Group estimates that around 13,100 migrants have become part of Cambridgeshire s resident population (remaining here for at 55 of 73

56 least one year). Of these, around 50% are estimated to be living in Cambridge, 17% in South Cambridgeshire, 14% in Huntingdonshire, 10% in Fenland and 9% in East Cambs. Within Cambridge City, the highest numbers of migrant workers live in Romsey and Petersfield wards. GP registration data suggest that the highest numbers of all migrants live in the Castle, Newnham and Market wards; this reflects the number of overseas students in Cambridge. Within South Cambridgeshire, Cambridge City and Huntingdonshire, the majority of migrants appear to be from Western Europe and Asia. Conversely, in East Cambridgeshire and Fenland, migration is dominated by Eastern Europeans, most likely due to the prevalence of agricultural and seasonal employment. Cambridge City has the highest overall number of work-related migrants within Cambridgeshire. Evidence suggests that numbers of new migrants in East Cambridgeshire, Fenland and South Cambridgeshire may have already begun to decline. Since 2006, there has been a decrease in the number of work registrations in Cambridgeshire. It is not known how long migrants have stayed or how many have returned home but the Report proposes a most likely total by exploring three possible scenarios in which either 30%, 50% or 70% of migrants have either returned or moved to another part of the UK. THE Research group concludes that 70% return is the most likely. In terms of future trends, it is estimated that in Cambridge City, annual numbers of new migrant workers will rise gradually into the future, from around 3,800 per year in 2006 to around 5,400 per year by In Huntingdonshire, we may see a faster increase from 1,300 in 2006 to 3,400 in In contrast, trends in East Cambridgeshire, Fenland and South Cambridgeshire suggest numbers will fall in the future. Overall this implies a gradual decrease in numbers of new migrant workers across Cambridgeshire as a whole, from 8,300 in 2006 to just over 6,000 in Clearly, however, changes in socioeconomic context in Cambridgeshire and the rest of the world have the potential to influence these future trends profoundly. The best indicator of migrant engagement with health services is through GP registrations. A comparison of National Insurance registrations and GP registrations suggests that many people who come to work in Cambridgeshire from overseas do not register with a GP. This is most apparent with Eastern Europeans with just one quarter were registered. This may point to a lack of awareness that they can access primary health services here, or relate to unwillingness to lose wages by taking the time to visit a doctor during working hours. This can also be due to the fact that many intend to remain within the country on a temporary basis only. Anecdotal evidence from Polish support groups within the county suggest that the main reasons for non-engagement with GP services include: Lack of awareness. New arrivals can be unsure of where and how to register with health services. Some migrants report difficulty in successfully registering their details on arrival at surgeries. Differences in services. The general set-up of the health system in this country is very different to that within Poland and can therefore not meet expectations. There is a preference to speak with GPs who speak their language, and therefore many either return to Poland for any treatment, or go to London to visit Polish doctors in private clinics. Within the wider population, it is typical for there to be a lower engagement rate with health services by single young adults, especially with males, than by those in a higher 56 of 73

57 age group or with children. Since most Eastern European migrants fall into this group, the lower number of registrations could also be a reflection of typical population statistics. With regards to substance misuse, as with any community, it can be a very sensitive issue to discuss with new or existing migrants alike. Few are willing to admit they have a problem, and if they do, they face a further hurdle of identifying how and where to seek support. Alcohol is typically the main substance of use both nationally and locally for these groups, although drug use has also been found. This picture is supported by data available through Cambridgeshire treatment agencies. Issues connected to alcohol and drug misuse include long hours of work, loneliness, and isolation. These correlate with some of the issues identified by Cambridgeshire clients in treatment. All of the above figures show that migration is a main driver of population growth in Cambridgeshire in the future. As this group tends to have low engagement with the health services, as explained above, there is a risk that any substance misuse treatment needs could be overlooked. Sex Workers The Sex Workers Rights Advocacy Network (SWAN) 12 is a network of civil society organizations engaged in advocating the Human Rights of the sex workers in Central and Eastern Europe, CIS and South-East Europe who wish to approach sex work issues in accordance with the following basic principles developed by the Central and Eastern European Harm Reduction Network (CEEHRN). A SWAN group exists in Cambridge City, with representation by approximately agencies. Members range from the police, healthcare services, substance misuse services, and the Cambridge Women s Resource Centre. Two meetings have been held so far, with decisions being made on the group s objectives and direction. The aim is to establish the extent to which sex work exists in Cambridge, and to ensure that the right referral pathways and services are accessible to women in these situations when they need them. They aim to learn from Ipswich SWAN, which is already well established, and linked into its local Sexual Abuse Referral Centre, where women who have been victim of rape or sexual abuse are taken for assessment and support. Currently, the SWAN is working towards widening their understanding of local sex worker populations. They are aware of various groups, including Polish, Chinese and local Cambridge women. However, whilst there are concerns amongst some members that there are under 18s at risk across the city, there is no formal intelligence available at this stage to confirm anyone s fears or suspicions, so there is no data which suggests that young sex workers should be a priority group to be targeted with substance misuse services in Cambridgeshire. However, we also cannot be sure that there are no vulnerable girls aged under 18 who are in need of substance misuse support and who are also involved in sexual exploitation. 12 SWAN 57 of 73

