The Isle of Wight Drugs and Alcohol Needs Assessment 2013

Transcription

1 The Isle of Wight Drugs and Alcohol Needs Assessment 2013 Full Report March 2013 IoWD&ANA2013.doc 0 30-Mar-13

2 Table of Contents 1 Executive Summary 2 2 Introduction and context 13 3 Needs Assessment NDTMS Data sets 16 4 TOPS 32 5 Criminal Justice (DIP) 44 7 Alternative Data Sources 53 8 Alcohol 70 9 Service User and Stakeholder Engagement 2011 and Partnership Review and Performance Provider Review and Performance Analysis of Long Term Client in the Island s Treatment System Options for improvement in service and outcomes VFM and Cost Impact of Services Service Modelling and Treatment Planning Implications Recommendations 156 IoWD&ANA2013.doc 1 30-Mar-13

3 1 Executive Summary 1.1 The performance of Isle of Wight s Substance Misuse treatment system has fluctuated in recent years. This needs assessment has reviewed the baseline needs from the substance misusing population within the Isle of Wight and identifies trends and patterns in the prevalence of substance misuse to support the DAAT and its wider partnership to respond to the demands for treatment in the future. 1.2 A Substance Misuse Needs Assessment is an essential part of the treatment planning and commissioning cycle. It reviews the demand for services, compares this to relevant regional and national baselines and assesses performance of the local partnership over a given period. Data used to support the needs assessment comes from a variety of sources. A central data source is the National Drug Treatment Monitoring System (NTDMS), which is critical as both a tool to assess service demand and service performance. Combined with other data sources the needs assessment can address trends in presentation and need which will serve as indicators of the demand for treatment and inform the drugs and alcohol intervention priorities for local partnerships going forward. 1.3 In Isle of Wight spent 1.7M on community based substance misuse treatment on the Island. The outcomes from this expenditure have been numerous, however in headline terms Isle of Wight achieved 100 new entries into treatment, 438 people in treatment and 98 people exiting the treatment system. Planned completions for Isle of Wight represented 52% of treatment exits which compares well with 48% in the South East and 48% nationally. 1.4 Successful completions are a critical measure of drug treatment and successful outcomes are a reward element which accounts for 20% of the drug treatment budget. Moreover the measure of successful completions as a proportion of the total number in treatment is performance indicator 2.15 of the Public Health Outcomes Framework. The Isle of Wight achieved 12% successful completions as a proportion of all in treatment for Opiate users up to Quarter 2 in , compared to 9.8% for the South East and 8.7% nationally. This is a string set of results and shows a real shift in the last few quarters to increase successful completions. 1.5 For non-opiates the Isle of Wight achieved 25.3% successful completions as a proportion of non-opiate clients in treatment, compared to South East with 42.3% and nationally with 40.4%. Clearly effort is needed to bridge these comparison gaps. 1.6 Demand for Opiate services across the country seem to be declining albeit very marginally. The Glasgow University estimation tool is a critical mechanism to estimate the prevalence of substance misusing populations in local areas. The opiate and/ or crack users (OCU) estimate for Isle of Wight provided by Glasgow University for 2010/11 shows there are 697 problematic crack and/or opiate users on the Island with a penetration rate into services of 39%, which is a decrease of 3% on the penetration rate for the previous year. However this is above the South East average penetration rate of 36% but below the national penetration rate of 41%. 1.7 Treatment Bulls eyes have been developed for the Isle of Wight and these indicate that in 2011/12 the Isle of Wight had 471 people in treatment of which 356 were men and 115 were women. This is a decrease from the base line position of 591. IoWD&ANA2013.doc 2 30-Mar-13

4 1.8 Isle of Wight Opiate and Crack users have been plotted and using the Glasgow estimate of 697 OCUs. By taking those already in treatment, those in treatment last year and those known to the treatment system there are some 318 treatment naïve opiate and crack users in the community not presenting or having not ever presented to services. This represents 46% of the estimate and would suggest that currently the treatment system is providing for just over half of the potential demand locally for opiate and crack users. The penetration rate for for opiate and crack users is 39% which shows a slight decline on the performance in when the penetration rate was 42%. The 39% penetration rate is above the South East Average (36%) but below the national average (41%). 1.9 Treatment maps for substance misuse have been developed. These show that in there were 100 clients that were referred into tier 3 treatment on the Island, and of these there is a strong proportion of clients coming via self-referral, 56% but with lower than expected proportions coming from the criminal justice system with CARAT 10%, CJS Other 9% Probation 1% and Arrest Referral 0%. 4% came from GPs, 9% from drug services and 11% other. Of those in treatment there is only a limited degree of in service transfer between providers Indeed by transferring clients between each other providers may be able to better ensure that the treatment needs of the client are more effectively met. Evidence has been proposed by treatment providers to confirm that there are often referrals from one provider to the other but this is somehow only happening to a limited extent to clients already in tier 3 treatment and hence registered to a particular provider Opiate and/or Crack users (OCU) are the largest set of clients (76%) in the Isle of Wight treatment system. This suggests that the treatment system is heavily focused on opiate use which in terms of tier 3 provision is relatively typical of partnerships. 14% of users in treatment were cannabis users. Glasgow estimates suggest a higher level of crack use on the island but this has not been evidenced through this needs assessment and crack is not a substance that is being presented in the same volumes as parts of the mainland National data suggests that there is greater difficulty in fulfilling the recovery agenda with clients in prescribing services many of whom have been in services for over four years. This shows a residual group of long standing clients who seem reluctant to move towards drug free recovery. In there were 437 people in treatment across all Isle of Wight providers, 61 had been in treatment from between 2 and 4 years and 169 had been in treatment for more than 4 years. Moreover a closer examination shows that there are 120 clients in treatment for over 6 years which is a particular concern both for the National Treatment Agency (NTA) and the partnership alike. Efforts have been put in place to address this large number of long term clients, most of whom (96%) are clients who use opiate The providers with the highest volume of clients were IDAS with 322 (74%) clients, Cranstoun CDA with 88 (20%) and Get Sorted 16 (4%). There is a broad reflection of the island s demographic profile in substance misuse treatment. Women are clearly under-represented in treatment in the community but at 31% hold a consistent rate with the South East and nationally. The ethnic profile is almost exclusively white Alcohol admissions to the treatment system are growing on the Isle of Wight. In there were 150 alcohol referrals, with 215 in treatment and 111 treatment exits. The IoWD&ANA2013.doc 3 30-Mar-13

5 highest volume of referrals came from self-referrals and or referrals from family or friends with 64 referrals or 43% of all referrals. The next highest was Health and Mental Health Services, including GPs with 39 (26%), and Criminal Justice System with 25 (17%) Isle of Wight is hitting a 51% successful completion rate for its alcohol users which is a strong achievement rate. This suggests that the approach to treatment for just over half of clients has been appropriate at least to enable them to complete their treatment successfully either by reducing their consumption or by enabling them to complete alcohol free. The figure for un-planned exits for Alcohol is however 48% which is high as just under half of clients have dropped out of treatment 1.16 Estimates from the North West Health Observatory have been used to assess local alcohol profiles across England. For the Isle of Wight 14.6% of those over 16 are estimated as being abstinent, 73% are lower risk drinkers, 20% increasing risk drinkers, 7% higher risk drinkers and 13% binge drinkers. Using the 2012 population profile this would suggest the island has some 17,181 alcohol abstainers, 86,494 lower risk drinkers, 23,065 increasing risk drinkers, 8,120 higher risk drinkers and 15,063 binge drinkers. This is profiled in the chart below Clearly these estimates seek to place the whole population in one or more of these categories, however in comparison the presentation to service is low with 215 Alcohol clients in treatment. Another indicator of the demand for alcohol services is Hospital admissions for alcohol related harm (NI39). A review of this measure in the last 10 years has shown a growth in alcohol related hospital admissions from 620 in 2002/03 to 1,193 in almost doubling over this period. It is clear from this data that Alcohol is an increasing concern locally and one which the treatment system needs to address. The Performance of the Partnership 1.18 The partnership has not achieved the baseline volume of successful completions for opiates and non-opiates. Whilst non-opiate successful completions have seen a continuous downward trend, opiate successful completions have since shown growth. As the numbers in treatment have not changed significantly the lower volume of successful completion has had an impact on the measure of successful completions as a proportion of the numbers in treatment, placing the Isle of Wight outside of the top quartile performance range This is a particularly of a concern for the non-opiate cohort, this would include users of cocaine, cannabis, diazepam, party drugs and even legal highs all of which are drugs of choice used in the community Planned exits from treatment are above cluster average for opiates and equal to Cluster average for non-opiates. There were 30% more treatment exits in compared to last year, with a higher proportion of planned exits, however there has also been an increase on the number recorded as having dropped out of treatment There has been a growth in the number of new treatment episodes compared to however the low level of new treatment episodes during means the overall numbers in effective treatment have declined. What is encouraging is the partnership has had growth in the volume of new treatment episodes and has maintained a good ratio of OCU and non-ocu clients new to treatment in , 60% and 40% respectively. The partnership is good at retaining clients in treatment and as these IoWD&ANA2013.doc 4 30-Mar-13

6 clients move through their treatment journeys this will have a positive impact on the numbers in effective. The Performance of substance misuse treatment providers 1.22 The volume of clients being recorded as dropped out of treatment is high, particularly with Cranstoun, for whom clients that have dropped out account for 30% of all exits, higher still for non-opiate clients. There have been low number of clients transferred between providers and none have successfully continued their treatment. In both instances this could be a result of inaccurate data recording processes and the lack of outreach and re-engagement of clients into treatment. Addressing this could have a positive impact on successful outcomes and number in effective treatment performance, as those clients that leave treatment in an unplanned way could have successfully completed or been retained in treatment An additional consideration needs to be made when looking purely at successful completions. In essence these charts show growth and or decline in performance in the volumes achieved since In the last 12 months IDAS has maintained a pattern of growth in the volume of opiate successful completions whilst Cranstoun has maintained a pattern of decline for both opiate and non-opiate successful completions, with the a more rapid decline for the non-opiate. Overall however for the partnership the pattern is one of slight decline. There is evidence of growth in the new treatment episodes for the majority of providers. This would indicate as the new clients mature in treatment the potential for higher volumes of successful completions exist However there are some strong factors that affect the ability for treatment providers to succeed in growing year on year. Firstly capacity is critical, providers need to have the capacity to maintain growth, secondly and most importantly clients need to be available to engage and this suggests an increase in numbers entering treatment and a prevailing commitment of new treatment entrants to see their treatment through to completion. This is critical to any successful scenario Using the Treatment Outcome Profiles (TOPS) review and exit data provided by NDTMS it is evident that the partnership is showing good results for the proportion who abstain from drug use at 6 month review and exit, with performance either within or exceeding expected abstinent rates, this is particularly evident for those clients citing the use of opiates or crack. This improvement is also seen the numbers of days used by the cohort of clients in the 28 days prior to the TOPS review, which shows declining levels of use Moreover the overall satisfaction with physical and psychological health and the quality of life is reported higher at treatment review and then at exit compared to the start of treatment. Indeed key to sustained recovery includes access to employment opportunities and stable accommodation. In both areas the partnership is performing beneath the national average, with fewer clients engaged in paid employment and a higher proportion reporting housing problems when leaving treatment From the Diagnostic and Outcomes Measure Executive Summary (DOMES) report the partnership is showing good performance on the successful completions and representations data of the opiate using clients in treatment which is at or around cluster top quartile range of performance. The non-opiate successful completions and representation data on the other hand has seen a decline in performance and consequently the Isle of Wight is performing below the top quartile range. The change in the number of clients in effective treatment is following the national trend, whilst non- IoWD&ANA2013.doc 5 30-Mar-13

