Commissioning a Recovery Orientated Substance Misuse Treatment System for Bristol

Transcription

1 Safer Bristol Commissioning a Recovery Orientated Substance Misuse Treatment System for Bristol Commissioning Strategy Author: Substance Misuse Team September

2 Version Control Document Review Version Amendment Pg 2.1 Added sentence to Summary section highlighting 5 this is now the final commissioning strategy following the consultation period. 2.2 Defined recovery according to UKDPC definition Sentence added to explain that where the term 6 substance is used in the document it refers to both drugs and alcohol. 2.4 Sentence removed We will be expecting the final 15 framework to be published at some point during A summary of responses from the Building Recovery in the Community document were published instead. 2.5 Putting Full Recovery First document was added to 16 the Key Legislation and other drivers section. 2.6 Consultation period section added Updated Recovery Model paragraph New recovery model added The names (and key components of the clusters) updated to reflect the new recovery model Updated outcomes framework in response to the 35 updated recovery model Expanded on the 8 best practice outcomes in the 35 framework to be consistent with the strategy 2.12 Paragraph in the Harm Reduction section added to 39 reflect recent policy and guidelines that have been published As further information is released regarding funding 41 levels sentence has been removed from the Resource analysis section. This information is still up to date as of the time of the final commissioning strategy being published Responding to consultation section removed from this version as the consultation period has now finished. N/A 2

3 Contents 1 Summary Introduction Key Demographics Key Priorities Current governance structure Values Commissioning Principles Legislation and other key drivers Needs assessment Substance Misuse Needs Assessment 2010/11 Key Findings Drug Intervention Programme (DIP) Alcohol Needs Initial consultations and developing the market Mapping and Gap Analysis ROIS Survey Market Development Formal consultation period Consultation Methods Quantitative analysis of the online survey Analysis of qualitative feedback Recovery Orientated Integrated System Proposed Model Substance Misuse Recovery System Outcome Framework Monitoring and review arrangements In scope services Out of scope services Harm reduction work Workforce development and equality & diversity Resource analysis Risk assessment Timeline References

4 1 Summary The Adult Drug Treatment Plan 2011/12 made clear the intention to develop a three to five year outcome focused commissioning strategy for Bristol. This commissioning strategy sets out the intended strategic outcomes and agreed approach for the three-to five-year timeframe. It signals the strategic direction for local services; highlights commissioning priorities, needs and opportunities to service providers; and is intended to offer a focus for discussion with service users and the local community, as well as an opportunity to open dialogues with potential providers. The strategy belongs to the Safer Bristol Partnership. It is an overarching plan and analysis outlining priorities and strategic direction for the next 3-5 years. It will work in conjunction with a number of complementary plans, and other Bristol City Council Strategies. Update 26/09/12: This is the final version of the Commissioning Strategy following a twelve-week consultation period. This consultation period has helped to inform and develop the final recovery model outlined in this strategy that will be commissioned over the next year. 4

5 2 Introduction Over the last two decades a number of substance misuse services have developed in Bristol. Since 2003 Safer Bristol, the Crime Drugs and Alcohol Partnership led by Bristol City Council, has commissioned many of these and a number of other services as part of a citywide treatment system. The treatment system in Bristol performs healthily but as well as our goal of continual systemic improvement there are two key drivers behind Safer Bristol s current exercise in developing and implementing a new commissioning strategy which will involve re-commissioning the majority of Bristol s services. Firstly, European procurement regulations dictate that many public services are regularly put out to competitive tender. This is an obligation under European legislation and many of the services we currently commission are now due to undergo this process. Secondly, in the last few years national developments in the substance misuse field including HM Government s 2010 Drug Strategy have put an emphasis on areas providing a recovery orientated treatment system with a more explicit focus on achieving successful, substance-free outcomes with service users. Safer Bristol s Substance Misuse Team has responded to this by supporting providers in the current system to make changes to the way they work. We are now proposing a new treatment model and outcomes framework to deliver a Recovery Orientated Integrated System (ROIS). Safer Bristol has adopted the UK Drug Policy Commission (UKDPC) definition of recovery which explains the process of recovery from problematic substance use is characterised by voluntarily-sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society (UKDPC, 2008). Following consultation, the model will be agreed by the Joint Commissioning Group and procured through a competitive tendering process using the Bristol City Council Procurement portal: Proactis- Provide to Bristol. The target for awarding the contracts to deliver the new model is August 2013 with an expected commencement date of November It is likely that TUPE will apply if there is a change in service provider, which may lead to a longer implementation time, but it is expected that the new model will be fully operational by January Throughout this strategy where the term substance is used, it is referring to both drugs and alcohol. 5

6 2.1 Key Demographics With a population of 433,100, Bristol is the largest city in the South West and is one of the eight Core Cities in England (excluding London), covering 112km 2 of the local area. At present, it is estimated that 221,300 are males and 220,000 females in the local area, with 32.3 as the median age in years for males and 33.6 median age in years for females respectively. Figure 1 below shows the Bristol Population Pyramid (2010) 1 : Males Females Figure 1: Bristol Population Pyramid (2010) Since 2001, there has been a small decrease in the number of children by an estimated 1,800 children (2.4%) and also a decrease in the number of people aged 65 and over, by an estimated 2,800 people (4.8%). The population aged has risen by 48,000 people, an increase of

7 Figure 2: Bristol Population by Ethnicity Groups Figure 2 above shows a breakdown of Bristol population by ethnicity. 19% of the population do not fall under White British category, and Other White shows the highest number compared to other ethnicity. The Council s intelligence suggests that since 2001 there has been a significant increase in the number of international migrants coming to live in Bristol, particularly Somali communities and Polish residents coming to work in Bristol following the expansion of the EU. Figure 3: Concentration of Bristol Population 7

