Developing the Guernsey treatment system for substance misusers: Phases One and Two. Helen Baldwin Linda Prickett Adam Marr Jim McVeigh

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1 Developing the Guernsey treatment system for substance misusers: Phases One and Two Helen Baldwin Linda Prickett Adam Marr Jim McVeigh

2 Roles and responsibilities of the LJMU research team Helen Baldwin Linda Prickett Adam Marr Jim McVeigh Development and production of report Primary research lead Monitoring and intelligence lead Strategic management

3 Executive Summary This report produced by the Centre for Public Health at Liverpool John Moores University (LJMU) presents the findings from Phases One and Two of a research project commissioned by the Bailiwick Drug and Alcohol Strategy Group (BDASG). The project aimed to determine measures needed within substance use and related health services in order to monitor and improve outcomes in the population of Guernsey. It is intended that this work will be used to inform debate on a Joint Strategic Needs Assessment (JSNA) which will underpin the development of a new Drug and Alcohol Strategy for This report provides a review of Guernsey s substance misuse treatment system, including the nature and level of existing service provision and data collection processes. It also provides a baseline of the characteristics and needs of Guernsey s population in relation to substance misuse. Gaps in the existing treatment monitoring system are identified and recommendations are made for the development of more robust systems. Areas of existing good working practice and barriers to effective treatment delivery are highlighted. Comparisons are made to examples of best practice in addressing the needs of substance users in other populations. The research made use of a range of available data sources. Data contained in client assessment forms were extracted from a central database and structured services provided information on referrals to treatment. The completion of scoping documents provided further clarification of data collection processes. Information relating to drug- and alcoholrelated harm among Guernsey s general population was available in published reports. Qualitative data were obtained via interviews and meetings with stakeholders, who provided insight into treatment provision and monitoring in Guernsey. The key findings from this project were as follows: Guernsey s substance misuse system consists of two statutory services and two voluntary sector services. Together, they provide structured and non-structured treatment for adults and young people, both in the community and in prison. A range of treatment modalities are available, including substitute prescribing, psychosocial interventions, community detoxification, residential rehabilitation and alternative therapies. There is currently variation in the data management procedures adopted by treatment providers. A central database containing client assessment data provides useful but limited information. Furthermore, information sharing protocols are not consistent across services, contributing to concerns about client confidentiality. Substance misuse in Guernsey is characterised by excessive drinking and illicit use of pharmaceutical opiates which are often injected in the absence of heroin. Use of cannabis and emerging drugs of concern is also widespread. Substance misuse is prevalent among young people.

4 Substance users engaged in treatment have a range of needs, particularly in relation to physical and mental health, housing and employment. Treatment providers work together with external agencies to address clients needs, however there is little communication between the providers of structured treatment. There are also no shared care arrangements between treatment services and GPs working in private practice. Substance misuse contributes to injury, disease and mortality among Guernsey s population. Many of the clients accessing treatment are involved with the criminal justice system. Treatment services work in partnership with criminal justice agencies to deliver initiatives to tackle drug- and alcohol-related offending. A recovery agenda is emerging in Guernsey but recovery-oriented treatment is not currently offered to all substance users. In conclusion, a number of developments to Guernsey s treatment monitoring system are required before it can produce robust data that can be used to assess the efficiency and effectiveness of service provision. Several areas of current good practice exist within Guernsey s current treatment system, however there are also gaps in addressing the needs of substance users; actions to address these gaps are recommended.