58 Support for Parents /Families /Carers & Significant Others Carer Support Therapeutic support groups have been set up for anyone who is affected by someone close to them who misuses drugs. These groups are in the process of being rolled out across the county for carers and significant others by Addaction. The aim of the group is to give carers an opportunity to meet others who are in similar situations, and therefore to act as a support network. The groups are advertised as safe and confidential places to discuss particular difficulties and work through how best to deal with whatever issues clients are facing. The groups would also give carers the opportunity to feedback their experiences and to identify ways to hone future services to be more effective. The groups give clients the opportunities to: Learn ways to live with and manage their emotions Listen to and learn from each other s experiences Learn how to remain loving and supportive whilst not colluding with the worrying behaviours Re-claim the right to a life that has nothing to do with all the problems and difficulties Support groups currently exist within Chatteris, with aims to form further groups in St. Neots, Cambridge, Wisbech and Ely. The aim would be to structure the groups sequentially to enable individuals to access more than one group per month if preferred. The groups would be advertised widely through posters, leaflets and literature. The existing group in Chatteris offers a range of support services including couples therapy, 1- to-1 and group support as necessary. Harm reduction and awareness training would be provided to each group throughout the year, and the possibility of moving into more generic carer support through social workers and main grade staff is organised. Substance-Misusing Parents According to a government report, interviews with the children of drug users indicate that children s understanding of their parents drug problems typically falls into place around the age of Due to poor parental supervision and role modelling there is a high risk of experimentation with smoking, drinking and drugs. Substance misuse at an early age is strongly associated with both parental drug use and associating with a delinquent or drugusing subculture. Taking the same road to problem drug use as their parents is thus a real possibility. At the age of 15 and over, substance misuse by those whose parents have serious drug problems becomes ever more likely. Teenage offending is also strongly associated with early substance misuse 13. In discussions we have with the young people s 13 (Hidden Harm Responding to the needs of children of problem drug users, Advisory Council on the Misuse of Drugs, 2003) 58 of 73

59 treatment agencies they have raised this as one of the key concerns and it was felt that CDAAT has not done enough to safeguard this highly vulnerable group. A Parental Substance Misuse working group has been set up that is attended by representatives from Addaction, social care, school nursing, health visiting teams and midwifery. CDAAT hopes to improve communications between agencies, in order to improve the safeguarding of the children of substance misusing parents. The group will address the 48 recommendations of Hidden Harm and aim to investigate how well we are doing locally against these. The group has met twice, a protocol between adult drug services and children s social care is already being planned. Referral routes from the county council s Contact Centre (which is the first port of call for all enquiries made to children and young people s services) into social care are also being examined. Safeguarding also plays a large part in the development of priorities for service plans within Childrens Social Care. Data relating to the numbers of children living with substance misusing parents is scarce due to the uptake of new recording systems within Childrens Social Care. It is a goal that for 2010 we will examine ways to continue to record this information, developing ways to analyse and improve upon effort made around preventative and supportive treatment routes. The chart below outlines how numbers have increased between December 2005 and March child with alcoholic parents child with drug taking parents Numbers of children who live with substance misusing parents, Office of Children and Young People's Services, 2008 We also have a certain level of understanding about what social services involvement is in cases where the parents are in specialist treatment. Between July and September 2009, Addaction conducted an audit of 30 case files where clients were recorded as being parents. The findings revealed that in 16 cases, the family was already known to social services, and there was social care involvement. In eight cases, a referral was made by Addaction, after an assessment, a discussion at team meeting, or after a particular incident that prompted a referral, e.g. disclosure of pregnancy or domestic violence. In the six other cases, a referral was considered but Addaction decided not to go ahead with it, on one occasion a referral was made to social services by another agency, and in others a referral was made to a GP instead of social services. This audit has provided a baseline for further work and progress to be monitored against, but has been viewed as a very useful piece of work as the information gathered about how 59 of 73