8 Figure 3 above shows the concentration of Bristol population by Lower Super Output Area (LSOAs). The top three LSOAs with the most condensed population, as reflected in the dark purple shades above, are: Old Market and the Dings LSOA 3981 people City Centre and Harbourside LSOA 3875 people University Halls LSOA 3433 people In addition, about 25,600 full time students live within Bristol boundaries during term time and 91,100 people are currently working in Bristol City Centre. The number of Job Seeker Allowance (JSA) claimants for Bristol more than doubled between July 2008 and July 2009 but has remained significantly lower than that of the recession of the early 1990s. Other key facts of Bristol include the following: Categories Bristol England and Wales Black and minority ethnic residents (BME) 13.5% (Overall BME population) 14.8% (16 59 (working age)) 12.5% (England) Notes and source Data from Office for National Statistics (ONS) 2010 Experimental Statistics Crown Copyright One person households Table 1: Other Key Facts of Bristol 38% 34% Department for Communities and Local Government (CLG) based Household Projections Average earnings 27,100 26,400 Median gross annual pay of full time workers workplace analysis. Data from ONS 2011 Annual survey of hours and earnings ONS Crown copyright reserved (NOMIS) Average house price Unemployment rate Qualified to HND or degree level 165, ,400 Average price of dwelling sold. Data from HM Land Registry Monthly Report December 2011 Crown Copyright 7.30% 7.70% Data from ONS Annual Population Survey (July June 2011) and modelled Bristol statistics ONS Crown Copyright Reserved (NOMIS) 37.10% 31.00% Qualified to NVQ4 equivalent or above. NVQ4 equivalent includes HND, degree and higher degree level qualifications. Data from ONS Annual Population Survey (January - December 2010) 8

9 2.2 Key Priorities Based on the Bristol Substance Misuse Needs Assessment 2010/11 the following key priorities were identified in by the Safer Bristol Partnership: Develop and consult on the Commissioning Strategy for a recoveryfocussed drug and alcohol treatment system appropriate for service users from all backgrounds in Bristol that will meet the performance indicators in the Public Health Outcomes Framework. Work with Bristol City Council Procurement and Commissioning Team to competitively tender services. Increase the numbers of clients successfully completing, exiting the treatment system and achieving sustained recovery. Increase the numbers of opiate, non opiate and crack users identified within the criminal justice system accessing and successfully exiting structured treatment services and not requiring further treatment (i.e. reentering the treatment system). Increase the numbers of clients in the Criminal Justice Intervention Team (CJIT) who access appropriate structured treatment and successfully complete, sustain recovery, reduce re-offending and subsequent representing to the treatment system. Work with Bristol Prison, Avon & Somerset Probation Trust, CJIT and the User Feedback Organisation (UFO) to implement plans for gate pick up on release from prison, to ensure continuity of care between prison and the community to support the clients recovery journey, and reduce reoffending rates. Implement recommendations from the psychosocial audit conducted by Public Health in the Primary Care Trust. Increase move on, throughput and increased successful completions from the treatment system. To achieve 90% plus compliance for start, review and exit TOPS and ensure providers utilise the TOP Quarterly Outcome Reports to monitor client s recovery journey. Work with Housing and Job Centre Plus to increase substance misusers uptake of services that will support treatment and recovery. Agree targets with all providers to decrease voids and improve accommodation outcomes for services users in drug and alcohol services. 9

10 Work with Troubled Families Coordinator (when appointed) to ensure priority access to, and joint working with services for identified clients and families. Work with Bristol City Council s Children and Young People s Service (CYPS) to implement the recommendations from the Serious Case Reviews. With CYPS, implement the new joint safeguarding children protocol children and families living with substance misuse and associated joint practice guidance. Work with CYPS, the Youth Offending Team (YOT) and Young People s Opening Doors services to ensure young people requiring Tier 3 treatment are referred to the appropriate service, complete a care plan including healthcare assessment and where appropriate are offered, and receive Hep B vaccination. Targets will be agreed to increase the numbers of young people successfully completing treatment and exiting the treatment system drug free. 10

11 2.3 Current governance structure Safer Bristol Partnership co-ordinates Bristol s response to issues of drugs, alcohol harm, crime and community safety and implements the Governments National Drug Strategy in Bristol. The Joint Commissioning Group (JCG) acts on behalf of the Safer Bristol Executive Board. The Service Director of Safer Bristol chairs the JCG and this group is responsible for commissioning services that deliver drug and alcohol treatment across Bristol. The Treatment Task Group (TTG) contributes towards the development and delivery of effective, efficient and evidence based substance misuse treatment services. The TTG consists of members from commissioned services, service users and other relevant stakeholders. The JCG are committed to ensuring that service users, carers and providers inform decisions. This is done by representatives of these groups sitting on various forums including the TTG, the Treatment Providers Forum, UFO Service Users Forum. From April 2013, Public Health will move in to the Local Authority and new Health & Wellbeing Boards will be in place. Their role will be to improve health, social care and public health services. They will develop a joint Health & Wellbeing Strategy. Additionally there will be an elected Police & Crime Commissioner for Avon & Somerset from November Both of these changes will impact on the level of funding, and commissioning accountabilities, for drug and alcohol services. Safer Bristol is working with all relevant partners during this transition period. Figure 4: Current governance substance misuse meeting structure 11

12 2.4 Values This Commissioning Strategy is informed by some shared values, which recognise that, while action on drugs and alcohol is fundamentally health-led, there is an equally important criminal justice focus. Our values and approach are therefore dependent on excellent collaboration between all stakeholders. This means that we will: Approach the commissioning of drug and alcohol services in a transparent way. Ensure service users feel able to influence and be involved in all stages of the commissioning cycle. Work to ensure that drug and alcohol provision, relevant to need is available to all residents of Bristol, including homeless people. Seek to enable people to move away from a culture of dependency. Aim to offer choice and opportunity to service users with a range of harm reduction and recovery options. Ensure best value for use of public money, seek to commission on the basis of evidence based good practice, and meeting greatest needs. Ensure that provision is high quality, and meets the needs of all equalities groups across Bristol. Move to an outcome based approach to commissioning and monitoring. 2.5 Commissioning Principles Safer Bristol will be using Bristol City Council s Enabling Commissioning Framework. The objective of this framework is to create a standardised approach across the Council to commissioning. The commissioning process is broken down into the four stages with each stage being dealt with in turn Analyse Plan Do Review 12