7 opiate clients in effective treatment has gone against the national trend showing growth against baselines. However with respect to employment opportunities and stable accommodation, in both areas the partnership is performing beneath the national average, with fewer clients engaged in paid employment and a higher proportion reporting housing problems when leaving treatment The number of clients in contact with the DIP but not in contact with the treatment system shows there were 103 compared to the 12 in treatment in , 12%. The profile of these clients differs to the wider treatment population in that a higher proportion are non-opiate drug users with 25% cannabis,19% crack and 17% cocaine. Quarter 2, shows the volume of clients referred through the DIP that engaged in structured treatment is very low and makes up around 8% of the total treatment population. With 60% of DIP referrals starting a structured treatment within 6 weeks of referral this performance places the Isle of Wight within the 3rd quartile performance range. The successful completions data shows 8% successfully complete treatment as a proportion of the DIP clients in treatment, lower than the South East and national average It is clear that there is potential demand for drug treatment for those in the criminal justice system, however there seems to be some real barriers to converting need to treatment for these clients, who are a group that are notoriously difficult to convert to treatment. The greater concern is that the Home Office element of DIP funding has shifted from the Home Office to the Hampshire Chief Constable and future allocations are likely to be based on both perceptions of demand and historic delivery. Primary Research Findings 1.30 A range of primary research has been carried out as part of this needs assessment. The key findings of these exercises are set out below. Stakeholder Survey 1.31 This survey was designed as an introductory questionnaire in part to illicit general views of the substance misuse system on the Island as well as to engage key partners and agencies in the needs assessment. The survey was completed by 51 stakeholders and a 46% response rate was achieved It is clear from this survey that there are some extremely committed stakeholders to the drugs and alcohol treatment system on the Island. There is equally a strong sense that people are passionate about the services that the Island provide and that they are committed to ensure that the services are as effective as possibly in delivering benefits to treatment clients. It is interesting that there are differing views as to the priorities of these services, however there are some clear priorities in particular to support clients on their journey to drug or alcohol free recovery, as well as the commitment to supporting behavioural change for treatment clients However it is equally clear that the local drugs and alcohol partnership needs to work to build a consensus with this stakeholder group to ensure that there is a common approach to supporting referrals to treatment and to ensure that the partnership has clearly defined priorities for treatment and for tackling drug and alcohol addiction and to preventing / reducing substance misuse. To this end the needs assessment will attempt to identify core priorities for the Island to take the drugs and alcohol services forward IoWD&ANA2013.doc 6 30-Mar-13

8 locally and to begin to define the targets within the drugs and alcohol treatment plans for Stakeholder interviews 1.34 The interviews carried out as part of this needs assessment were extremely helpful in establishing the context and history of local services and perceptions of need. What is encouraging is that all the stakeholders wanted to ensure that the whole approach to drugs and alcohol is addressed collectively with partner agencies and commissioned providers pulling together through a drugs and alcohol strategy A variety of points in the needs assessment have been embellished through these interviews and whilst it is not right to transcribe them in detail the essence of their findings have been extremely useful in clarifying the needs locally and understanding the way in which the Island s treatment system can support improvement, growth in achievements and to adapt to change effectively. Service User Questionnaire 1.36 Service Users are particularly supportive of current treatment providers and supporting providers in this way shows a positive relationship and clear commitment to working together to achieve treatment goals. In terms of the priority motivation to enter treatment the survey s respondents highlighted improvement to their health (79%), enjoying more the company of families, children and friends and reducing the stress caused by substance misuse with families, children and friends (both 57%). This was followed by increasing longevity of life, employment, reducing trouble with the police and generating more money. 97% of service users responding to the survey felt they had a good relationship with their treatment providers. 91.5% stated that the skills and abilities of their treatment provider are good. 87% felt their treatment provider was good at meeting their needs. 77% of respondents stated that they had a care /recovery plan 70% of these had developed their care/recovery plan with their key worker. These are generally strong responses and this reinforces the strong links with these client s treatment providers With respect to recommendation for the future, several referred to the importance of aftercare provision, after hours services and general service access across the island. There were also concerns that some services needed to be accessed on the mainland and convenience and cost was seen as a factor in these concerns. Specific provision and improvements wanted were; greater GP access through treatment, better information and communication about what s available. Essentially the survey has provided a strong set of returns confirm the general support clients have for the way services are currently run. Service User Focus Groups 1.38 Two focus groups were held on the Island and the main purpose of these focus groups was to give service users and ex-service users the time and the space to explain what it is and was like for them in the treatment system on the Isle of Wight. There was more female representation in the ex-service user group than in the in treatment group, this is also reflective of the general low female to male ratios in treatment. Participants were in or had been in treatment to address alcoholism and drug misuse including opiate, crack, IoWD&ANA2013.doc 7 30-Mar-13

9 cocaine and a range of poly substance misuse and the length of time in treatment spanned from 2 to 20 years although in some case not all spent on the island The two focus groups were made up from different sets of people at different stages of their drug or alcohol recovery. The Result+ group, which consisted of ex-service users, seemingly had a clearer focus on the whole journey enhanced by their commitment to support people through treatment and onto drug and alcohol free recovery. In particular they were driven to provide pier led support towards aftercare. Many of the group saw from a personal perspective the benefits of this approach to peer supported aftercare. However the focus group with current treatment clients saw individuals who were far more immersed in their treatment experiences and their current position on their journey to recovery. It was clear from this group that they had strong support for their treatment providers and that they were benefitting from this experience It was also clear that there are different perceptions of treatment provision by alcohol and drug clients. Essentially drug users were preoccupied with substitute prescribing from a stabilisation and then a recovery perspective. Whereas alcohol misusers were more aware that they needed one to one support to tackle their alcohol addictions, indeed some had previously been prescribed alcohol reactive medication which was deemed awful and repugnant In summary the two groups felt that: There is real support for providers particularly from current service users A general concern as to the adequacy of detox provision on the Island Strong conviction for the need for drug use stabilisation before drug free recovery On-going support of provision for aftercare is critical Support for service user groups and provision of resources to maintain this important component of aftercare support. Long Term Opiate Clients 1.42 There are 120 clients who have been in treatment for over 6 years with the some being in treatment for up to 20 years. The demographics of the long term clients in treatment on the Isle of Wight are clear. They are all long term opiate clients, the majority are male (67%) and 70% are aged between 30 and 44 years. 42% been in treatment for seven years although there are some who have been in treatment on the island for up to 20 years In some cases these clients have had treatment elsewhere on the mainland and or in the criminal justice system. From a clinical treatment perspective these have had various doses of substitute prescriptions but essentially all have been on a maintenance regime for a long time. Whist this has created stability there seems to have been little historic drive to move these clients on to drug free recovery. In some cases members of this cohort are sufficiently instable to shift their maintenance treatment but in other cases there is a clear opportunity to free this part of the treatment system up and move some of these clients on Essentially there are five or six main options to treat these long term clients and providers are applying the majority of these approaches, certainly since July last year when this issue became more of a priority for the Island. In some instances for some clients these are sequential. These are: Undertake clinical reviews for all long term clients IoWD&ANA2013.doc 8 30-Mar-13

10 Review the stabilising factors of substitute prescribing and to review the context for the client to move on from their maintenance treatment to a recovery focus to their treatment For all clients that meet the points above, to commence an intensive reduction of substitute prescribing to bring them in line with NICE guidelines for detox and rehab Continue to offer community, residential detox and residential rehab Familiarisation with Result+ members to begin an awareness and transition to aftercare opportunities on the Island. To keep a close eye on re-presentation of clients that have proceeded through this transfer from maintenance to recovery treatment and to identify what would work for them next time. VFM 1.45 Addressing the cost impact of substance misuse locally and hence its value is important for partnerships. The NDTMS have developed a tool that can support a better understanding. The VFM tool uses historic drugs data matched with crime and offending patterns and other core health and social care costs to estimate the cost of problematic drug use if there were no provision for this key drug user group. For the Isle of Wight this costs is estimated at 69.6m over the next three years. However based on a budget of 5.3m over the spending review period there is a net benefit of 19.5m. Therefore based on 2012 performance the Isle of Wight Drugs and Alcohol treatment system generates a cost benefit ratio of 1: In short for every pound the partnership spends they generate a cost benefit of Another approach to cost assessment is the cost effectiveness tool. This NDTMS tool calculates the unit cost of delivering component activities within the treatment system and compares this to the top performing quartile and the national average. The cost per day of community prescribing is 9.32 compared to 5.08 for the top quartile and 6.19 nationally Subsidy levels per head of beneficiary have also been calculated based on Tier 3 and 4 interventions only and this suggests that from a partnership perspective that in , 759 beneficiaries were achieved (including treatment entries, those in effective treatment and successful completions) and based on a total budget of 2,016, this calculates a subsidy per outcome of 2, (n.b this includes all DAAT overhead costs as well as treatment costs) individual breakdowns for treatment providers are contained in section 14 of the assessment. This will act as a strong benchmark going forward. IoWD&ANA2013.doc 9 30-Mar-13

11 Treatment Targets 1.48 Partnership targets have been set by analysing outcomes for the last two years and taking the highest number of outcomes and increasing them by 20%. This should be achievable through the consolidation and improvements set out in the recommendations below. These targets are based on opiate and non-opiate users and are focused on the core target requirements of the National Drugs Strategy. Partnership Performance Indicator Target New Treatment Episodes (all drugs) 168 Clients in Treatment (opiates) 469 Clients in Treatment (non-opiates) 102 Clients in Treatment (all drugs) 566 Treatment Exits (all drugs) 160 Successful Completions (opiates) 65 Successful Completions (non-opiates) 52 Successful Completions (all drugs) 116 Successful Completions as % of those in treatment (opiates) 14% Successful Completions as % of those in treatment (non-opiates) 51% Recommendations 1.49 This Substance Misuse Needs Assessment has highlighted a range of information and research data about the needs of different treatment clients presenting to services on the Isle of Wight. The key focus of the needs assessment has been to review the existing utilisation of treatment services. The Isle of Wight has a set of clients, reflecting its population. Problematic drug users remain the primary focus for treatment provision and the Isle of Wight has commissioned services to reflect the needs of these clients. Referrals into services are being channelled in a variety of ways with self-referral still being the strongest route. However referral pathways need to be built with all potential sources and this should reinvigorate the DAAT especially as now it is part of the Council s Public Health team. Across those in treatment, opiate and/or crack, opiate and crack users are the most prevalent, although there is an increasing volume of alcohol presentation. The Isle of Wight s service users have significant defined levels of opiates use as their main drug of choice. Assessment indicates that problematic alcohol use is an increasing concern locally as well as being a strong secondary substance to Opiates and other drugs. However there are still levels of unmet need, with a sizeable proportion of OCU and high risk Alcohol users not entering the system It is also the view of this needs assessment that cannabis is a high use drug (particularly if crime/possessions rates are taken into consideration) although there are low levels of presentation to services. In some case the use of cannabis is almost as normalised as the use of alcohol. Moreover the strong opiate driven services on the island have always been a priority and this would have masked other substances which are prevalent in the community. Legal highs have also been stated as a significant concern locally, although there is little evidence in the current treatment system of addressing this re-emerging IoWD&ANA2013.doc Mar-13

12 problem. In short non-opiate pathways to treatment need to be reviewed to increase this component of the treatment system Problematic alcohol use is increasing both as a primary and secondary drug of choice and the implementation of the island s alcohol strategy is a high priority to meet the increasing potential need for services. However the contrast between those estimated to have an alcohol problem and those in treatment is great. The low level of presentation against estimated need suggests a level of treatment naivety which needs to be challenged As with all forms of substance misuse, many people are reluctant to seek treatment. Barriers to accessing services are well-known and service providers must address/mitigate these Aims of the Integrated Drug and Alcohol Treatment Service should be: To offer personalised opportunities for those using drugs and/or alcohol to move towards total cessation. To reduce the harm caused by substance misuse on the local community including contributing to a reduction in crime and anti-social behaviour To ensure that the principles of harm minimisation underpin the delivery of all interventions in order to improve the health and well-being of service users To deliver a non-judgemental and inclusive service which treats service users with dignity, respecting gender, sexual orientation, age, ethnicity, physical or mental health ability, religion, culture, social background and lifestyle choice To deliver services which are accessible, responsive and offer greater service user choice To improve the outcomes for children of service users by reducing the impact of drug and alcohol related harm on family life and to promote positive family involvement in treatment To facilitate a co-ordinated and holistic approach to recovery which emphasises the inclusion, or re-entry into society of service users by working with a range of local partner agencies To reduce the impact of drug and alcohol misuse on the wider public sector economy by promoting effective treatment and harm reduction responses in a range of settings including primary and community health care, mental health and criminal justice services To identify and safeguard vulnerable adults and children of adults who use the services 1.54 The Isle of Wight s partnership between its providers and with other statutory agencies has been well established but there is a current opportunity to revamp these relationships and to build a stronger set of local commitments to drugs and alcohol. It is on this basis that the following recommendations and treatment plan priorities are made: 1.55 Strategic Recommendations: Establish the management of drugs and alcohol treatment planning, commissioning and performance management through the new Public Health team within the Council Establish evidence based commissioning and treatment planning by using this needs assessment and in establishing an appropriate performance management approach for the island s drugs and alcohol treatment system IoWD&ANA2013.doc Mar-13