60 cases ended up being dealt with jointly by Social Service and Addaction will help to inform future good practice and identify issues that are not working and need to be improved. The chart below outlines information on the parental status of Cambridgeshire residents within the treatment system in 2008/09. It is clear that there has been a significant improvement in data recording this year, with a reduction on case numbers either logged under other, or not being logged at all. Just under a quarter of NDTMS records did not file a parental status. Whilst this is a significant improvement from 2007/08 (50%), this should be taken into account during overall analysis of this data. The most significant increase from 2007/08 has been with regards to the number of clients with no children, which has increased by 13%. Client Parental Status Episodes % Not recorded % No children % Children living with client % Children living with partner % Children living with other family member 82 4% Children in care 26 1% Client pregnant 6 0% All children live with client 4 0% Some of the children live with client 0 0% None of the children live with client 6 0% Not a parent 6 0% Other 83 5% Client declined to answer 0 0% Total episodes % Cambridgeshire Parental status, 2008/09 60 of 73

61 Public Opinion There are a variety of ways in which we analyse public perception of services available, their effectiveness, and the perceived community impact. Nationally, there are a variety of indicators relevant to the prevalence of substance misuse, ranging from those relating to specific drug offences, numbers in effective treatment, antisocial behaviour and reoffending rates. These are analysed in greater detail within the 2009 Adult Treatment Plan. Locally, we have also conducted a variety of surveys over the year. The Place Survey The Government requires all local authorities in England and Wales to carry out 'The Place Survey' on a yearly basis. Of the 15,300 households who received the questionnaire, 39% responded (5,925).The results were then used to examine the public perception on a number of issues relating to council services, with some also feeding into yearly NI (National Indicator) data submissions. The national results of the 2008 survey were released in June % of Cambridgeshire residents felt that drug use or drug dealing was a problem in their local area, which is well below the England average of 30.5%, and is an improvement on last year (42%). 41% of respondents felt that drug use or drug dealing was not a problem in their area, with a further 35% judging it to be a minor problem. Only 7% felt it was a major issue. 24% felt that the use or dealing of drugs was the biggest anti-social behaviour problem in the local area. These estimations were fairly evenly balanced across gender, ethnicity and age groups; with the only notable difference in opinion coming from those aged 18-24, who on general felt it was less of an issue. Drug/Alcohol Survey for Community Beat Managers In September 2009 a drugs and alcohol survey was carried out with Community Beat Managers. The majority of officers came from Central Division. 8 officers completed the survey over the month. Due to the very small number, these have therefore not been formally analysed. However, key findings were as follows: A main area of concern with regards to substance misuse was raised around underage purchasing and the use of rural areas to use drugs (such as isolated fields), with problems typically reaching a peak on weekends. Alcohol and Cannabis were seen to be most prevalent, especially within the Central divisional region. St Ives was deemed to have a significant heroin problem. For officers in all areas, drug misuse was an issue that appeared more than once a week. Drug users were typically younger, aged under 25 and often male, whereas dealers were in all cases described as being males aged over of 73