13 Agreed framework for Bristol City Council - The 4 Stage Cycle This is the agreed four stage commissioning cycle that has been adopted from the IPC (Institute of Public Care) joint commissioning model for public care. Figure 5: Four Stage Commissioning Cycle In pursuit of these activities, the Commissioning Strategy conforms to some key principles: All four activities are sequential and equally important. Commissioning and purchasing cycles are linked, and activities in one must inform the ongoing development of the other. The commissioning process must be equitable and transparent, and open to influence from all stakeholders through ongoing dialogue with service users and providers. There is a focus on needs identified by all agencies, ensuring a joint approach. 13

14 3 Legislation and other key drivers The agenda of the present Government is clear, underlining considerable change in the broader policy context, to be seen in conjunction with significant reductions to public expenditure. A number of policy developments are drivers for change: The National Drug Strategy: Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life(2010) signalled a shift in emphasis from harm reduction to a focus on recovery. The goal is to increase the numbers successfully completing treatment drug free and reintegrating in to their communities. The Government s Alcohol Strategy (2012) focuses on irresponsible drinking, closer working with the drinks industry and support for individuals to make informed choices about responsible drinking and reducing the numbers of people drinking to excess. NTA s Medications in Recovery: Re-orientating Drug Dependence Treatment in July 2012 looked at delivering good practice for OST (Opiate Substitution Therapy) to maximise a persons recovery. The Joint Strategic Needs Assessment (JSNA) Pack for Commissioners (2011) was published by the NTA. This informs the commissioning of a recovery-orientated system, in line with the 2010 Drug Strategy aim of replacing the national service framework (set out in Models of Care 2002 & 2006) with a stronger recovery focus and updated evidence base. The publication in 2010 by the NTA of Commissioning for Recovery, which focuses on outcome-based commissioning for the drug treatment, re-integration and recovery system in drug partnership areas for drug users. It sets out to highlight good practice in a recovery-based treatment system. While it relates to the 2008 drug strategy, it clearly anticipates the change of emphasis set out in the 2010 strategy. A consultation paper titled Building Recovery in the Community was published by the NTA in 2011 to gather views on how to develop a recovery orientated framework to replace the current Models of Care(originally published in 2002 and updated in 2006). The NTA published a summary of the responses to this consultation on 18 May. The key messages from the consultation were that an integrated recovery system should focus on the following: Collaborative working between all partners to commission services based on outcomes. Prompt access to appropriate interventions for drug-dependent people, including offenders. High-quality treatment that prepares service users for recovery while protecting communities. Encouraging service users to successfully complete treatment without putting them at risk. 14

15 Links to support networks to sustain long-term recovery and reintegrate people back into society. Putting Full Recovery First a cross governmental paper was published in March The document outlines the Government s roadmap for building a new treatment system based on recovery, guided by three overarching principles- wellbeing, citizenship and freedom from dependence. The Ministry of Justice (MOJ) Green Paper, Breaking the Cycle Effective Punishment,Rehabilitation and Sentencing of Offenders focused on rehabilitating offenders to reduce crime. Offenders on community sentences or on release from prison will face a tough and coordinated response from the police, probation and other services. Offenders will be required to tackle the problems which underlie their criminal activity, this includes getting drug and alcohol dependent offenders off drugs and alcohol via effective treatment programmes in prison and the community. The Substance Misuse Skills Consortium launched as an independent network in The Skills Consortium have developed a framework of drug treatment that constitutes a consensus on effective treatment- known as the Skills Hub- and is used as an online resource for commissioners, managers and practitioners. In the Open Public Services (2012) paper the Government outline their desire to make sure that everyone has access to the best possible public services. To improve the effectiveness of public services the Government have looked at rolling out new commissioning regimes based on payment by results. There are currently 8 pilots taking place across the country that are aiming to achieve better outcomes for drug and alcohol users, their families and communities utilising different payment by results models. The Healthy Lives, Healthy People-Update & Way Forward White Paper (2011) proposes a new public health system for England in which: Local authorities take new responsibilities for public health. They will be supported by a new integrated public health service, Public Health England. The functions of the National Treatment Agency (NTA) will be subsumed within Public Health England from April There will be a stronger focus on the outcomes that need to be achieved across the system. In terms of drug and alcohol treatment, the public health outcomes we will be responsible for are listed below: Domain 2.15 (Health Improvement): Successful completion of drug treatment. Domain 2.16 (Health Improvement): People entering prison with substance dependence issues who are previously not known to community treatment. Domain 2.18 (Health Improvement): Alcohol-related admissions to hospital. 15