13 Maintain the priority of Substance Misuse Treatment Services through current and future changes to funding streams for Substance Misuse in Isle of Wight Develop a Drugs and Alcohol Strategy for the Island Develop and maintain annual treatment plans which fit into the Public Health commissioning priorities to tackle addictions in the community The Isle of Wight Joint Commissioning Group needs to establish or become an expert group led by Public Health The Isle of Wight DAAT needs to maintain up to date data and to review performance against the treatment plan 1.56 Key Treatment Plan Priorities: Isle of Wight has seen a decrease in opiate presentations over the last three years. However this does not address the wider treatment naive population. Opiate users should always be a priority group within substance misuse treatment provision Services will need to be maintained and strengthened for non-opiate and other problematic substance misuse There is a clear need to plan for and target the increasing emergence of alcohol. Increase the numbers of those entering the treatment system Undertake a more dynamic approach to sourcing new clients and or targeting ex clients who may now be treatment naive Maximise the numbers of clients in effective treatment, this is currently falling and may affect future service success and impact Work to address the recovery agenda and drive forward the increase in Successful Completions for the Island Maintain the current focus on addressing the long term clients i.e. clients in service for more than 6 years Operational Priorities Set targets for the new treatment provision secured through the retendering exercise Support Result+ to develop more effective peer mentoring and support group provision potentially to include some level of out of hours support. Define service scope and capacity to expand the community focus of the work and to provide beyond the traditional 9-5 operational model, extending to more evening and or weekend provision where feasible Review and support aftercare and consider effective options to extend aftercare services Support providers to introduce assertive outreach services to support re-engagement and to engage new clients Target non-opiate and alcohol treatment provision with associated treatment options in particular psychosocial analysis, behavioural treatment and motivational interviewing. Seek to address the provision of community detox and work with provider arms in the Trust to support the retention of acute bed alcohol detox on the Seven Acres Site and the Real World Trust Work with partners to secure effective up to date data exchange on; A&E admissions, drugs and alcohol Hospital admissions, Ambulance service call outs and maintain a working review of Policing, drug and alcohol crime and IOM and Probation client data. IoWD&ANA2013.doc Mar-13

14 2 Introduction and context 2.1 A Substance Misuse Needs Assessment is an essential part of the treatment planning and commissioning cycle. In effect a needs assessment reviews the baseline demand for services in a local area, compares this were relevant to regional and national baselines and assesses performance of the local partnership over a given period. Data provided by NTDMS is critical to this process however this data is often retrospective data and by its nature it reviews what has happened in the recent past rather than estimating what is going to happen in the future. Nonetheless specific trends can be established which are strong indicators of the demand for treatment services and as such will inform the priorities the local partnership should address going forward. Chart 1: Commissioning Cycle (Commissioning for Recovery NTA 2010) 2.2 The commissioning of substance misuse treatment provision is co-ordinated by Isle of Wight DAAT on behalf of the Isle of Wight Joint Commissioning group. It is based on an analysis of local substance misuse needs with a focus on what is required locally. There has not been a treatment plan since when the last needs assessment was completed. 2.3 In the treatment budget was 3,162,951. This includes IoW s DAAT Adult treatment Budget, DIP, Drugs and Alcohol Tier 4, IDAS and the Prison Drugs Service. The breakdown within each of these headings provides more insight into the way the budget is spent. Contributory funding for this programme came from NHS 2,681,938 and IoW Council 481,013, although in both cases components of the programme are funded through the NTA, DoH, and Home Office Grant. 2.4 The commissioning of substance misuse is due to undergo a retendering exercise in IoWD&ANA2013.doc Mar-13

15 2.5 Recovery Agenda, National Drugs Strategy, commissioning priorities Each service has a responsibility to deliver drug treatment within the context of the National Drug Treatment Strategy to enable an: Increase in those reducing their drug and alcohol misuse and those achieving abstinence Increase in those reducing their offending include repeat offenders Increase in those improving health and well being Increase in those reintegrating with education, training and employment, housing & other services 2.6 Substance Misuse treatment provision in Isle of Wight is delivered through a range of tier 2 and 3 providers set out below and is based on commissioning intentions: Island Drug and Alcohol Service IDAS is part of the NHS on the Isle of Wight. It is a specialist Tier 3 community based prescribing drug treatment service. Open referral. IDAS also offers planned communitybased detoxification for dependent alcohol users. Services IDAS offer: Comprehensive drug and alcohol assessments Information and advice on harm reduction Needle exchange Hepatitis B and C testing and Hepatitis B vaccinations Care planning Substitute prescribing Clinics Psychosocial interventions aimed at reducing harm and facilitating change Specialist community alcohol detoxification Referral to other support services On-going support and information for families / friends / carers affected by someone else's drug or alcohol misuse Cranstoun CDA Isle of Wight Cranstoun provides: One-to-one key-working, using Brief Solution Focused Therapy, Motivational Interviewing, BTEI and Cognitional Behavioural Techniques Advice on Harm Reduction and Relapse Prevention Workshops: One-off group sessions providing advice and information regarding substance misuse Structured Groups including: "Motivational Enhancement", "Relapse Prevention" and "Cranstoun Choosing to Change", Breaking Free Programme. Onward referrals to relevant agencies both Statutory and Voluntary, including Residential Rehabilitation. Get Sorted The role of the Get Sorted team is to provide an under 24 s substance misuse service for young people. They provide a holistic, needs-led service for young people and their IoWD&ANA2013.doc Mar-13

16 families/carers affected by substance misuse. They also provide advice, consultancy and training to other agencies working with young people. They are a specialist team, offering friendly, safe, confidential up-to-date advice on drugs and alcohol use and harm reduction. Specifically they offer: screening and assessment an outreach service structured one-to-one sessions and group workshops in youth offending early interventions with education, pupil referral units and hostels specialist substance misuse counselling relapse prevention Recovery Café: Job Club 1st and 3rd Tuesday morning every month. Stonham Housing Support 2nd and 4th Tuesday morning every month Open access available, including Client IT facilities: - Monday: 1pm-4pm - Wednesday: 1pm-4pm - Friday: 1pm-4pm 2.7 Isle of Wight s DAAT is currently going through some transition. Whilst it currently sits within the council and is likely to continue to do so in the future, the pooled treatment budget will be transferring to the Isle of Wight s Health and Well-being Board, who will be deciding the contracts emerging out of Public Health next year. 2.8 The Isle of Wight is also undergoing a service retendering process in and this Needs Assessment aims to set some baselines for this service. Moreover this needs assessment provides details of the current state of need for substance misuse on the island and additional reviews of existing performance both of the DAAT and its main provider agencies. IoWD&ANA2013.doc Mar-13

17 3 Needs Assessment NDTMS Data sets 3.1 The National Treatment Agency (NTA) encourages each local partnership to undertake an assessment of need every year. A clear aim of the assessment is to distinguish between met and unmet need. There are many reasons why need can be unmet. 3.2 According to the NTA, the needs assessment should identify the following: What works in open access and structured drug treatment services and what unmet needs are there across the system Where the system is failing to engage and retain people Hidden populations and their risk profiles Enablers and blocks to treatment pathways Relationships between treatment agencies and harm profiles 3.3 Ideally, the needs assessment should be used by the Joint Commissioning Group to: Inform the annual treatment plan Make evidence-based commissioning decisions Inform and develop JCG strategy 3.4 By developing these areas, partnerships should develop a shared understanding of evidence-based need in relation to drug treatment services, which should help commissioning, treatment planning and the allocation of resources. The needs assessment is a systematic and strategic process which informs the Adult Treatment Plan, a document which sets out the partnership s strategy for service provision in the coming year. 3.5 This substance misuse needs assessment has been developed in accordance with the NTA guidance for partnership needs assessments. In particular, information has been used which has come from the National Drug Treatment Monitoring System (NDTMS) data sets as provided by the NTA. These show who is in treatment, prevalence rates and participation in the treatment process. This data has been used for the treatment bull'seye process and the treatment journey assessments. If was felt that, where practical, Isle of Wight DAAT has assessed other local data to draw together the full needs assessment. Treatment bull's-eyes 3.6 The NTA has provided all DAATs with a methodology for estimating the size of their unmet need. It is called the bull's-eye technique and is similar to a Venn diagram. The bull's-eye has four circles, each of which represents drug treatment populations between 2009/10 and 2011/ The process for calculating the treatment bull's-eyes has been taken from a database provided by NDTMS. The details of this information are set out in accompanying tables of data. 3.8 The information provided by the NTA sets out the data recorded by treatment providers operating within Isle of Wight, but only includes clients living in Isle of Wight. If a service provider is treating clients that live outside the geographical boundary, it is likely they are not included in the data. In short, these figures are solely for clients that have come to a service provider in Isle of Wight and that live on the Island. IoWD&ANA2013.doc Mar-13

18 What do the bull's-eyes show us? The inner most circle relates to those clients that were in treatment on March 31, 2012 The second circle were in treatment in but not in contact on March 31, 2011 The third circle represents those that accessed treatment in 2009/10 but who were not in treatment in The circle within the space between the second, third and fourth rings of the Bulls Eye represents those known to the Drugs Intervention Programme but who were not in treatment in and this data is compared with and Finally, the outer circle represents the drug users who did not access treatment in any year. These are called "treatment naïve". Treatment naïve figures are derived by adding all the individuals in treatment during the past 2 years and subtracting this figure from the Glasgow University Opiate and Crack User estimate for the Isle of Wight. Chart 2: All treatment clients by gender Bull's-eye 1 - All treatment clients by gender (Table 2) In broad terms, this bull's-eye shows the number of clients in treatment by gender, in contact recently and those no longer in contact with services It is clear that the number in treatment has at first risen and then in the last year gone down from 540 in to 591 in and 471 in In contrast DIP clients but not in treatment have risen in to 103, whilst having been 76 in but reducing by more than 50% compared to 229 in The figure for those in contact during the past 12 months has declined as has the figure for those no longer in contact. This would suggest that Isle of Wight is seeing fewer clients although they may be taking more clients through to effective treatment programmes. IoWD&ANA2013.doc Mar-13

19 Chart 3: Opiate and Crack OCUs NDTMS Bull's-eye 2 - Gender in crack and/or opiate using OCUs (Table 3) This shows that for opiate and crack users the gender split for the last three years data is broadly consistent at male 74%-73%-72% compared to female 28%-27%-28%. This bull's-eye has used data from Glasgow University ( ) which estimates that there are 697 crack and opiate users in Isle of Wight leaving a treatment naive population of 318. This suggests that the level of treatment naivety in the Islands population has declined slightly. However the estimate is based on a calculation and as such is likely to be out of sync with the reducing level of OCUs nationally and regionally. Whilst there has been a 5% reduction in the national OCU clients in treatment from 128,982 in to 122,712 in , regionally the figures show less than 1% decline in OCU clients in treatment from 11,932 in to 11,903 in Furthermore looking at the change in the number of OCU clients in treatment between and nationally this fell be 7% (131,264 in to 128,982 in ) and regionally this fell by 3% (12,242 in to 11,932 in ). This suggests that regionally change in the number of OCU clients in treatment in the last 3 years is less than the national trend of declining numbers. IoWD&ANA2013.doc Mar-13

20 Chart 4: All treatment clients NDTMS by drug type Bull's-eye 3 - All drugs (Table 4) This Bulls eye shows the main drugs that Isle of Wight clients presented to services in , and, (these represent the major problematic substances used by clients in treatment). In total, 471 clients were in treatment to the year end March 31, In , 272, 58% presented with crack and/ or opiate as their main drugs used, this is a reduction in numbers on when there were 294 clients (50%) in treatment presenting with crack and/or opiate use 271 presented with opiates as their main drug of choice (58%), this too has shown a decline in numbers since , as then it was 291 (50%) presenting with opiates as their main drug of choice 26 presented with crack cocaine as their main drug of choice (6%) this also has declined since when it was 31 (5%) that presented with crack cocaine as their main drug of choice Powder cocaine users have decreased from 4% in to 2% in of those in treatment as has cannabis which has decreased from 21% in to 13 in % The DIP bulls eye show the numbers known to the DIP but not in treatment. These patterns remain consistent across the bull's-eye and DIP figures show an increase in clients who are not presenting to services, which may be a reason for the decline in numbers across all these key substances. IoWD&ANA2013.doc Mar-13