62 Concerns were raised around there being a strong focus on acquisitive crime in place of direct county focus on drug crimes, leaving local officers to address street dealers without the potential to investigate middle level dealers. It was also felt that there was an over-emphasis on heroin users, and less support for those taking softer drugs such as cannabis. The greatest issue raised by all was around alcohol misuse and the significant issues this raised within communities, such as ASB and violent crime. National Drugs Week 2009 Stalls were set up at central locations across the county during National Tackling Drugs Week in early June to raise awareness of issues around substance misuse. Alongside this, the CDAAT carried out a survey in order to gather public opinions about substance misuse in their neighbourhood. Please see appendix 1 for the questionnaire. All responses were evaluated accordingly, both countywide and locally. All percentages are recorded to within one decimal point. Some respondents did not answer all questions; however percentages have still be taken against the total number of respondents to ensure a balanced picture. Therefore, some of the chart percentages may not add up to 100%. The outcomes of this consultation will be used to inform the decisions taken by the DAAT regarding future strategy and direction. 226 people from across the county responded to the survey. 57% of respondents were female. As indicated in the chart to the right, the majority (44.3%) were aged between years. Age Percentage <18 9.7% % % > % The first part of the survey asked respondents to consider three priorities and to analyse them in order of importance. As you can see, people felt, by far, that it was most important to address issues around young people (66.9%) Respondents were least concerned about the treatment of drug users, with mixed views concerning the need to target drug dealing in communities. Priority % respondents who consider this to be the most important issue % respondents who consider this to be a secondary issue Young People 66.8% 21.2% 9.3% Treating drug users 22.6% 28.3% 45.6% Targeting drug dealing 41.6% 36.7% 19.0% % respondents who consider this to be the least important issue The second part of the survey invited people to give their opinion on four potential concerns around substance misuse in their communities. Respondents were given the option of 5 responses ranging from very concerned to not concerned atall. Percentages calculated are specific to the type of response each concern. 62 of 73

63 Concern Use of illegal drugs Drug dealing in your community Underage drinking Alcohol-related ASB % very concerned % concerned % with some concern % a little concerned % not atall concerned 24.8% 25.7% 17.3% 13.7% 12.4% 27.4% 19.0% 19.5% 12.4% 13.3% 33.6% 24.8% 19.0% 10.6% 9.7% 38.5% 26.6% 15.5% 8.8% 7.5% On the whole, drinking issues raised more concern than those around drugs. By combining the very concerned and concerned responses, we see that 65.1% expressed concern around alcohol-related ASB issues, and 58.4% highlighting their concerns about underage drinking. This is in contrast to against 50.5% concerned about the use of illegal drugs and 46.4% who felt concerned around drug dealing in their community. 63 of Client Satisfaction Survey In October 2009 CDAAT carried out a confidential survey with clients of substance misuse services within Cambridgeshire. Questions ranged from overall satisfaction, service availability, harm reduction issues, and treatment retention. 114 clients were interviewed. 94% of these were white, and 73% were male, with 15% living with a child aged under 16. Most respondents felt services have improved since the amalgamation of the treatment processes, and the majority felt that in-house detoxification, preferably away from Cambridgeshire, would be of most benefit. The chart below lists the substances clients recorded themselves as using. Since many were taking more than one drug, the amounts will be significantly higher than the number of clients interviewed. Heroin: 69 Cocaine/Crack: 22 Cannabis: 16 Alcohol: 10 Amphetamines: 2 Ecstasy (MDMA/pills): 2 Other: 17 Outcomes: The DAAT service user survey indicated that 49% (58) of respondents were positive about the effect the substance misuse service they had accessed had had on their lives. 31% (36) were very positive. 9% (10) said it was negative or had no effect. 17 clients considered themselves to be clean, with periods of abstinence ranging from a number of weeks to 30 years. Retention: Additional evidence from the 114 service users that replied to the DAAT service user survey indicated that 32% (37) reported that they had been in contact with treatment services for between 1 5 years with 26% (30) service users reporting over 5 years in treatment. Other comments raised during the interviews included a concern

64 about waiting times, either to enter the service, be referred into treatment, or when being moved into Tier 4 support. Harm reduction: The DAAT service user survey asked Do you think that you are provided with enough information regarding minimising the risk of harm? The overwhelming response was yes. Many clients commented on the low availability of inhouse detoxification provision. The DAAT service user survey asked for reasons respondents might have left or dropped out of service in the previous 12 months. Although there was a low response rate, reasons included moving areas, failing a treatment and returning to prison. The DAAT service user survey reported that 35% (40) of respondents thought that services had improved in the last 12 months, 21% (24) said services had remained the same. 15% thought services had got worse. Concerns were raised during interviews about the degrees of support offered by caseworkers, including concerns about availability, ease of access and difficulties when being transferred to a new caseworker. KISS FM Survey In June 2009, Cambridgeshire DAAT jointly funded some radio advertising that raised awareness of FRANK on KISS FM. A competition was promoted on the radio, and in order to enter, young people had to complete a survey about their drug use via the Kiss FM website. 34% of people who completed the survey were from Cambridgeshire. Others primarily lived in the neighbouring areas of Suffolk and Norfolk and far smaller proportions of respondents were from Essex, Lincolnshire and Northamptonshire. All responses can be considered to be of benefit however, since people do travel across these counties and people who live outside of Cambridgeshire may well be going to services within Cambridgeshire. 68% of respondents were female and 32% male. The survey was open to all age groups and therefore, some responses were from under 18s. Age % 16 and under 18% % % % 35 and over 7.5% Respondents were asked whether they or their friends are taking drugs at the moment. 46% said yes and only slightly more (53%) said no. The chart to the right outlines responses to the question Which of the following drugs are you or your friends taking at the moment? 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Cocaine Cannabis Crack Ecstasy Heroin Ketamine Poppers Speed Solvents Other Me My friends 64 of 73