16 In addition to this the drug and alcohol field will contribute to number of wider PH outcomes (see Outcome Framework on pg 19). The abolition of PCTs from April 2013 and the introduction of GP Commissioning and Health & Wellbeing Boards. Public Health England and local authorities will play a key role in tackling the harms caused by alcohol and drugs. Local authorities will be responsible for commissioning treatment, harm reduction and prevention services for their local population, providing an opportunity to more comprehensively join up the commissioning of drug and alcohol intervention and recovery services locally. The Police Reform and Social Responsibility Bill - September 2011,introduces major changes to the way policing locally. It includes provisions for: Making the Police service more accountable to local people by replacing Police authorities with directly elected Police and Crime Commissioners to be introduced from November These Commissioners will have local control of both the Home Office part of the DIP funding and the Safer & Stronger Communities funding. An integrated working approach will be required with Police And Crime Commissioner s to ensure effective treatment for drug and alcohol users locally. Overhauling the Licensing Act to give more powers to local authorities and police to tackle any premises that are causing problems, doubling the maximum fine for persistent underage sales and permitting local authorities to charge more for late-night licences to contribute towards the cost of policing the late-night economy. Introducing a system of temporary bans for new psychoactive substances, so-called 'legal highs', whilst the health issues are considered by independent experts, to ensure our legislative process can respond quickly to emerging harmful substances. The Think Local, Act Personal agreement, which recommends how councils, health bodies and providers need to work more efficiently to personalise and integrate service delivery across health and adult social care. The proposal sets out what needs to be done to ensure further transformation of adult social care. It reiterates the need for integration of health and social care, in particular, around outcome based commissioning and procurement and effectively engaging with local markets to deliver on the choices and outcomes people require. To target supply effectively requires commissioners to develop stronger and more collaborative relationships to develop new models of provision and reduce cost; to work with providers to diversify their services and commissioners to develop better ways of gathering and utilising market intelligence. Whilst the personalisation agenda is moving forward for many client groups there has been limited progress regarding widespread implementation of personalised budgets for clients with drug and alcohol problems. However this may be a feature in the future. On 8 March 2012 the Welfare Reform Act 2012 received Royal Ascent. The main elements of the Act are: 16

17 Introduction of Universal Credit, replacing the current complex range of benefits including Jobseekers' Allowance by Replacing Disability Living Allowance with the Personal Independence Payment, where the focus will be on supporting claimant s to work. Everyone on DLA currently will be reassessed and moved onto the new relevant benefit. New powers to tackle fraud, which costs the Government 5.2bn annually, and tougher sanctions including "three strike" rule for the unemployed who do not seek work. A cap, linked to average weekly earnings, which will limit the amount of benefits one household can receive. Employment Support Allowance will be limited to 12 months' support for those able to prepare for work. These changes will have a significant impact on residents locally, especially those who are already marginalised such as drug and alcohol users. Aside from the overall context for public expenditure, and the aforementioned proposals impacting directly on drugs and alcohol, health, crime and policing, there are a number of broader policy developments which will have implications for the business of the Substance Misuse Team and how it approaches its commissioning responsibilities. Of particular significance are: The momentum for localism, and a likely focus on place-based budgeting, moving the Total Place approach on to another stage. There will be an imperative to achieve greater value for money through collaboration, and in turn this will require service transformation. Tackling social problems around families with complex needs. This approach will be rolled out nationally by The Localism Bill was introduced to Parliament in December 2010, and included proposals for community empowerment, greater accountability to local people, and, of huge significance for commissioning activity, diversifying the supply of public services, aimed at increasing choice, best value for public money and achieving a better standard of public services. The Big Society agenda, supported by a Commissioning Green Paper13, which sets out the Government s intention to create an enhanced role in public service delivery for voluntary and community sector organisations.. This will clearly have implications for the role of commissioners, not least in developing broader provider markets. 17

18 4 Needs assessments 4.1 Substance Misuse Needs Assessment 2010/11 Key Findings Safer Bristol completes and publishes an annual needs assessment. The following section summarises the latest Substance Misuse Needs Assessment (2010/11) for Bristol. Prevalence of Opiate and Crack Users: National Treatment Agency (NTA) prevalence data suggests that there are 4777 Opiate and Crack Users (OCUs) in Bristol. 74% of the OCUs (3512 users in treatment / 4777 prevalence) have had contact with structured treatment services in 2010/2011 compared to 68% (3572 users in treatment / 5285 prevalence) in 2009/2010. Based on this prevalence data, it is estimated that there are 15 OCUs per 1,000 Bristol population. Bristol ranks the highest rate of OCUs among the similar cities,( NTA complexity cluster) of Birmingham, Doncaster, Leeds, Leicester, Liverpool, Manchester, Nottingham, Sheffield and Stoke-on-Trent. Other Drug Use: In line with national trends and work in Bristol to encourage people who misuse drugs other than opiates into treatment the numbers of cocaine, cannabis, amphetamine and benzodiazepine users in treatment have increased.in 2011/12 there was a 69% increase in the numbers in effective treatment compared to 2010/11. Engagement: The level of penetration in Bristol is 74%, compared to 68% last year for heroin and crack users. Whilst this looks like an improvement in penetration rates it must be remembered that the baseline figures have been changed from 5,285 in 2009/10 to 4,777in 2010/11. Bristol is ranked sixth out of the ten DAATs in the same complexity cluster for penetration rates. The number of arrests for trigger offences has been consistently lower throughout The proportion of offenders testing positive for class A drugs has remained static at approximately 40% of those tested. There is a decrease in the number of offenders testing positive for sole opiate use and a decrease in combined opiate and crack use. There was an increase in the number of offenders testing positive for cocaine. The number of cocaine, cannabis, amphetamine and benzodiazepine users who accessed treatment services during 2010/11 has increased compared to 2009/10. Clients Exiting the Treatment System: Work with all agencies to increase the numbers of planned exits has resulted in an increase of the exits from the treatment system. In 2011/12 there was a 35% increase in successful completions, with a 109% growth in Non Opiate clients successful completing treatment in January-March The percentage of Criminal Justice clients who successfully complete treatment has increased to 16% of all criminal justice clients in treatment. Positive outcomes for criminal justice clients leaving the treatment system has increased by 3%. 18