21 What this suggests is that whilst there are fewer clients in the system more of them proportionately are opiate and/ or crack users implying that those with the most problematic substance misuse are still being targeted. Of those citing problematic drugs almost all (99.6%) cited opiates as primary drug. Moreover given that these numbers are falling nationally it is important to review treatment exits and recovery rates to establish if the performance of the partnership is strong with a smaller number of clients. Chart 5: Opiate and Crack Users, OCUs by ethnicity NDTMS Bull's-eye 4 - Ethnic breakdown of crack and/or opiate using OCUs (Table 5) The ethnic composition seems to have remained similar in the last 3 years. Of those OCU s in treatment the ethnic profile is dominated by the White population which almost makes up the entire treatment population at 97% in to 98% in both and The Asian and Black population has reduced from 1% in to 0% in both and In contrast to the DIP client base which although reduced in numbers presented 90% White population, 2% Asian, 2% Black and 5% other populations in to 100% White population in and IoWD&ANA2013.doc Mar-13

22 University of Glasgow Prevalence Estimates and Methodology The Home Office commissioned a research study to produce prevalence estimates of problematic drug users (PDU) at both local and national levels. It should be noted that the term PDU refers to users of opiates and/or crack, including those who inject either of these drugs. The figures do not include people who inject other drugs or use powder cocaine, amphetamine, ecstasy or cannabis. The term PDU has now been replaced by the term OCU It is expected that all partnerships will use these Home Office estimates as part of their needs assessment process each year. This needs assessment is using 2010/11 OCU estimates which is the latest available estimate from Glasgow University. How these estimates were produced The Capture Recapture (CRC) process was used to provide the majority of local DAAT estimates. Essentially, this method estimates the "hidden" or "unknown" drug populations by assessing the overlap between known problematic drug users who appear in data sets (such as treatment data and criminal justice system data) and using this information to estimate the number who do not appear in any of the data sources. Once the hidden population is estimated, it is added to the total "known" population to provide an estimate of the whole population of problem drug users. Here is a simple example showing how this might translate into estimating populations: In "A Town" 1,000 OCUs are in prison, 1,500 are in treatment and 100 are in both. We can then calculate the total OCU population by inversing the ratio of overlapping OCUs in prison 10/1 and multiplying the known number of treatment users by this ratio (1500 x 10/1 = 15,000) To supplement this calculation four other data sources were factored in: NDTMS (Tier 3 and 4) only National offender management service offender assessment system (OASys) Drug users cautioned and convicted under the Misuse Of Drugs Act (1971) for offences involving possession (or possession with intent to supply) heroin, methadone, and or/crack cocaine from the Police National Computer (PNC) Counselling, assessment, referral, advice and through care (CARAT) teams working with drug users in prison The opiate and/ or crack user, (OCU), estimate for Isle of Wight provided by the University of Glasgow for 2010/11 shows at its mid-point there are 697 problematic crack and/or opiate users in the Island. Local estimates of crack and/or opiate (OCUs) accessing treatment calculated from bull's-eye data 2011/12 (this has been calculated using the 2009/10 University of Glasgow UCU estimates) o Combined numbers in treatment 272 o Estimated crack and/or opiate OCUs 697 o Estimated Treatment Naïve 425 o Proportion of treatment Naïve (425/697) 61% o Penetration Rate of those in treatment (272/697) 39% IoWD&ANA2013.doc Mar-13

23 Local estimates of opiate users accessing treatment calculated from bull's-eye data 2011/12 (calculations using 2010/11 OCU estimates,) Number in treatment 271 Estimated number of opiate users 572 Estimated treatment naïve 301 Proportion of treatment Naïve (301/572) 53% Treatment penetration rate for opiate users in Isle of Wight (271/572) 47% Local estimates of crack users accessing treatment calculated from bull's-eye data 2011/12 (calculations using 2010/11 OCU estimates) Numbers in treatment 26 Estimated number of crack OCUs 140 Estimated treatment naïve 114 Proportion of treatment Naïve (114/140) 81% Treatment penetration rate for crack users in Isle of Wight (26/140) 19% The table below shows South East-wide figures for this calculation. It suggests for Isle of Wight 697 problematic drugs users with a penetration rate into services of 39%, which is a decrease of 3% on the penetration rate for the previous year. This is 3% above the South East average penetration rate of 36% but sits below the national penetration rate of 41%. Table 2: Isle of Wight, South East, National comparison table showing 2009/10, 2010/11 and 2011/12 treatment penetration rates for crack and/or opiates Partnership Isle of Wight South East National 2010/11 Estimated OCU Population (University of Glasgow) , , /10 Estimated OCU Population (University of Glasgow) , , /10 OCU Population compared to 2010/ ,975-7,398 Numbers in Treatment 2009/ , ,549 Numbers of Crack and/or Opiate Users in treatment 2009/ , ,264 OCUs as a % of Treatment population 2009/10 56% 51% 52% Penetration Rate 2009/10 41% 34% 41% Numbers in Treatment 2010/ , ,892 Numbers of Crack and/or Opiate Users in treatment 2010/ , ,982 OCUs as a % of Treatment population 2010/11 50% 42% 42% Penetration Rate 2010/11 42% 36% 43% Numbers in Treatment 2011/ , ,516 Numbers of Crack and/or Opiate Users in treatment 2011/ , ,712 OCUs as a % of Treatment population 2011/12 58% 52% 35% Penetration Rate 2011/12 39% 36% 41% 2011/12 Penetration rate variation from 2009/10 baseline -2% 2% 0% IoWD&ANA2013.doc Mar-13

24 What this table indicates is that Isle of Wight seems to be showing a higher penetration rate (39%) in providing treatment for its Opiate and/or Crack users than in the South East 36% but below the national rate of 41% The estimates show that the numbers in treatment are increasing when one looks at 2009/10, 2010/11 and 2011/12 both nationally and regionally (although not in 2012) but they have declined in Isle of Wight and are lower than the numbers in The numbers of OCU in treatment however is in decline across Isle of Wight, regionally and nationally but for Isle of Wight the reducing numbers of those in treatment means that proportionally the numbers of OCU are likely to have a greater impact on the Island s penetration rate One way to try to address this is to increase the number of those in treatment and to prioritise OCU, in particular Crack users as this group present the lowest penetration rates, through targeted outreach and working with clients that are known to the treatment system but who are no longer presenting. It should be noted that the Glasgow Estimates for Crack have shown a significant decline, as in they were estimated at 411 and in they are more realistically 140, in fact this better reflects the numbers of Crack presentation to the Island s treatment providers. Treatment Journey Mapping Data 3.9 The diagram below is a treatment journey map based on information provided through the NTDMS Needs Assessment report. The treatment map is taken from data that shows how clients are referred from 7 main referral routes and other. This is critical to assessing where clients come from and how they access services. This is then translated in to clients in treatment with each of the main Adult services providers with separate exit routes. Agency transfers are set out on a different table to make it slightly less complicated. The 438 in treatment does not correspond to the treatment bulls eye data which is a separate cleansed NDTMS data set. IoWD&ANA2013.doc Mar-13

25 Chart 6: Treatment Journey Map (NDTMS Needs Assessment Data) IoWD&ANA2013.doc Mar-13

26 3.9.1 The table above maps out the treatment journeys, focusing on the main sources of referral, those in treatment by main service providers and the transfer between service providers of these clients and of those leaving the system. The data has been provided by NDTMS as part of the treatment mapping tool kit. In summary, the map simply refers to those clients who have moved into and through the treatment system in Isle of Wight over this period. Each of these elements of the treatment journey will be reviewed in further detail below. The treatment transfers between clients show that as a proportion of the 438 in treatment 5% clients are transferred between providers. This is particularly low as movement between providers provides the best options to support the client in their journey to recovery, preferably completing drug free. Chart 7: Treatment referral pathways (NDTMS 2011/12) The pie chart above shows clearly a solid volume of self-referrals (52%) to substance misuse providers. The overall criminal justice referrals are low with no referrals from DIP. The high volume of self-referrals gives a sense that whilst there may be people in the community that are treatment naive the self-referral route is still a strong route of referral suggesting that those that do come to treatment via the self-referrals route do so because they want to. This is important in that this is a critical ingredient to treatment completion and positive treatment outcomes. This is broken down in more detail below. IoWD&ANA2013.doc Mar-13

27 3.10 Referral Pathways compared nationally and regionally Table 3: Referral pathways (NDTMS 2011/12), Isle of Wight Compared to South East and England. Isle of Wight South East National N % N % N % GP 4 4% 609 7% % Self 56 56% % % Drug Service 9 9% % % Arrest Referral DIP 0 0% 592 7% % Probation 1 1% 417 5% % CARAT 10 10% 750 8% % CJS Other 9 9% 563 6% % Other 11 11% 720 8% % Total % % % Self-referrals represent the highest proportion of referrals for Isle of Wight (56%) higher than the South East (45%) and national (40%) profiles. There were no referrals from the arrest referral which is a concern in comparison to the South East 7% and nationally at 9% In total 20% came through the criminal justice system (probation, CARAT and CJS other). This was higher in at 22%. This total for criminal justice referrals is lower than the South East and national profiles of 26% and 31% respectively. On reflection there seems to be a need to maintain and or increase self-referrals where possible to assist clients to start a journey they will complete successfully. Active engagement and effective target marketing may assist this although it must be stated that this is a notoriously difficult task to achieve. The remaining profiles are broadly consistent to the regional and national profiles The numbers and profile of referrals to treatment by provider in is set out below. The highest volume of referrals were to Cranstoun CDA 49 (49%), n.b this was 61 (36%) in , followed by IDAS 45 (45%) of referrals. Table 4: Clients Referrals to key providers (NDTMS 2011/12) Provider Total Referrals N % Cranstoun CDS 49 49% IDAS 45 45% Get Sorted 6 6% Total % South East 8826 National IoWD&ANA2013.doc Mar-13

28 3.12 In Treatment From the NDTMS data for individual treatment providers there were 437 people in treatment with Isle of Wight providers, 61 had been in treatment from between 2 and 4 years and 169 had been in treatment for more than 4 years. These clients in treatment for 2 or more years are in treatment with IDAS, with 52% in treatment for more than 4 years. Table 5: Clients in Treatment (NDTMS ), Client in treatment 2-4 years and more than 4 years. % of In clients in treatme In treatment 2-4 In treatment 4 treatment nt years years + for more 2011/12 than 2 years Isle of Wight Clients In treatment by main provider % of clients in treatment for more than 4 years n n OCU n OCU The Island Drug & Alcohol Service (IDAS) % % 19% 52% Cranstoun CDA Isle of Wight % 0 0% 0% 0% Get Sorted % 0 0% 0% 0% Other % 0 0% 0% 0% Total of all providers % % 14% 39% South East DNA DNA DNA DNA DNA 15% 15% Nationally DNA DNA DNA DNA DNA 16% 17% What is clearly evident is that clients that are in treatment for the longest periods are in the opiate prescribing services. This suggests that there is greater difficulty in fulfilling the recovery agenda with clients at these services. Closer examination confirms that in the majority of cases a high percentage of those in treatment for longer than 2 years are opiate users. This suggests that some of these clients are simply taking receipt of their substitute scripts and not benefiting from other services on offer to assist recovery. However in reality there will always be some clients that need more time to stabilise their drug misuse before they can move onto recovery. The treatment system needs to be mindful to support these clients to move onto recovery and to free up capacity to tackle new clients It is clear that the percentage of clients in treatment between 2 and 4 years is slightly below the South East and national profile and has increased from 14% in Those clients in treatment for more than 4 years make up 39% of the Isle of Wight profile and this is significantly higher than the South East (15%) and Nationally (17%). This has also increased from 34% in This suggests the partnership has an exceptionally high proportion of clients that have been in treatment for a long time and this will need to be addressed. The concerns with a growing volume of long term opiate users in treatment will be examined in more detail in section 12 of this assessment Movement within the system also seems limited in Isle of Wight as shown in the Treatment map above. This suggests that there is little inter-provider transfers of tier 3 clients and that these clients are not moving across providers to secure the best approach to meet their care planning and treatment journey requirements. This approach needs to be considered for the partnership to respond effectively to the recovery agenda. It is clear that the two main IoWD&ANA2013.doc Mar-13