65 In terms of how much money, people estimated that they or their friends spend on drugs every month, the majority (31%) stated that they spent A far smaller proportion (8%) stated that they spent per month on drugs. 93.5% said they took drugs with friends. When asked whether they were aware of the side effects and risks of certain drugs, as shown in the chart to the right, respondents ranged from being very confident about certain substances (such as cannabis) to having far less knowledge about others (poppers and Ketamine). Other None of the above Solvents Speed Poppers Ketamine Heroin Ecstasy Crack Cocaine Cannabis 0% 20% 40% 60% 80% 100% 65 of 73

66 Recommendations and Analysis of Unmet Need Data analysis has defined the population of Cambridgeshire and identified the numbers in treatment and the nature, scale and likely whereabouts of those predicted as requiring treatment but not engaging. Gender, ethnicity, age and other socio-economic data was also reviewed to ascertain the level of representation of sub-populations in treatment. Key points of unmet need have been identified as follows: 1. Data Accuracy A primary issue which arose within this needs assessment has been the need for improved data quality across the board. This should be addressed over the coming year, and underpin all further targets. A primary example of this is that the NDTMS bullseye data suggests that we have only a potential 20 clients outside of the treatment / CDIP systems. The need to improve quality of data recording (NDTMS) to ensure it effectively supports future planning and commissioning, e.g., parental status, accommodation status, residency of those in treatment, needle exchange etc Ensure that sufficient data is submitted by agencies to the NDTMS to ensure data is of greater value, especially for future needs assessments. Look into the development of specific data records to set a baseline to measure improvements with interlinked services. JC+ will be looking into ways to improve data recording processes with frontline staff 2. Communications Communications between services and peripheral organisations (Housing Services, Jobcentre Plus) have improved over the year, and should continue to strengthen in Although the implementation of IDTS is in its early stages within Cambridgeshire, it is recommended that attention is paid to communications within prisons and community services. This will serve to improve client transitions from one service to the next. There is a disparity between the numbers recorded on HES and those known in treatment. This should be addressed over the next year, to ensure that more of those known to hospital admissions are, where necessary, also moved into the treatment system. Work with housing agencies to ensure a continued positive relationship with treatment services, and to maintain the awareness that secure housing is an important element to moving clients through the treatment system to a positive conclusion. Improve multi-agency communications such as those with social care to boost referral rates and ensure the safeguarding of vulnerable children and adults. 3. Improved Provision and Capacity - within all steps of the treatment process The client survey raised many positive areas of the system. Those outside of the system have similar reasons for not seeking help. Stigma needs to be addressed The partnership has identified that the local treatment system is good at attracting and engaging with problem drug users, but that too few people successfully leave treatment. There are people who have been in treatment for many years and it is 66 of 73