19 On the negative side, data for the rolling year that ended March 2012 showed representations (clients re-entering the treatment system having left successfully), was higher than the national figures.17% of opiate users have returned to treatment within six months of having been successfully discharged. For non-opiate users, 4% of clients have returned to treatment within six months of having been successfully discharged. Improvement in performance is required to reach the best performing DATs in our complexity cluster. However, whilst we would aspire to reduce the number of representations, we would also want to ensure that if clients relapse they can quickly re-engage rather than waiting until their offending and drug use escalates. Treatment System Map: The total referrals in 2010/2011 reduced by 25%, from 1294 to The ratio of exits to entries increased from 57% (739 / 1294) to 74% (822 / 1115) whilst the ratio of exits to clients in treatment (turnover of clients) has increased from 18% (739 / 4149) to 20% (822 / 4192). Similarly, the total number of agency transfers has decreased during 2010/2011. For tier 4 treatment, there had been a 19% increase for the number in treatment in 2010/11. In 2011/12 the average length of time clients had been in the system was 2.3 years, 14% had been in treatment between 1-2 years, 28% 2-4 years and 13% 6 years and over. Treatment Outcomes Data (TOPs): The information from the NTA for the Needs Assessment included Start and Review TOPS data. Exit TOP data was not provided to any Drug Action Team. In , Bristol achieved 85% completion of start TOPS but only (54%) of review TOPS (between 5 52 weeks). Substance use as declared in TOPS shows that Bristol has significantly higher use of opiate and crack throughout baseline and review TOPS against the national rate. There have been significantly fewer people declaring cocaine use in TOP than the national picture. Bristol has more injecting users (23% of clients at start TOP); injecting rate declines in the first year of treatment (10% at review TOPS). Sharing at baseline is also higher than the national average (20%). Sharing declines during the course of engagement after one year it is reported as 6.9%. Bristol is much less likely to have people in paid employment throughout their treatment - the baseline of 11.5%. This is also higher than the Bristol unemployment rate of 7.30%. 2011/12 Data for exit TOPs shows only 6% of opiate clients were employed, this compares very poorly with the national figure of 21%.For non opiate clients the local figure is 17% compared to the national figure of 28%. Analysis of the TOPs data for housing shows that 18% recorded an acute housing problem at the start TOP, which dropped to 2.8% after one year. Clients successfully completing treatment with no reported housing need was 77% Physical health, psychosocial health and quality of life are in line with national trends. 19

20 Key Demographic Issues for Bristol Age: The decrease in drug users aged accessing services that was highlighted in 2009 has continued. However, the exception is amphetamine use, increasing by 2%. Within the age group accessing services, cocaine and cannabis use rose by 2% and all other drugs decreased. In contrast, those aged showed a notable increase in the use of most drugs particularly cocaine (+11%) and other drugs (+13%). These findings show that drug use varies with age and that there is an ageing cohort of poly drug users. Gender: There has not been much variation between genders in 2009/2010 and 2010/ % and 30% compared with 71% and 29% in However, the choice of drug has changed, for male users in treatment, the largest variation is amphetamine (+4%) and other drugs (-4%), this may be due to recording practices. A similar trend is identified for women in treatment where the largest variation is amphetamine (-4%) and other drug use (+5%). Ethnicity: Within the treatment system in clients identified their ethnicity as 91% White and 9% of BME drug users. As we do not know about the prevalence of drug use in the BME community it might not be appropriate to use the percentage of adult BME in Bristol, which is 14.8%, as a comparator. Looking at drug use in the BME Opiate & Crack Users, 14% of cocaine users are from BME. For DIP clients, 14% of the clients are from BME background. Bristol is home to a diverse community and this impacts on the services we provide. We are resolute about understanding more about the diverse groups within our community and safeguarding equality of access for all groups. We will work hard towards ensuring that our services are as accessible as possible for all whilst ensuring individual needs are met. Bristol City Council has achieved Excellence Standard of the Equality Framework for Local Government the work within the Substance Misuse Team to tackle inequalities contributed to the submission of evidence to support the award. 4.2 The Drug Intervention Programme (DIP) The DIP programme continues to be a key component of Bristol s treatment system. It aims to engage drug and alcohol misusing offenders in structured treatment, thereby reducing offending behaviour. Bristol is an Intensive DIP area. 20

21 Bristol s data from Home Office DIP Dashboard and DIP Quarterly Reports for 2011/12 shows: 1059 clients tested positive on arrest and had an initial required assessment imposed. 678 clients attended an initial required assessment. 476 clients taken onto the DIP caseload. 566 clients were referred to treatment. Of these, 352 clients were already in contact with treatment services whilst 214 clients were treatment naïve. 14% of clients in the treatment system are DIP clients. 128 DIP clients successfully completed treatment. Further to these 128, 43 clients successfully completed but re-presented within the year. HMP Bristol Prison HMP Bristol is part of the Ministry of Justice pilot projects for Drug Recovery Wing s and Drug Free Wing s. The Integrated Drug Treatment Programme is jointly commissioned with NHS Bristol and is part of Bristol s overall treatment system. Based on data from quarter /12: There were 425 individuals starting a treatment episode in prison. Of these 390 were opiate users whilst 35 were non opiate users. 187 of individuals were currently injecting and 123 were previously injecting 41% were drinking above six units a day. For individuals completing treatment in prison, 12% required no further treatment whilst 78% were transferred with an onward treatment referral. For individuals leaving prison, 22% were transferred to CJIT and 25% were transferred to another prison. 50% of those in treatment were aged between In terms of ethnicity, 84% were White British, 1% were White Irish, 3% were Other White whilst the BME population totalled 11% with 1% not being stated. 4.3 Alcohol Needs Alcohol is now generally recognised as a major national concern across the United Kingdom. Some of the main issues are as follows: Alcohol related harm is estimated to cost society 21 billion annually. 25% of hospital admissions are related to alcohol. There are almost a million alcohol-related violent crimes each year in England & Wales. 40% of domestic violence incidents are alcohol related. One third of cases of child abuse are associated with alcohol consumption. 11 people are killed each week in road traffic accidents due to drinking. 21