29 providers are referring clients to each other but this still does not transmit to clients in one service being transferred to the other provider to continue appropriate treatment The range of substances used by clients in the treatment system on the Isle of Wight in is set out in the table below. This data has been taken from the Treatment Bulls Eye tables provided by the NDTMS. Table 6: Clients in Treatment (NDTMS ) by Drugs use and by Gender Clients in treatment 11/12 All Clients Male Female N. % N. % `N. % Opiate &/or Crack Users % % 75 39% Opiate Users % % 75 39% Crack Users 26 3% 18 3% 8 4% Cocaine Users 10 1% 8 1% 2 1% Amphetamine Users 12 2% 10 2% 2 1% Cannabis Users % 83 15% 19 10% Benzodiazepines Users 28 4% 24 4% 4 2% Other Drug Users 22 3% 17 3% 5 3% Total % % % Opiate and/or crack users are the majority of users in the Isle of Wight treatment system. This makes up 37% of the total client population with opiate users on their own making up an overwhelming 36% with Crack 3% and 14% of users in treatment are cannabis users Exits and completions The table below sets out treatment exits in by provider and compares this with South East and England. The data represents those that exited services in this year. The highest volume of planned exits was IDAS with 26 exits which is 8% of those in treatment in that service and 68% as a proportion of the total exits from treatment. In comparison this was 24 exits in representing 7% of those in treatment and 50% from total exits. This was followed by Cranstoun CDA with 22 planned exits which represent 25% of those in treatment and 42% as a proportion of the total exits from treatment. This was 42 exits in representing 38% of those in treatment and 88% from total exits These percentage rates are useful to compare providers although it must be recognised that the client base is not the same in each service and that services vary between providers. From a partnership perspective the Isle of Wight achieved better performance in with 69% planned exit compared to 52% in , but remains higher than the South East and England both at 48%. Referrals onto other providers on the Isle of Wight are consistent with the South East and slightly below the national (25%). However the Isle of Wight s Dropped out rate of 16% is lower than that of the South East 22% and England 21%. IoWD&ANA2013.doc Mar-13

30 Overall for the Isle of Wight, 52% of the total exits were planned which is higher than the South East 48% and nationally 48%, which demonstrates a higher proportion of exits are successful outcomes. In this area of the partnership demonstrates its effectiveness. Table 7: Treatment Exits (NDTMS 2011/12) Provider Planned Referred on Dropped out Unplanned - Unplanned - prison other Total n % n % n % n % n % n % Cranstoun CDS 22 42% 19 37% 6 12% 4 8% 1 2% % IDAS 26 68% 2 5% 8 21% 1 3% 1 3% % Get Sorted 3 50% 0 0% 2 33% 0 0% 1 17% 6 100% All Isle of Wight Total 51 52% 22 22% 16 16% 5 5% 4 4% % South East % % % 182 2% 419 5% % National % % % 951 1% % % Tier 4 Treatment Provision 3.14 The level of Tier 4 treatment provision on the Island is relatively limited both in budget available and in the outcomes addressed in this needs assessment. The chart below sets out the treatment map for Tier 4 activity on the Island. The volume of clients in Tier 4 treatment in was 13 clients, 10 from IDAS and 3 from Cranstoun. In essence these were the referral sources of these clients into Tier 4. In discussion with Cranstoun they are questioning this as they are not aware of having made these referrals, however on second checking, the three referrals are clearly in the NDTMS Tier 5 treatment map database The Tier 4 providers are set out in the Tier 4 treatment Map. The distribution of clients seems to be evenly spread amongst 7 providers all offering specific specialisms However what is alarming is that there are no planned exits from this provision and only one referred on and one unplanned exit. What is clear is that 6 are still in treatment, with Tier 4 providers and the remainder (5) have returned to their initial local provider 3.17 Since 2012/13 additional funding has been released to Tier 4 treatment and in addition IDAS are developing a number of local community detox arrangements which may if successful mitigate the need for Tier 4 treatment for these clients. IoWD&ANA2013.doc Mar-13

31 Chart 8: Tier 4 Treatment Journey Map (NDTMS Needs Assessment Data) IoWD&ANA2013.doc Mar-13

32 3.18 Summary of key findings from NDTMS Needs Assessment Data Treatment Bulls Eyes suggest that IoW DAAT is seeing less clients and taking less clients through effective treatment programmes It is clear that the number in treatment has reduced from 591 in to 471 in , 20.3% reduction or 1/5 less clients The opiate and/ or crack users (OCU) estimate for Isle of Wight provided by Glasgow University for 2010/11 shows there are 697 problematic crack and/or opiate users on the Island with a penetration rate into services of 39%, which is a decrease of 3% on the penetration rate for the previous year. However this is above the South East average penetration rate of 36% but below the national penetration rate of 41%. There were 100 referrals into treatment in with self-referrals representing 56% and 20% through the Criminal Justice System (DIP, Probation, CARAT and other CJS). 9% came through Drugs Services, 11% came through other sources and 4% came via GPs The highest volume of referrals were to Cranstoun CDS 49%, IDAS 45% and Get Sorted 6% In there were 437 people in treatment with Isle of Wight providers, 61 had been in treatment from between 2 and 4 years and 169 had been in treatment for more than 4 years. These clients in treatment for 2 or more years are in treatment with IDAS, with 52% in treatment for more than 4 years. Those clients in treatment for more than 4 years make up 39% of the Isle of Wight profile and this is significantly higher than the South East (15%) nationally (17%). This has also increased from 34% in Data suggests that there is greater difficult in fulfilling the recovery agenda with clients at prescribing services Opiate and/ or Crack users are the majority of users in the Isle of Wight treatment system. This makes up 37% of the total client population with opiate users on their own making up an overwhelming 36% with Crack 3% and 14% of users in treatment were cannabis users From a partnership perspective Isle of Wight achieved better performance in with 69% planned exits from treatment compared to 52% in , but remains higher than the South East and England both at 48%. In summary the Isle of Wight in seemed to have performed slightly worse than in , with fewer clients and fewer referrals. However a key factor for further consideration and partnership priority is the need to move long established, mainly opiate users who have been in treatment with IDAS for more than 4 years, indeed this is further emphasised by the large number of those in treatment for over 6 years. Limited numbers in Tier 4 treatment (13 in ) and none with planned exits. This performance is relatively poor. However the DAAT commissioner is current prioritising Tier 4 treatment outcomes for IoWD&ANA2013.doc Mar-13

33 4 TOPS 4.1 The Treatment Outcomes Profile (TOPs) Annual Outcomes Report provides an opportunity for a more effective drill down on outcomes for people who have been through the treatment system. Specifically it provides data on the outcomes accrued in the first 6 months of treatment and by the time of their planned exit The TOPS report also has a summary section which provides an overview of drug, employment and housing outcomes and the drill down section allows for an in-depth review of all TOP related outcomes with the following or combination of filters to see the outcomes by; gender, age, referral source, drug combination, opiate or non-opiate and client engagement. 4.3 The TOPS review also provides data on the case mix in a local partnership. Case mix profiling is the process where expected TOP outcomes are adjusted for the complexity which surrounds a service user when they enter treatment, for example the concurrent use of crack cocaine interferes with opiate abstinence. If one area has a lot more crack than another, it would not be reasonable to expect the same level of abstinence in both areas. Case mix profiling makes these adjustments to the expected level of outcomes that can be reasonably anticipated. 4.4 There are 8 TOP areas where case mix is applied; six drug abstinence (opiates, crack, cocaine, amphetamines, cannabis and alcohol), injecting cessation and gained employment. Each drug outcome shows an observed rate of what the partnership actually achieved and a lower and higher estimate of the performance rate that could be expected. 4.5 The Reliable Change Index (RCI) provides a way of analysing individual based outcomes for those individuals using a given substance at the start of treatment. The RCI reports on the percentage that have become abstinent from that substance for the 28 days prior to the review (or exit) TOP. The proportion of those who improve or deteriorate is shown. The proportion of those who were not using the substance at the start of treatment but that have now re-initiated use at treatment review is also shown. 4.6 The 6-month review and planned exit reports detail the change in treatment outcome brought about in 4 broad categories: Substance use Injecting behaviour risk Crime Health and social functioning TOP 6 Month Review The following outcomes are based on 106 clients that had a TOP start and review completed in Timeframes: 6 month review outcomes based on clients that had a review TOP which was completed between 1 st April 2011 and 31 st March Planned exit outcomes based on clients that had a planned exit (treatment complete drug free/occasional user) between 1 st April 2011 to 31 st March IoWD&ANA2013.doc Mar-13

34 Substance Use Opiate Abstinence 4.7 The chart below shows the change in opiate use at treatment review. 65 clients cited opiate use as problematic at the start of their treatment. Of this 46 or 71% were using at the start of their treatment, the remaining 19 or 29% were not. Clients reported using on average 22 days in the 28 days prior to treatment, which is higher than the national average of 20.4 days 4.8 The RCI shows of those 46 using opiates at the start of their treatment 33 or 72% were abstinent at the treatment review. This is well above the expected performance range of between 29% and 55%. The remaining 13 or 28% did not abstain and continued using at the treatment review. Of the 19 who were not using at the start of their treatment 0 or 0% initiated the use of opiates compared to 21% nationally. Therefore the overall total using at treatment review fell from 46 at the start of treatment to 13 at treatment review. The average number of days also reduced to 22 days in the 28 days prior to treatment review, which is slightly higher than the national average of 11.9 days, but nonetheless, a solid set of results. 4.9 The RCI further shows of the 46 using opiates at the start of their treatment 7 or 15% had reduced their use by more than the boundary of 13 days thereby improving. Whilst none detriorated, that is their use did not increase to 13 days, nationally 3% deteriorated. These too are strong results for the treatment providers, particularly IDAS. Chart 9: Opiate Abstinence (6 month review) IoWD&ANA2013.doc Mar-13

35 Cannabis Abstinence 4.10 The chart below shows the change in cannabis use at treatment review. This is the second highest reported problematic drug at treatment start. 56 clients cited cannabis as problematic at the start of their treatment. Of this 93% were using at the start of their treatment for 20.8 days in the 28 days prior to treatment start which is higher than the national average of 17.3 days Of those using cannabis at the start of their treatment 46% were abstinent at treatment review, within the expected performance. 25% who were not using at the start of their treatment initiated, equal to the national average. Therefore the overall total number using fell from 52 at the start of treatment to 29 using at treatment review. The average number of days also reduced to 17.3 days, only just above the national average of 17 days in the 28 days prior to treatment review. It is worth pointing out that the rate at which reported use reduced was greater on the Isle of Wight than nationally % of those using at the start of treatment had reduced their use by more than the boundary of 12 days thereby improving. Whilst 2% detriorated, that is their use increased to 12 days or more, nationally 3% deteriorated. Chart 10: Cannabis Abstinence (6 month review) IoWD&ANA2013.doc Mar-13

36 4.13 The table below shows the change in all drugs from treatment start to review Table 8: All Drugs (6 month review) Treatment START TOP Reliable Change Index Treatment REVIEW TOP Substance Citing drug Using at start Days used in last 28 days Abstinent Improved Deteriorated Initiated Using at review Days used in last 28 days IoW IoW IoW National IoW lower expected upper expected IoW IoW Nation al IoW National % IoW Opiates 65 71% % 29% 55% 15% 0% 3% 0% 21% 20% Crack 9 89% % 40% 75% 0% 0% 4% 0% 20% 11% Cocaine 14 79% % 52% 81% 0% 9% 1% 0% 10% 7% Amphetamines 14 71% % 71% 98% 0% 20% 3% 0% 14% 43% Cannabis 56 93% % 27% 49% 15% 2% 4% 25% 25% 52% Other Drugs % % n/a n/a n/a n/a n/a 6% 5% 9% Nation al 4.14 The volume of clients citing crack as the problematic drug at the start of their treatment is low compared to those citing opiates. 9 clients cited crack as their problematic drug at the start of their treatment, the majority of which, 89% were using at the start of their treatment, with average use of 8.4 days in the 28 days prior to treatment start, which is lower than the national average. Of those using at the start 88% were abstinent at treatment review, this is above the expected performance range clients cited cocaine as their problematic drug at the start of their treatment. Of this 79% were using at the start of their treatment, with average use of 2.1 days in the 28 days prior to treatment start, which is considerably lower than the national average of 8 days. Of those using cocaine at the start of their treatment 91% were abstinent at the treatment review, which is above the expected performance range. 0 clients initiated the use of cocaine compared to 10% nationally. 1 client reported using at treatment review clients cited amphetamines as problematic at the start of their treatment. Of this 71% were using at the start of their treatment, on average using for 6.4 days in the 28 days prior to treatment start, lower than the national average of 12.9 days Of those using amphetamines at the start of their treatment 40% were abstinent at the treatment review. This is the one outcome where the performance is below the expected range of between 71% and 98%. A higher proportion did not abstain at treatment review. 0 clients initiated the use of amphetamines compared to 14% nationally. 6 or 43% were using at treatment review. However the average days used at review increased significantly from 6.4 days to 13.7 days in the 28 days prior to treatment review, higher than the national average of 11.1 days. 20% deteriorated as the number of days use exceeded the boundary of 13 or more days, nationally 2% deteriorated What is significant here is that for many users the use of amphetamines seems to be more part of the lives they lead and hence more of a struggle to become abstinent, it also certainly suggests that the extent of their use is not necessarily as problematic or as serious as opiate use The volume of clients citing crack, cocaine and amphetamines is low and whilst the performance with those the partnership works with is strong, the numbers are nonetheless IoWD&ANA2013.doc Mar-13