5 Conclusions and recommendations The conclusions and recommendations detailed in this section have wider implications than the headings they are assembled under but have been presented in this way for ease of enacting recommendations. 1. Treatment monitoring A review of Guernsey s existing substance misuse treatment monitoring system has identified several of its limitations. Key figures needed to determine the efficiency and effectiveness of treatment are not currently available. The extent to which client needs are being met is unclear because (i) the current monitoring system does not allow for tracking of clients throughout their treatment journeys, and (ii) client outcomes are not measured in a consistent manner across services. Furthermore, apprehension among treatment providers about sharing client data creates a barrier to inter-agency working. Recommendation 1: Implement the measures suggested in this report to bring existing monitoring processes in line with best practice monitoring systems such as the National Drug Treatment Monitoring System (NDTMS), the Inter Agency Drug Misuse Database (IAD) and the Non-Structured Treatment Monitoring System (NSTMS). Primarily, introduce a Core Data Set (CDS); ensure data capture and transfer tools are compliant to this CDS; develop data sharing protocols to ensure the secure transfer of non-identifiable attributable data; and determine who will perform the data analysis function. Recommendation 2: Establish mechanisms within threshold services to collect information from drug users regarding emerging trends in drug use. Recommendation 3: Introduce a system of recording electronic and attributable needle and syringe exchange activity data to allow for monitoring of this service. Recommendation 4: Establish use of a common outcomes measurement tool for use across all treatment providers; data collected by this tool should form part of the CDS. 2. Service delivery Misuse of prescription-only medication is a significant problem in Guernsey. This raises questions about the effectiveness of measures to prevent diversion (i.e. supervised consumption) and the clinical management of clients substance misuse problems. Recommendation 5: Update guidelines for the prescribing and dispensing of pharmaceutical opioids, hypnotics and anxiolytics to reflect the international evidence base and encourage practitioners to prescribe in accordance with these guidelines. Recommendation 6: Expand provision of supervised consumption to community pharmacies.

6 Recommendation 7: Examine service users experiences of treatment provision, including their perceptions of treatment effectiveness and reasons for illicit use of pharmaceutical opioids (as this was not possible during Phase Two of this project). Excessive alcohol consumption is a major substance misuse problem in Guernsey, which contributes to injury, disease and mortality among its population. Training for healthcare professionals on Identification and Brief Advice (IBA) for misuse of alcohol has been delivered. Recommendation 8: Pilot and evaluate the use of IBA in primary and acute care settings. 3. Engagement Stakeholders perceived the main barriers to engaging clients in treatment to be incapacity within treatment services, the necessity to obtain referral from a GP to access the prescribing services, and waiting times to access substitute prescribing. Recommendation 9: Investigate appropriate methods of rapid open access and entry into appropriate modes of treatment. Such methods might include: (i) allowing individuals to self-refer to prescribing services, and (ii) increasing availability of supervised consumption to reduce waiting times. 4. Inter-agency working Individuals presenting to structured treatment services have a range of needs, particularly in relation to physical and mental health, housing and employment. Treatment providers work with external agencies to address clients needs. However, there is a need for greater interagency working between treatment providers, and between treatment providers and primary and acute care services. Recommendation 10: Strengthen collaborative working between treatment providers and GPs in private practice, possibly through provision of shared care. Recommendation 11: Establish joint-working arrangements between providers of structured treatment and acute care in order to: (i) provide the most appropriate acute care for substance users, and (ii) facilitate the referral of substance users to specialist substance misuse treatment following attendance to A&E. Recommendation 12: Drawing on best practice within the field of addiction and other health and social care fields look to develop sharing of non-identifiable attributable data to enhance care in treatment. Recommendation 13: Maintain existing links between treatment providers and other agencies and develop initiatives to foster additional partnership working.

7 5. Young people Many findings in this report apply to both adults and young people. The following recommendations are specific areas of concern for young people. Problematic drug and alcohol use is prevalent among Guernsey s younger population and substance misuse by family members is likely to be an influencing factor. Recommendation 14: Continue to fund posts which deliver drug and alcohol awareness programmes in schools and perform outreach with young people. Recommendation 15: Implement family-focused strategies to reduce substance misuse. 6. Criminal justice system Treatment providers and criminal justice agencies work together to tackle drug- and alcohol-related crime, however not all treatment modalities are accessible to offenders. Recommendation 16: Continue to fund existing schemes designed to tackle drug and alcohol related offending. Recommendation 17: Consider the risks and benefits of introducing Opioid Substitution Treatment (OST) in prisons and of enabling parolees to access needle and syringe exchange services. Recommendation 18: Continue to develop the existing interface between prison care and care in the community. 7. Rehabilitation and recovery A recovery agenda is emerging in Guernsey but it seems as though recovery is not presented as an option to all clients engaged in treatment. There is also limited access to residential rehabilitation and aftercare. Recommendation 19: Forge better links with providers of off-island residential rehabilitation and review the effectiveness of their services. Recommendation 20: Address any unintentional stigma which may hinder the formation of recovery-oriented treatment goals. Recommendation 21: Adopt a consistent approach to following-up agency transfers and treatment exits to reduce unplanned discharges and relapses post-treatment. Recommendation 22: Increase the provision of aftercare services to foster recovery and ensure progress made by clients during treatment is maintained in the long-term.

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