22 33,000 people die each year from alcohol related causes. 19% of men and 5% of women in Britain report having had some sort of alcohol related problem. The North West Public Health Observatory, which profiles alcohol harm, has found that Bristol performs significantly worse than the national average on these measures: Male alcohol specific mortality. Male mortality from chronic lever disease. Male and female alcohol specific hospital admissions. Male and female alcohol attributable hospital admissions. Alcohol related recorded crime. Alcohol attributable violent crimes. Alcohol attributable sexual offences. Claimants of incapacity benefits working age. Binge drinking. The Observatory provides estimates of alcohol use in Bristol. It estimates that there are 19,591 people drinking at higher risk levels in Bristol; drinking at these levels can cause clear harm to the drinker and/ or to others. Of this group, 16,256 are dependent drinkers. In addition there are over 69,000 who are drinking at increasing risk levels. This means they are drinking more than the national low risk guidelines and may well develop alcohol related conditions in the future; they are currently at risk of injury, accidents and alcohol poisoning. Dependent Drinkers: Evidence tells us that dependent drinkers cost the NHS twice as much as other drinkers. The Department of Health alcohol commissioning guidelines, Signs of Improvement (2006), states that providing treatment services for 15% of the population of dependent drinkers each year will produce the largest and most immediate reduction in alcohol-related admissions. Dependent drinkers fall into 3 broad categories: Severely dependent drinkers who need intensive specialist treatment and medical supervision when they detoxify. They may experience withdrawal fits (for instance confusion or hallucinations) and may drink to escape from or to avoid these symptoms. Moderately dependent drinkers many of whom will experience the best outcome if they take a harm reduction approach. If they do decide to go through detoxification they will need a medically assisted detoxification as they can suffer withdrawal symptoms. They need specialist treatment in a generalist or specialist setting. Mildly dependent drinkers who will have the best outcome if they take a harm reduction approach. 22

23 NICE identifies additional groups of drinkers that, though not necessarily severely dependent, need specialist treatment, and possibly an inpatient detoxification. These groups include vulnerable adults such as: Older people. Homeless people. Pregnant women. People with a history of epilepsy or experience of withdrawal symptoms or DTs during a previous assisted detoxification programme. Concurrent withdrawal from alcohol and benzodiazepines. Significant physical or psychiatric comorbidities (for instance chronic severe depression, psychosis, malnutrition, congestive heart failure, unstable angina, chronic liver disease or significant learning difficulties or cognitive impairment. Higher risk drinkers who do not actually fall into the dependency category, can benefit from brief alcohol advice or longer interventions addressing lifestyle choices. Increasing risk drinkers can benefit from brief alcohol advice. This is mainly delivered in primary care. The Safer Bristol Alcohol Strategic Needs Assessment 2012 describes the current situation in Bristol and the numbers in treatment: 696 clients were referred to the specialist service in 10-11, of these 318 attended appointments, and 83 went on to be detoxified in the community and 36 had an inpatient detoxification. 729 clients were treated by the community alcohol service in They received support, advice and information. 23

24 5 Initial consultations and developing the market 5.1 Mapping and gap analysis The mapping and gap exercise was carried out in the following way: A series of consultations were undertaken with the following groups: Treatment Task Group, Shared Care Monitoring Group, UFO, Practice Governance, Young People s Managers Meeting, Safer Bristol Communities Team, Safer Bristol Crime & Substance Misuse Manager meeting and thematic lead groups (e.g. Employment). (Approximately 130 participated). An online survey was designed and circulated to all relevant stakeholders. (191 participated). UFO representatives carried out face to face interviews with current service users from commissioned services. (64 participated). The Substance Misuse Team contacted other DAATs (Drug & Alcohol Action Team) in the complexity cluster to gather information on their services and future commissioning intentions. Through these consultations a number of common themes emerged: Priority areas to look at: Addressing and improving the balance of the treatment system by looking at: Abstinence vs Harm Reduction. Opiates vs Non Opiates. Drugs vs Alcohol Provision. Developing a fully integrated system that is flexible and can change to reflect emerging patterns of substance use. Improve joined up working across agencies by incorporating a system wide-care co-ordination model. Improve the access in to and out of the recovery system for our most complex clients (e.g. serious mental health issues, sex workers) etc by strengthening links across different strategies. Improve and expand aftercare/wrap around services to promote the recovery culture. Central to this is service users taking ownership of their recovery. There needs to be an increased focus on the recovery capital of clients: families, employment, housing etc. Many of the services are located centrally - Not many services in the North or South of city (e.g. group work). Need to look at how community day programmes are delivered in Bristol. A high demand but also a need to reduce waiting times for clients. 24

25 Improve information sharing in regards to recovery and housing. HSR (Housing Support Register) process is not explained clearly enough to clients. What is good about the treatment system: We have a very diverse set of services and service users have a range of options: An accessible and mobile needle exchange service that can often initiate the start of a client s recovery. The accessibility of shared care is also good. We have a spread of services across the city with a large number of GP surgeries involved. The quality and choice of community day programmes are impressive It is easy to access Tier 4 provision in Bristol. Communication has improved between different parts of the system. The prison drug and alcohol service has improved their relationship with community drug and alcohol services over the past couple of years. We have good Jobcentre+ links in prison. Consultant psychiatrists are available for drug and alcohol clients with dual diagnosis. The development of more non opiate provision is encouraging. Women s provision is strong in the community. Our system keeps people safe and effectively reduces drug related deaths. There is a strong focus on service user involvement that helps shape the treatment system. What needs to be improved in the treatment system: Joined up working across agencies needs to be improved. There is a lack of a system wide approach with care pathways being unclear. Some clients always end up going to the same agencies with not enough movement between the agencies. There can sometimes be an unhelpful ownership of clients, e.g. my client. Multi-agency working can produce variable quality. It is difficult to standardise (e.g. One GP surgery can perform well whilst another one doesn t). The balance of spend in the treatment system needs be addressed with too much being spent on prescribing. There remains a risk of parking service users on scripts. The Bristol treatment system is currently very opiate-based. More nonopiate provision needs to be offered in a more flexible treatment system to allow for any potential changes in drug trends. There are still blocks in the system, especially around community day programmes, due to waiting times and inconsistent referral systems, that impact on a client s recovery. There needs to be more provision offered to primary alcohol clients. We need to look at how we jointly commission with mental health services in order to offer more effective services to clients with dual diagnosis. 25