37 very low and present extorted percentages that puts into question the statistical validity of this performance individuals cited other drugs as problematic at the start of their treatment but only a small proportion of 25% were using these drugs at the start of their treatment. On average using for 16.3 days in the 28 days which is less than the national average of 17.4 days. By treatment review 85% abstained. Injecting Risk Behaviour 4.21 The chart below shows the change in injecting drug use at treatment review. These outcomes relate to 105 clients who had a start and review TOP and responded. Of the 105 responses 30% which is 31 clients were injecting drugs at the start of their treatment. On average injecting for 23.8 days in the 28 days prior to treatment start, higher than the national average of 19.1 days Of those injecting at the start 71% were abstinent at the treatment review, this is within the expected performance range. 1 client initiated injecting and 9 did not abstain at the treatment review. Of the 74 who were not injecting at the start of their treatment 1 or 1% initiated injecting, nationally 4% initiated. Therefore the overall total number injecting fell from 31 at the start of treatment to 10 or 32% at treatment review. The average number of days also reduced to by more than 50% to 9.8 in the 28 days prior to treatment review, compared to the national average of What is interesting is the rate by which the number of days injecting drugs has reduced, compared to the national change. Chart 11: Injecting Cessation (6 month review) IoWD&ANA2013.doc Mar-13

38 4.23 Of the 31 injecting drug users at treatment start 5 or 16.1% reported sharing injecting equipment at the start of their treatment, there were 0 or 0% sharing at treatment review, compared to 1.1% nationally. Crime 4.24 The table below shows the outcomes related to criminal behaviour of the 106 who had a start and review TOP completed. Table 9: Crime (6 month review) Treatment START TOP Reliable Change Index Treatment REVIEW TOP Crime Total Clients Reporting at start Days in last 28 days No longer reporting Improved Deteriorate d Initiated Reporting at review Days in last 28 days IoW n. % IoW Nation al IoW IoW IoW Natio nal IoW Nation al n. % National IoW Shop Lifting % % 0% 0% 3% 0% 1% 1 0.9% n/a Drug Selling % n/a n/a n/a 0% 1% 0% 1 0.9% n/a Other theft % n/a n/a n/a n/a n/a n/a n/a n/a 0 0% 1.2% n/a n/a Assault % n/a n/a n/a n/a n/a n/a n/a n/a 0 0% 0.9% n/a n/a Natio nal or 5.7% reported shop lifting at treatment start. This offence was committed on average for 18.2 days in the 28 days prior to treatment, which is higher than the national average of 11.4 days. The reliable change index shows by treatment review 100% no longer reported shoplifting. However of the 100 who were not shoplifting at the start of their treatment 1 or 1% initiated shoplifting, nationally 2% initiated. Therefore the overall number shoplifting fell from 6 at the start of treatment to 1 at treatment review. The However at treatment review 1 client who did not report shop lifting, initiated this behaviour at an average rate of 2 days in the 28 prior to treatment review, which is lower than the national average of 8.6 days There were no reported incidences of other theft or assault offences by this cohort; nationally the reporting of these offences is low (1.2% and 0.9% respectively). Equally no clients reported selling drugs at the start of treatment by review there was 1 who had initiated drug selling. This shows a strong correlation between reducing offending behaviour and treatment provision. IoWD&ANA2013.doc Mar-13

39 Health and Social Functioning Employment and Education 4.27 The table below shows the outcomes related to employment and educational of the 106 who had a start and review TOP completed. Table 10: Education and Employment (6 month review) Treatment START TOP Reliable Change Index Treatment REVIEW TOP Education & Employment Reporting at start Days in work / education in past 28 days No longer reporting Improved Deteriorated Initiated Reporting at review Days in work / education in last 28 days n. % IoW Natio nal n. % IoW IoW Natio nal n. % lower upper Nation al n. % IoW Paid Work 23 22% % 4% 0% 3% 7 8% 4% 21% 21% 22 21% Education 6 6% % 0% 0% 3% 1 1% n/a n/a 3% 3 3% Natio nal % reported being in paid work at treatment start, with an average of 17 days worked in the 28 days prior to treatment, slightly under the national average of 17.4 days. However 35% of those who were in paid work at treatment start were no longer at treatment review. 7 or 8% of those 83 who were not in paid work at the start of treatment initiated this at treatment review, performing within the expected performance range of 4% and 21%, albeit at the lower end of the range. This is considerably lower compared to the national average of 21% initiated paid work by treatment review. In total 22 or 20% reported being in paid work at treatment review. This is lower than the numbers who were in paid work at the start of treatment. The number of days increased slightly to 17.9 in the 28 days prior to treatment review, the national average remained the same. This would suggest access to work is still a major barrier for clients in treatment and there is little to help clients in treatment sustain employment % reported being in education at treatment start, spending an average of 8.2 days in the 28 days prior to treatment, lower than the national average of 10.3 days. 67% who were in education at treatment start were no longer at treatment review; with only 1 initiated this at treatment review, nationally 3% initiate education. By treatment review there were 50% less in education the number of days in education also fell to 7.3 days in the 28 days prior to treatment. This suggests sustained education whist in treatment is difficult and access once in treatment to education presents barriers for clients. Housing Need 4.30 The housing related outcomes of the 106 who had a start and review TOP completed. 16 or 15% reported an acute housing risk at the start of treatment. Of this 10 or 63% no longer reported an acute housing risk at treatment review. However 7 who did not report an acute housing risk at the start of treatment did so by treatment review, therefore the total number reporting an acute housing risk was 13 or 12%. Nationally 12% reported acute housing risks at treatment review. IoWD&ANA2013.doc Mar-13

40 or 9% reported an eviction risk at treatment start, by treatment review 7 or 70% no longer reported an eviction risk. However 4 clients who did not report an eviction risk at the start of treatment did so by treatment review. Therefore by review there were 7 or 7% who reported an eviction risk Housing support is always a critical issues for substance misuser, there is evidence in this TOPS data that the likelihood of evictions are affected by treatment but also that eviction can still apply even if treatment is provided Physical, Psychological and Quality of Life 4.33 The chart below shows how clients have rated their physical, psychological and quality of life on a scale of 0 to 20, with 0 being poor and 20 being good at the start of their treatment and then again at treatment review. From 106 with start and review TOP completed, 90 reported on their physical and psychological health and quality of life. Table 11: Physical, Psychological, Quality of Life (6 month review) Physical Health/Psychological Heath/Quality of Life Treatment START TOP Treatment REVIEW TOP Total Clients Reporting at start Reporting at review IoW IoW National IoW National Physical Health / / / /20 Psychological Health / / / /20 Quality of Life / / /20 13/ In all areas clients scored themselves better at treatment review than they did at the start of treatment. at treatment review clients scored themselves on average 13.2 out of 20 for their physical health, 12.4 out of 20 for their psychological health and an overall 13.5 out of 20 for the quality of life. TOP Planned Exit Substance Use 4.35 The following outcomes are based on 43 clients that had a TOP start and exit completed in A planned exit from treatment is where an individual leaves with a treatment complete drug free or occasional user (not heroin or crack) status The table below shows the change in all drugs from treatment start to treatment exit. The RCI here does not provide an expected performance range and there are no national averages for comparison. The RCI provides the proportions that abstain, improve, deteriorate or initiate at treatment exit. IoWD&ANA2013.doc Mar-13

41 Substance Table 12: All Drugs (planned exit) Treatment START TOP Reliable Change Index Treatment EXIT TOP Days Days used Using at Citing used in Using at start in last 28 Abstinent Improved Deteriorated Initiated exit drug last 28 days days IoW n. % IoW IoW IoW IoW IoW n. % IoW Opiates % % 0% 0% 0% 0 0% 0 Crack % % 0% 0% 0% 0 0% 0 Cocaine % % 0% 0% 0% 0 0% 0 Amphetamines % % 0% 0% 0% 3 43% 11 Cannabis % % 16% 0% 33% 10 45% Of those citing opiates, crack and cocaine use at treatment start 100% were abstinent on exit. These are good results and expected for a treatment system seeking to achieve drug free recovery cited amphetamines as problematic at the start of treatment of which 86% were using at the start of treatment. Of those 50% were abstinent at treatment exit. Therefore 43% were using at treatment exit, however those using at treatment review have reported using for 11 days in the 28 days prior to treatment exit, this doubled when compared to the number of days reported at the start. It is still important to point out this relates to 3 clients cited cannabis a problematic with 89% using at the start of their treatment. Of those 53% abstained at treatment exit. 1 client initiated use at treatment exit which represents 33%. Therefore 45% were using at treatment exit, with 16% reporting their use as improved, that is using less than 12 days in the 28 days prior to exit Whilst the occasional use of amphetamines and cannabis at treatment exit is within the definition of a planned exit and treatment complete, the proportions that continue to use at treatment exit 50% amphetamines and 53% cannabis may warrant some further investigation. To this end the partnership may want to consider improving the pathways for users of these drugs. Injecting Risk Behaviour clients reported injected drug use as problematic of this 19% were injected at the start of treatment, on average for 21.3 days in the 28 days prior to treatment. 100% abstained at treatment exit. There were 0 clients injecting at treatment exit. 3 reported sharing injecting equipment at the start of their treatment and 0 where sharing at treatment exit. Not injecting or sharing of equipment shows good results. IoWD&ANA2013.doc Mar-13

42 Crime 4.42 The crime outcomes related to the criminal behaviour of the 43 who had a start and exit TOP completed. 2 or 5% reported shop lifting at treatment start. This offence was committed on average for 14 days in the 28 days prior to treatment start. There were no reports of criminal behaviour at treatment exit. 1 or 2% reported committing other theft at treatment start but none at treatment exit. There were no reported drug selling or assault offences by this cohort. These are expected crime reduction results, especially given the low level of criminality at treatment commencement. Health and Social Functioning Employment and Education 4.43 The table below shows the outcomes related to employment and housing of the 43 who had a start and exit top completed. Education & Employment Total Clients Table 13: Treatment START TOP Reporting at start Days in work / education in last 28 days Education and Employment (planned exit) Reliable Change Index No longer reporting Improved Deteriorated Initiated Treatment EXIT TOP Reporting at exit Days in work / education in last 28 days IoW n. % IoW n. % IoW IoW n. % n. % IoW Paid Work % % 0% 0% 5 13% 12 28% 18.7 Education % % 0% 0% 0 0% 2 5% % reported being in paid work at treatment start, with an average of 19.1 days worked in the 28 days prior to treatment. 3 or 27% of those who were in paid work at treatment start were no longer at treatment exit and 5 who were not in paid work at the start of treatment initiated this at treatment exit. Therefore 28% reported being in paid work at treatment exit which is 1 more than at treatment start and with a decrease in the number of days worked, 18.7 in the 28 days prior to treatment exit % reported being in education at treatment start, spending an average of 10.2 days in the 28 days prior to treatment. 50% who were in education at treatment start were no longer at treatment exit. Therefore 5% reported being in education at treatment exit on average for 10 days in the 28 days prior to treatment exit Education and employment opportunities play a vital role in supporting recovery. This shows there was little increase in the numbers reporting being in paid work from start to exit. It also shows there were fewer in education on treatment exit than at the start. Housing Need 4.47 The outcomes for housing relate to the 43 who had a start and exit top competed. 7 or 16% reported an acute housing risk at the start of their treatment. Of this 5 or 71% no longer reported an acute housing risk at treatment exit. The remaining 2 or 5% continued to report an acute housing risk at treatment exit. 0 clients reported an acute housing risk having not reports so at treatment start. Therefore the overall total number reporting an acute housing risk fell from 7 to 2 or 5% at treatment exit. There were 5 or 12% that reported an eviction risk at the start of their treatment, of those 5 who reported an eviction IoWD&ANA2013.doc Mar-13