67 possible that in some areas, too little emphasis is based upon the attainment and maintenance of abstinence as a goal of treatment. Whilst this is a common picture across not only the region but also the country, it is still a topic that should be addressed. Client numbers in longer-term treatment are currently being investigated as a result. Planned discharges. In 2008/09, 415 clients left the treatment system. Of these, 78% had an unplanned discharge. A review of Care Planning and treatment pathways would support improvements in treatment exits. Addaction have developed a Performance Management Plan focussing on Planned Discharge issues, and DAAT have set services an aim to increase the numbers of planned discharge rates to 40% by the end of 2009/2010. Work with the Community Safety Partnerships to promote drug treatment services and seek to ensure that every local neighbourhood has at least one GP practice that participates in the Shared Care scheme. CDIP services are improving significantly, as demonstrated by the findings outlined in this needs assessment. Following the retendering of the service, this should further promote the interlinking of treatment pathways. Look at ways to continue to increase the numbers of PDUs known to treatment services, and to reduce the numbers that are unknown We currently have a very low number of cocaine users presenting themselves to the treatment system. However, prevalence of its use is being monitored, especially amongst the younger age groups. 4. Needle Services Exchanges, Virus Testing and Support The continued promotion and enhancement of Harm Reduction with a consideration of attracting poly-drug users into services has proven to improve services. Harm reduction services must be made available to all who require them across the treatment system and data records should indicate this. The findings in the needs assessment suggest that there is a level of disparity in respect of their general availability and appropriateness. Consistent data collection methods would support more effective planning. In many cases it is not recorded on a client s file whether or not they have been offered a vaccination, or that they have been advised of harm reduction methods which has resulted in a lower percentage recorded. The data suggests that clients in Cambridgeshire would benefit from continued improvements in Hepatitis B and Hepatitis C interventions. The expansion of the open access service would improve the accessibility and availability of this service to more clients. 5. Service User Input Sustaining the developments made in service users, parents and carers support and ensure they have a voice in service review and development. Continue to monitor treatment access in relation to diversity and locality ensuring fair and equitable access to all members of all communities and take appropriate action if gaps are identified. Better access to treatment for crack users, black and minority ethnic communities and parents. This can be addressed through improved engagement with community and faith groups. 67 of 73

68 References Population Forecasts, Cambridgeshire County Council Research Group, 2008 Demographic Impact of International Migration in Cambridgeshire - Cambridgeshire County Council Research Group, 2008 Cambridgeshire Population and Dwelling Stock Estimates: Cambridgeshire County Council Research Group, Oct 2009 Review of Ethnicity in the East of England, Cambridgeshire County Council Research Group, 2005 Estimates of the prevalence of opiate use and/or crack cocaine use (2006/07), East of England Centre for Drug Misuse Research, University of Glasgow, 2008 CELLOmruk: Place Survey Report of Findings for Cambridgeshire County Council Drugs: Protecting Families and Communities Press Release: Street Drug Trends Ormiston Trust/ NHS Cambridgeshire (2008): An insight into the health of Gypsies and Travellers. A booklet for health professionals in Cambridgeshire Crack Users in Treatment in the East of England, 04/05 08/09: MUSE/ERPHO Analysis Drug related deaths, St George s Hospital Medical School, 2008 Improving the quality and provision of Tier 4 interventions as part of client treatment journeys: A best practice guide. NTA, September 2008 Review of Ethnicity in the East of England, Cambridgeshire County Council Research Group, 2005 Cambridge Access Surgery webpage 68 of 73

69 Appendix 1 Appendices

70 APPENDIX 2 Summary of Current Jobcentre Plus Support for Problem Drug Users Jobcentre Plus commissions or provides over 40 different services to support the education, employment, skills and training needs of those in receipt of Employment and Support Allowance (ESA), Incapacity Benefit (IB), Income Support (IS) and Jobseeker s Allowance (JSA). Many of these services will be available to problem drug users from the date that they feel able to share this information with their adviser. Below is a list of services currently in operation that may be available to problem drug users in receipt of the above benefits via a referral from their adviser. P2W (Progress2Work) a voluntary programme, available from day one of unemployment. It provides support for clients who have made sufficient progress in their recovery to be drug free or stabilised, but their history of problem drug use is likely to be a significant factor in preventing them from getting or keeping work. P2W-LinkUP an initiative that builds on the P2W model. It is a pilot that currently operates in almost half of Jobcentre Plus districts. It targets specific disadvantaged groups of clients who face significant barriers in the labour market. This includes clients who have an offending background, including those under probation supervision, those with homelessness issues, and alcohol misusers. Relapse (P2W participant leaves mainstream/new Deal provision) clients attending P2W may at some time relapse in to problem drug use. During these periods the client may benefit from relaxation in current programme rules. This is intended to help maintain participation and re-engage with mainstream/new Deal providers after a period of relapse. It also allows them to leave mainstream/new Deal provision/gateway/follow-through without threat of sanctions (where contact is maintained with the P2W provider). In cases of gateway and follow-through the client will still be required to attend Jobcentre Plus office on a fortnightly basis 70 of 73

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