26 There needs to be more of a link in with aftercare and mutual aid when a client exits Tier 4 treatment. A better geographical spread of services across the city would be helpful. We need to more effectively challenge the stigma encountered by those in recovery. More work needs to be done around housing. In particular the Housing Support Register process needs to be explained more clearly to clients. More tailored provision is required for mothers and baby as 12 week programmes are not long enough for this group. Need more accessibility for clients to employment and training provision. In particular we need to develop clearer links with the Work Programme. Messages about positive changes to system are not promoted to service users enough (i.e. police not routinely coming to those who overdose). Gaps and needs in the provision of alcohol treatment services according to the Alcohol Strategic Needs Assessment 2012: In order to reach the commissioning target of service provision for 15% of dependent drinkers every year we need to work towards increasing provision by 1,096 places. Improve links between mental health and general practice health for complex and chaotic alcohol patients. Develop pathways for people with alcohol related brain disease. There is a perceived lack of community base services. There is no entry group dealing with motivational enhancement in the specialist services to boost engagement in treatment. There is no dual diagnosis service this would enhance service for this cohort of clients. There is a lack of capacity for community assessment for complex and chaotic or vulnerable clients. Consideration needs to be given to a single point of assess to all commissioned substance misuse services. There needs to be a harm reduction inpatient facility for chaotic drinkers. 5.2 ROIS Survey There were 255 questionnaire responses over the course of the information gathering process with both service users and providers completing questionnaires, with input also coming from professionals in the field and from the wider Partnership. Analyses of the many responses show that a number of current treatment options are working well and helping with recovery. By the same token, there are also areas in which current service delivery has been challenged and its contribution to recovery questioned. 26

27 The most commonly identified issue has been around the poor integration of services within the Bristol treatment system. Respondents felt that the current treatment system works well in areas but that the services work in silo, often in competition with one another. Referral pathways between agencies were criticised as being too inflexible with multiple assessments being cited as a barrier to engaging with more than one agency. Individuals felt that the ease of accessing treatment was very much dependant on where you live and the complexity of your need. Treatment provision outside of the city centre was felt to be minimal and the access to alcohol and non-opiate treatment was said to be difficult due to the focus on opiate services. Many contributors felt that current provision did not really include or have any significant focus on the roles of family and concerned others in a service user s treatment journey. Analysis of the replies suggests that respondents felt there is not currently enough funding made available to currently commissioned community based services and that locally available community rooted organisations are under used. Looking forward to recommissioning, concerns were raised about those from specific communities, especially Black & Minority Ethnic and also British Sign Language and disabled clients being able to access treatment if the already minimal outreach service were to be withdrawn. 5.3 Market Development The drug and alcohol field is a relatively well developed market with a number of different providers of varying size (including NHS and 3 rd sector VCS services) delivering services locally. In addition to these local providers there are a significant number of other providers delivering substance misuse services in other comparable areas and nationally. The Substance Misuse Outcome Focus Fund (SMOFF) has been identified as a potential method by which to test the market and identify new ways of working in areas where gaps in services have been identified through the Needs analysis process. Through a competitive tendering process applicants will be evaluated on their ability to achieve outcomes through the delivery of evidence based services. Lessons will be learned with regard to an outcomes based approach to purchasing services in addition to any impact of the new services. The Substance misuse team are always on the lookout for new and innovative treatment options. This is achieved by keeping up to date with new trends and regional and national contacts. Nationwide advertising will be carried out when issuing the tenders. 27

28 6 Formal Consultation Stage 6.1 Consultation Methods The formal consultation on the draft model and strategy was carried out in the following way over the period of Friday 18 th May Friday 17 th August 2012: There were over 400 attendees (although some representatives attended more than 1 meeting) at the various consultation events held by Safer Bristol. There were 6 main events open to a range of stakeholders. There were 8 specific service user events. Including targeted equalities communities and agency service user groups. Presentations were also given to a number of other standing groups e.g. Alcohol High Impact Users group and the Mental Health Partnership. Presentations and workshops were also given at trustees and staff meetings in a number of agencies. An online survey was designed and included in the Bristol Consultation Finder to gather a wider range of views from individuals and organisations. There were 173 responses to the online questionnaire. Following the completion of the consultation events and online questionnaire a number of common themes emerged that was then considered within Safer Bristol. A rationale for each of the decisions was recorded and will be included in the We asked, you said, we did document. 6.2 Quantitative analysis of the online survey The quantitative results from the online survey validate the proposed approach with nearly 75% agreeing with the statement that the key components of the treatment system were aligned with the correct clusters. 45% of respondents agreed or strongly agreed that the proposed model improved access to services whilst 43% neither agreed nor disagreed. 40% of respondents agreed or strongly agreed that the proposed model improves involvement and support for 'concerned others & families' whilst 46% neither agreed nor disagreed. 47% of respondents agreed or strongly agreed that the proposed model fosters increased integration between and within services whilst 33% neither agreed nor disagreed. 48% of respondents agreed or strongly agreed that the proposed model facilitates movement through and within the treatment system whilst 36% neither agreed nor disagreed. 39% of respondents agreed or strongly agreed that the proposed model enables sustained recovery from substances of dependence whilst 37% neither agreed nor disagreed. 28