43 risk at the start of their treatment, 4 or 80% no longer reported an eviction risk at treatment exit. The remaining 1 or 20% did Acute housing problems or the threat of eviction at treatment exit does not aid the recovery process and the wider health and well-being needs of clients, whilst this relates to only 3 clients, it is nonetheless a concern. Physical, Psychological and Quality of Life 4.49 The table below shows how clients have rated their physical, psychological health and overall quality of life at the start of their treatment and then again at treatment exit. Table 14: Physical, Psychological, Quality of Life (planned exit) Physical Health/Psychological Heath/Quality of Life Treatment START TOP Total Clients Reporting at start Treatment EXIT TOP Reporting at exit IoW IoW n. Physical Health / /20 Psychological Health / /20 Quality of Life / / In all areas clients scored themselves better at treatment exit than they did at the start of treatment. At treatment review clients scored themselves on average 14.9 out of 20 for their physical health, 14.4 out of 20 for their psychological health and an overall 14.7 out of 20 for the quality of life Summary of key findings from TOP Needs Assessment Data The effectiveness of the Treatment Outcome Profile process is clear in Isle of Wight. The focus the partnership has on the recovery agenda is evident from the change in the pattern of drug use, crime and the wider health and social aspects which has been positive for Isle of Wight. Essentially this review of TOPS is very encouraging. What it suggests is that clients tended to reduce their drug consumption almost completely across all drugs at the 6 month treatment review and at the end of their treatment (apart from a small number of amphetamine and cannabis users). The overwhelming majority we abstinent at the point of the TOPS review and exit. Opiates and cannabis were the most commonly used substances and for each client that had a start and review TOP completed the use of approximately 3 drugs were cited as problematic, with similar ratios for those who had a top start and exit completed. In the case of opiate TOP start and review cohort 71% were using at the commencement of their treatment, 13% at review with the volume of consumption reducing from 22 days to In the case of the opiate TOP start and exit cohort 74% were using at the commencement of treatment, 0% at treatment exit. In the case of crack TOP start and review cohort 89% were using at the commencement of their treatment, 11% at review with the volume of consumption reducing from 8.4 days to 1. IoWD&ANA2013.doc Mar-13

44 In the case of the crack TOP start and exit cohort 100% were using at the commencement of treatment, 0% at treatment exit. In the case of cocaine TOP start and review cohort 79% were using at the commencement of their treatment, 7% at review with the volume of consumption reducing from 2.1 days to 1.6. In the case of the cocaine TOP start and exit cohort 100% were using at the commencement of treatment, 0% at treatment exit. In the case of amphetamines TOP start and review cohort 71% were using at the commencement of their treatment, 43% at review however the volume of consumption increasing from 6.4 days to Similar in the case of the amphetamine TOP start and exit cohort 86% were using at the commencement of treatment, 43% at treatment exit again the volume of consumption increased from 5.3 days to 11. In the case of cannabis TOP start and review cohort 93% were using at the commencement of their treatment, 52% at review with the volume of consumption reducing from 19.5 days to In the case of the cannabis the TOP start and exit cohort 86% were using at the commencement of treatment, 45% at treatment exit with the volume of consumption reducing from 22.9 days to The overall satisfaction with physical and psychological health and quality of life was reported proportionality higher at treatment exit than at review However key to sustained recovery includes access to employment opportunities and stable accommodation. In both areas the partnership is performing beneath the national average, with fewer clients engaged in paid employment and a higher proportion reporting housing problems when leaving treatment. IoWD&ANA2013.doc Mar-13

45 5 Criminal Justice (DIP) 5.1 Isle of Wight has commissioned Cranstoun CDS as their Drug Interventions Programme (DIP) provider. The Cranstoun service consists of: Through care and after care Onward referral Prison and treatment aftercare Advice about substance misuse Relapse prevention Harm minimization Motivational interviewing Stress management Brief solution focused therapy General advice and support Housing advice People can self-refer or can access the service through the Criminal Justice System, via Newport Police station or the Law Courts, the Probation Service and local Substance Misuse agencies. The service operates like other DIPs and incudes: Enhanced Arrest Referral provision (courts and custody) Case Management Provision A Single Point Of Contact (SPOC) Drug Rehabilitation Requirement (DRR) Assessments Integrated Offender Management (IOM) provision Supported Housing Provision 5.2 The performance of the DIP can be reviewed through the low levels of referrals from the DIP into the treatment system on the Island. Table 15: Criminal Justice Clients on the isle of Wight (DOMES report Q4 2011/12) Criminal Justice Clients Q1 Q2 Q3 Q4 total No of DIP referrals YTD 11/ No/(%) of DIP referrals already n treatment 3 (75%) (75%) No of New DIP referrals referred into treatment % of new DIP referrals not picked up in treatment and who have never been in treatment 0% 0% 0% 3 (60%) 3 (60%) 5.3 The table above shows that the year to date (YtD) referrals for Isle of Wight fluctuate across each quarter nonetheless the number of referrals are very low with only 12 referrals made for the whole of Of those 12 referrals made throughout the year 3 were already in treatment and 3 did not to engage with treatment services and were treatment naive i.e. no matched treatment episodes for the last 7 years or since DIP recording of this form started. This shows a poor level of service referral and take-up and clearly a lower level than the funding allocated expected. IoWD&ANA2013.doc Mar-13

46 5.4 The Needs Assessment data for the Isle of Wight s DIP profile of clients not in treatment is set out below. The data has been extracted from the NDTMS Needs Assessment Report The table summarises the number of clients in contact with the DIP but not within the treatment system set against drug type and broken down by gender, ethnicity and age. Essentially this is useful in addressing likely demand. What this does suggest however is that there is a real need to support clients in contact with the DIP to enter treatment and to benefit from the provision on the Island. Currently the numbers of DIP clients in treatment is low and from a needs assessment perspective a closer examination of this data can support a better understanding of likely treatment demand. Table 16: Clients in contact with DIP not within the treatment system (NDTMS 2011/12) Gender Opiate &/or Crack Users Opiate Users Crack Users Cocai ne Users Amphe tamine Users Cann abis Users Benzo diazepi ne Users Other Drug Users Male Female Ethnic group White Asian or Asian British Black or Black British Other Age on 30th September years years years Total Total 5.5 There are 103 clients in contact with DIP but not in the treatment system. The Isle of Wight s ethnic profile shows an almost exclusive representation of clients from White backgrounds across all drugs. The drug use profile shows 35% are opiate and/or crack users, 29% opiate, 19% crack, 17% cocaine and 25% cannabis using clients. What is interesting is there are a lower proportion opiates users and a higher proportion of crack, cocaine and cannabis clients accessing treatment through the DIP, compared to the overall treatment populations, which shows 58% are opiate and/or crack users, 58% opiates, 6% crack, 2% cocaine and 12% cannabis. 5.6 Interestingly the age profiles are spread evenly there is higher proportion of younger cannabis users and higher proportion of older opiate users. 5.7 This table would suggest that the level of DIP clients not in the treatment system is proportionately quite high given that there are 471 clients in treatment in and those not in treatment but known to the DIP is 103 almost 22%, which is a sizeable additional source of potential clients. This figure has varied in the last three years with the numbers of client known to DIP but not in the treatment system being 229 in , 76 in and 103 in 2011/12. Nonetheless this contrasts significantly with the 12 that were IoWD&ANA2013.doc Mar-13

47 referred into treatment of which there were 9 presentations to treatment (3 were already in treatment). Indeed these 9 clients represent only 8.7% of this group, which is a woefully low level of attrition. 5.8 Another measure of performance for a DIP is through the quarterly summary reports. The DIP Quarterly Summary quarter report contains the key outcome and diagnostic data at partnership level for clients referred into structured treatment via DIP and the treatment outcomes for this cohort. 5.9 The table below shows the performance of those referred into structure treatment via the DIP in the last 3 months (set back 1 month), the summary measures local performance against South East and national trends and performance. 60% of the new referrals were recorded on NDTMS as being triaged within 6 weeks and starting a structured treatment modality. This is above South East and national average performance but does place the Isle of Wight in the 3rd quartile range of performance across all DAAT partnerships. Table 17: Treatment uptake of DIP clients Q Referrals made in last three months for which final figures have been published. Data Source: DIMIS & NDTMS Isle of Wight South East National Total clients referred ,500 Number already in contact with structured treatment services ,880 New referrals to structured treatment ,620 Triaged within 6 weeks of DIP referral AND starting n ,895 a modality % 60% 58% 63% Not triaged within 6 weeks of DIP referral but n previously in treatment % 0% 12% 10% No treatment matches n ,285 (since April 2004) % 0% 31% 28% 5.10 The table below shows the in treatment activities of clients referred by the DIP in the last 12 months (Oct12 Sep12), compared to the South East and national average performance. The non-opiate DIP clients make up 17% of the total non-opiate clients in treatment, which is double that of the South East average, 8%. The opiate DIP clients make up 6% of the total opiate clients in treatment compared to 13% in the South East and 16% nationally, and as there are significantly more opiate clients in treatment this brings down the overall proportion of DIP clients to 8% of the of the treatment population, which is lower than the South East and national average (12% and 15% respectively) Overall 12% as a proportion of the total number of DIP clients achieve successful completions from treatment (0% for opiates and 29% for non-opiates); this is lower than the South East average of 13% and national average of 15%. Of the 4 successful completions none have re-presented to treatment in the preceding 6 months, whilst across the South East and nationally it is 13% and 15% respectively that have re-presented. Again this shows in the most recent reporting period the levels of DIP referrals are still strikingly low. IoWD&ANA2013.doc Mar-13

48 Table 18: Treatment Activity of clients referred to DIP Q In treatment activity of clients referred by DIP Rolling 12 month period (to end of current quarter) Number of DIP clients in treatment and proportion of treatment population Opiate users Non opiate users All Isle of Wight South East National n 19 2,089 24,434 % 6% 13% 16% n ,691 % 17% 8% 15% n 33 24,144 30,125 % 8% 12% 15% Successful completions given as a number and as a proportion of total DIP clients in treatment (i.e. as reported above) Number of successful completions in first 6 months of 12 month rolling period and proportion of these who re-present to treatment within 6 months of their discharge Opiate users Non opiate users All Opiate users Non opiate users All n ,731 % 0% 8% 7% n ,660 % 29% 49% 47% n ,391 % 12% 13% 15% n ,076 % 0% 28% 23% n ,454 % 0% 4% 5% n ,530 % 0% 17% 13% Partnership/Police Force Area DIP Report (2012/13 Quarter 2) 5.12 The Partnership/Police Force Area DIP quarter report shows an additional measure of performance on crime and re-offending. The table below shows Isle of Wight has a lower number of trigger offence rates, 11 per 1000 residents compared to the Hampshire Police Force Area, of 14 per 1000 and lower still against that national average of 15 per 1000 residents. However estimates of proven re-offending for drug using offenders shows no data. The re-offending rate for the Hampshire Police Force Area is higher than the national average. Table 19: Crime and re-offending of DIP clients Q Crime and Re-Offending Partnership Police Force Area National Trigger offence rate/1000 population Early estimates of proven re-offending for drug using offenders 21 * % % 5.13 Discussions with service providers has pointed to the fact that almost exclusively those service users returning to the community from prison have highlighted housing needs as being their main concern with access of structured aftercare support their second most significant concern. IoWD&ANA2013.doc Mar-13

49 5.14 Providers have also stressed that they have worked hard to maximise referrals inspite of the low number of outcomes. Moreover there are also efforts made to engage other clients known to DIP but who are not in the treatment system, in particular through advice and guidance, Tier 2 activities and brief interventions although this is not currently recorded through the NDTMS and hence do not constitute a referral into structured treatment It is clear that there is potential demand for drug treatment for those in the criminal justice system; however there seems to be some real barriers to converting need to treatment for these clients, who are a group that are notoriously difficult to convert to treatment. The greater concern is that the funding for DIP has shifted from Home office and DoH grant to the Hampshire chief constable and future allocations are likely to be based on both perceptions of demand and historic delivery. It is likely that there is strong demand for services but that this demand is not being met and hence this puts future funding in jeopardy It is critical that the partnership work with partners in the criminal justice system and prisons to ensure that effective referral pathways are put in place and that this is reviewed to ensure that funding allocated to DIP is well spent. IoWD&ANA2013.doc Mar-13