29 6.3 Analysis of qualitative feedback The following key themes emerged from the events and the online questionnaire: Housing support to be put into own cluster separate from Support cluster and to contain both accommodation based support and floating support. Concerned/significant others to be added to the support for carers section in the Support cluster. Change the name of the Intake cluster to Engagement. Change the name of Recovery cluster to Completion. Move peer support opportunities from Completion to Support cluster. Create family support component and add it to Change cluster. Add relapse prevention/aftercare provision to Completion cluster. Recovery Support interventions to be brought in to line with the forthcoming NDTMS Data Set J (November 2012). Remove residential rehabilitation from model and create CCA for access to residential rehabilitation row in Change cluster. Include residential rehabilitation as a framework agreement rather than a single provider or consortia agreement. Add a paragraph clearly explaining that Substance Misuse refers to both Drugs and Alcohol throughout the strategy. Provide a definition of Recovery in strategy. UKPDC (UK Drug Policy Commission) definition of recovery to be used. There are a number of points that will be removed from the model and added to the commissioning intentions document as a core requirement for all clusters. These include but are not limited to: We will expect all providers to create strong pathways to work together enable appropriate movement between clusters Deliver harm reduction and healthcare interventions Maximising the skills of the workforce and ensure staff are in accordance with the Skills Consortium All providers to promote, encourage and support referrals to mutual aid e.g. SMART, 12 Step Fellowship All providers to use our current case management system- Theseus. We will be seeking to commission only evidence based interventions. All providers to work with other DAATs for clients who move to different local authorities. All potential providers to be culturally competent. Out of hours provision to be provided for those clients wishing to access services outside 9-5 hours Monday to Friday. Suggestions that were not included in the final strategy will be detailed in the forthcoming We asked, you said, we did document. 29

30 7 Recovery Orientated Integrated System To comply with legal obligations, Bristol City Council (BCC) Procurement Guidance and evidence collected from the consultation exercises, Safer Bristol will re-commission the majority of adult drug and alcohol treatment services, including Supporting People drug and alcohol accommodation and floating support services, with a new recovery orientated treatment model expected to become operational in November The contracts are expected to be awarded in August 2013, with the target commencement date of November 2013 at which time all current services will be decommissioned. Those services that are out of scope will be integrated within the proposed model, contracts will be renegotiated with new levels of funding and outcome focused performance targets. It is likely that TUPE will apply if there is a change in service provider, which may lead to a longer implementation time, but it is expected that the new model will be fully operational by January Recovery Model The model that we are implementing is driven from various national and local strategic priorities. This structure has drawn on the feedback we have gained from stakeholders in both the pre-consultation and formal consultation stage. All clusters will contribute to the outcomes set out in the outcomes framework. In the new model, clients new to the treatment system or those re-presenting for treatment will be expected to enter via the engagement cluster and move through change to completion and into community based support networks. During and throughout a client s treatment journey, they will receive ongoing integrated assistance from both the support and housing support clusters if required. When the new model is operationally embedded, those clients already in treatment will have their needs reassessed and goals revisited to better align their care with the new services. 30

31 Figure 6: Recovery Model The Bristol recovery system will comprise of five integrated clusters: 1) Engagement: During the engagement phase clients will begin to get help with their substance misuse. At this stage of a client s journey they will have access to a triage, comprehensive assessment and recovery planning service. This will enable them to access appropriate recovery-focused treatment and support. We envisage key components of this cluster to be: Triage, comprehensive assessment and recovery planning. Low threshold and brief interventions. Needle and syringe provision. Harm reduction and healthcare interventions. Transition from YP services. 2) Change: During the change phase of a client s journey they will have access to a fully integrated treatment service enabling clients to stabilise and reduce their drug/alcohol use, facilitate recovery and promote health and wellbeing. We envisage key components of this cluster to be: Care coordination and recovery planning. Specialist treatment provision. 31

32 GP substance misuse liaison workers. Inpatient/community detox and stabilisation. Structured psychosocial interventions. Family support. CCA for access to residential rehab.* *There will be a residential rehab framework for approved providers that will be procured separately. 3) Completion: The completion phase of a client s journey will deliver interventions to enable people to become drug or alcohol free and recover. This will include promoting and supporting reintegration to other services such as training and employment. As recovery involves areas of work that treatment services are not able to provide directly this will involve a high level of partnership working with agencies that can provide these services. We envisage key components of this cluster to be: Access to training, education and employment. Relapse prevention/aftercare. 4) Support: These services will enhance and develop the support that is offered to clients through the engagement, change and completion clusters in order to help aid their recovery. We envisage key components of this cluster to be: Tackling discrimination and stigma in the community. Advocacy. Support for carers and concerned/significant others. Peer support opportunities. 5) Housing Support: Clients will be able to access housing, via Bristol City Council s Housing Support Register, during any stage of moving through the recovery model. We envisage key components of this cluster to be: Accommodation based support. Floating support. 32

33 7.2 Substance Misuse Recovery System Outcome Framework Safer Bristol will be using an outcome based commissioning process. An outcome-focused approach is not overtly prescriptive in the specification about the services being commissioned. The service specifications will detail the outcomes being sought and the target cohort of clients identified in the needs assessment and consultation exercises. The outcomes framework is set out below. The outcomes in the Green (bottom) box are the nationally set Public Health Outcomes being sought for service users. It will be the achievement of these outcomes that will determine the funding available for Bristol and used as a comparison of Bristol s performance nationally. With the exception of 2.15 Successful Completion of Drug Treatment, service providers will not be expected to individually evidence these outcomes as part of their reporting requirements as they are achieved within the context of integrated working. Service providers will be required to evidence the achievement of the best practice outcomes in the Yellow (middle) box. This will be evidenced through various performance measures including, but not restricted to, National Drug Treatment Monitoring System (NDTMS) measures, Treatment Outcome Profile (TOP) forms and Outcomes Stars. 33

34 Figure 7: Outcome Framework 34