50 6 DOMES Reports Summary last 4 quarters 6.1 The Diagnostic and Outcomes Measure Executive Summary (DOMES) report is a quarterly report that contains key treatment outcome and diagnostic data at a partnership level to assist local areas to monitor performance and compare with national trends. There are 7 key areas that the DOMES report covers, successful completions, effective treatment, time in treatment, reduced drug use, housing and employment, waiting times, harm reduction and parent and families. Clusters have been determined for opiate and non-opiate populations. Top quartile average performance for clusters are used as comparators, this is the range required to be in the top 25% of partnerships in a given cluster. 6.2 Successful completions as a proportion of the total number in treatment are a key performance indicator, which aligns with the ambition of both public health and the Governments drug strategy of increasing the number of individuals recovering from addiction. It also aligns with the reducing re-offending outcomes as offending behaviour is closely linked to substance use. 6.3 Public Health Indicator 2.15 is defined as the number of drug users that left drug treatment successfully.who do not then re-present to treatment again within 6 months as a proportion of the total number in treatment. 6.4 Individuals achieving successful completions demonstrate a significant improvement in health and well-being in terms of increased longevity, reduced blood-borne virus transmissions, improved parenting skills and improved physical and psychological health. 6.5 In October 2012 the Isle of Wight had 12.0% opiate successful completions as a proportion of the total number in treatment, fractionally below the top quartile performance range of 12.1% to 15.9%. However this has improved greatly from 10.2% in quarter , 8% in quarter and 9% in quarter This is a result of 60% growth in the number of successful completions since baseline data. This is good performance compared against the cluster average which shows a -6.6% decrease in the number of successful completions. This growth is also against a decline in the numbers in treatment since quarter , which will push percentages up. In quarter there have been 2 out of 19 clients who re-presented to treatment giving a 10.5% representation to treatment rate, which is within the top quartile performance range of 11.1% to 0%. Since quarter the proportion of re-presentations to treatment has fluctuated between 8% and 14%. Overall performance for opiate clients is good. 6.6 Non-opiate successful completions on the other hand has seen a decline in performance since quarter , where 42% non-opiate successful completions as a proportion of the total number in treatment was achieved, compared to 36% in quarter , 27.5% in quarter and 25.3% in quarter This puts the Isle of Wight significantly below the top quartile range of 42.7% to 65%. This is the result of 16.7% decrease in the number of non-opiate successful completions compared with baseline data, whereas the cluster on average has shown a 5.5% growth. The proportion of clients re-presenting to treatment has deteriorated, it is worth bearing in mind the actual IoWD&ANA2013.doc Mar-13

51 volume of re-presentations are low as are the number who successfully completed, therefore the percentages are greater. In quarter , 20% (2 out of 10) have represented to treatment, this is significantly less than the top quartile range of 0% to 0%. This is a critical indicator for both public health and the National drug strategy for which addressing non-opiate performance is necessary. 6.7 Criminal justice client successful completions as a proportion of the criminal justice clients in treatment had fallen from 27% in quarter to 12% in quarter Representations to treatment up to quarter have been around 14% which has been higher than the national average; however quarter shows 0% representations to treatment. Successful completions data and performance is covered in detail at partnership and provider level in sections 10 and The chart below shows the change in the numbers in effective treatment for opiate and non-opiate clients since Q Whilst the Isle of Wight (dark blue) has followed the national opiate trend (light blue), the non-opiate clients has seen a higher than national average decrease in the numbers in effective treatment up to baseline data, in the 2 quarters of with 9.8% (light purple) growth compared to the baseline data and higher growth compared to the national trend (dark purple) of 0.7%. Improvement is necessary to bring the numbers up from a year of decline, the Isle of Wight are on track for this. In effective treatment data and performance is covered in detail at partnership and provider level in sections 10 and 11. Chart 12: Effective Treatment Q to Q (DOMES.) IoWD&ANA2013.doc Mar-13

52 6.9 The table below shows the proportion of clients in treatment between 4-6 years has started to decline from 14% in quarter to 11% in quarter , whilst nationally this has remained at 14%. However this could simply be that those clients are shifting into the cohort that are now in treatment for 6 or more years. The proportion who are in treatment for 6 or more years is considerably higher than the national average at around 37% nationally this has increased from 21% in quarter to 22% in quarter Time in treatment data and performance is covered in detail in section 12 of this needs assessment. Table 20: Time in Treatment (Q to Q ) Time in 4-6 years 6+ years treatment Isle of Wight National Isle of Wight National Q % 14 37% 20 Q % 14 36% 21 Q % 14 37% 22 Q % 14 37% The Treatment Outcome Profile (TOP) which covers reduced drug use, housing and employment outcomes. Isle of Wight is seeing higher levels of abstinence at 6 month review stage when compared to the national average. However employment outcomes show there are less clients working for 10 days or more in the 28 days prior to treatment exit (44%) when compared to the national average of 49%, in quarter 3 and , in quarter 1 and there are no national comparators. 66% reported no housing problems in the 28 days prior to treatment exit, compared to 84% nationally; again this national comparator is only available for quarter 3 and Employment and Housing outcomes are key factors to effective client recovery and the partnerships should look to improve these outcomes During quarters 3 and no clients waited to be seen outside of the acceptable timescales, however by quarter % waited more than three weeks to start treatment with 1 client waiting longer than 6 weeks. By quarter clients waiting longer than 3 weeks to start treatment rose to 7%, with 1 client waiting over 6 weeks. Although the numbers are low, this is something the partnership will need to monitor The percentage of new presentations in the year to date period that have accepted a HBV vaccinations is low in the Isle of Wight, with 9%, 7%, 14% and 18% take up in the last 4 quarters, compared to the national average of 41% take up over the same period. The proportion of clients injecting and who receive a HCV test is on average 78% compared to 68% nationally The DOMES reports since April 2012 have reported on the number of clients in treatment living with children and the outcomes of their treatment. In quarter there were 105 opiate clients in treatment living with children, as a proportion 9 or 8.6% successfully completing treatment, compared to 8.9% nationally, by quarter the number in treatment remained similar at 102 with 14 or 13.7% successfully completing, compared to 8.8% nationally. Looking at re-presentations 50% (1 from 2) and 33.3% (1 from 3) represented to treatment within 6 months of having completed treatment in quarter 1 and 2 IoWD&ANA2013.doc Mar-13

53 respectively. The numbers are low and a single client will represent a high percentage value. However this is still higher than the national average re-presentation rates of 20.9% and 19.7% for the same periods The volume of non-opiate clients living with children is much less (17) and as a proportion 5 or 29.4% successful completing treatment in quarter and with a similar number in treatment in quarter (18) and with 6 or 33.3% successful completions, the non-opiate performance is lower than the national average of 41.7% for both quarters. There were no re-presentations to treatment The key priorities emerging from the DOMES reports relate to the performance of the nonopiate successful completions both in terms of the volume and proportion, the latter being critical to the public health outcomes framework and the Governments drug strategy. The partnership should strive to achieve cluster top quartile performance as it once had. The proportion of clients in treatment for 6 or more years is another key priority the partnership must address as this clearly shows the lack of movement thought the treatment system. Both points have been highlighted in the NTA commentary section of the DOMES report consistently in the last 4 quarters In summary the partnership is showing good performance on the successful completions and re-presentation to treatment performance of the opiate using clients in treatment which is at or around cluster top quartile range of performance. The non-opiate successful completions and re-presentation data on the other hand has seen a decline in performance and consequently the Isle of Wight performing below the cluster top quartile range. The change in the number of clients in effective treatment is following the national trend, whilst non-opiate clients in effective treatment has gone against the national trend showing growth against baselines. However key to sustained recovery includes access to employment opportunities and stable accommodation. In both areas the partnership is performing beneath the national average, with fewer clients engaged in paid employment and a higher proportion reporting housing problems when leaving treatment. IoWD&ANA2013.doc Mar-13

54 7 Alternative Data Sources 7.1 This section identifies data from a range of key partners to the DAAT both from Health and the Criminal Justice environment. Essentially this data supplements treatment data to support an assessment of drugs and alcohol treatment needs in the community. In particular the data seeks to identify the levels of health incidents as a result of alcohol or drug misuse and drug offending crime rates, ambulance service callouts and the profile of substance misuse attributable to clients of the probation service. There are also other key data sets which at this stage are not available to this needs assessment, however the data available does provide a context for treatment needs and profiles those incidents associated with drugs and alcohol misuse which add to the understanding of needs on the Island. Health Data 7.2 In developing this needs assessment some potentially useful data was either not available or not researched. This included substance misuse information from NHS walk-in centres, the BBV screening and vaccination service, A&E department presentation data, minor injuries units, gynaecology, midwifery and antenatal services. Community mental health, inpatient, dual diagnosis services and GP practices all come into contact with drug and alcohol users and sometimes collect potentially useful statistics on those who may not be in the formal treatment data provided by NDTMS. Essentially this provides a greater understanding of the alcohol and drugs misusers who are not presenting to treatment. 7.3 The following health and "other" data would also help treatment planning and highlight some of the services treatment naïve clients are accessing: Needle exchange data data on needle exchange services operating in Isle of Wight is currently unavailable. Needle exchange is provided through the Island s pharmacies, however this data is not systematically recorded and hence any data held is deemed unreliable. A full picture of needle exchange activity is a strong indicator of opiate and injecting profile in the community. Indeed whilst being a harm minimisation action (tier 2 service) this activity does give a picture of the level of injecting in the community. General practice research database (GPRD) - contains data on more than 3 million randomly sampled patients in GP practices across England. It includes demographic profiles, clinical diagnoses, drugs prescribed and immunisation details. It is good as a comparison tool for incidence/prevalence in the general population with NDTMS/local data sources. Public health colleagues could advise on accessing and making use of this rich data in the future. 7.4 Other areas of key health related data could include: Prescribing analyses and cost data (PACT) - records all prescriptions issued within a PCT area. This identifies those clients accessing opiate substitute prescriptions outside of the usual shared care practice. This information has been collected and is available in section 10 of this assessment. IoWD&ANA2013.doc Mar-13

55 Health Protection Agency data - for disease notifications and prevalence data, this data has not been collected at this stage in the needs assessment and the drug treatment strategy this is unlikely to support any greater knowledge of need. 7.5 Sexual Health Data where Alcohol or Substance misuse is an associated activity This data has been provided and through interviews with staff at the Sexual Health Services at St Mary s Hospital they have confirmed that drugs and alcohol related sexual health admissions has not been formally collected. Nonetheless it was felt that at least 50% of females and 40% of males seen by the Sexual Health Service have described behaviour that is associated with drugs and or alcohol misuse. The data includes all male, males under 25 and all females and females under The table below sets out the profile of male and female presentations based on this profile of 40% for men and 50% for women. Through the interviews it was suggested that this was a conservative estimate. It is clear that all groups have grown in their attendance at Sexual Health Services over the three years of the data being available. This purports that those who have associated drugs and or alcohol consumption linked to their presentation to the service has grown as well. Chart 13: Isle of Wight Drug Sexual health attendance of those with associated drug and or alcohol consumption. 7.6 Substance Abuse Deaths (SAD) (Office of National Statistics 2010) In England total of 1,358 deaths were reported for 2010 (1,524 in 2009). The demographic and drug profiles remained stable. However, there was a significant fall in the proportion of deaths involving heroin/morphine and a modest increase in the proportion involving methadone. The most common prescribed medications implicated in death were antidepressants (58%) followed by hypnotics/sedatives (42%) With respect to Coroners jurisdiction district on the Isle of Wight in 2009 there were 6 SAD deaths and in 2010 there were 5. In contrast Portsmouth and South East Hampshire had 43 IoWD&ANA2013.doc Mar-13

56 in 2009 and 30 in 2010 and Southampton and the New Forrest had 28 in 2009 and 18 in A&E Admissions data was not available to the Public Health Team who supported this needs assessment with additional searches for key local data. However, as will be described below the data for hospital admissions for drugs and alcohol is available and this coupled with Ambulance Service data would suffice to provide a picture of needs especially from the perspective of call outs and admissions to hospital. 7.8 Isle of Wight NHS Trust: Mental Health Services The Island s Mental Health Services operate at Seven Acres on the St Mary s hospital site. The service includes three wards for psychologically intensive clients, acute beds for the working age population and acute beds for older people. Additionally there is a rehab unit on the Wotton site and a dementia admissions unit which is soon to be relocated onto the St Mary s Hospital site. Chart 14: Isle of Wight Drug Acute bed Admissions with related drugs and Alcohol presentations Data provided by the Mental Health Services based on an audit of crisis admission beds from 1 st January 2012 to 31 st March 2012 showed 66 admissions of which 22 (33%) presented with alcohol presentation often in association with a failed suicide attempt and 19 (29%) with a history of drug taking associated in some cases with a drug overdose, often at the same time as excessive alcohol consumption. It is evident from this data that there is a clear association with a sizable proportion of the client base that have had extreme alcohol and drug consumption leading up to their admission, in many cases 15 (23%) with an overdose based suicide attempt The Isle of Wight NHS Trust s Mental Health Service sees a significant number of patients with either drug and or alcohol concerns ranging from addiction to extreme use often linked with an attempted suicide. Indeed this confirms the service s belief that there are strong links between alcohol and drug consumption either as a cause of or a factor in extreme psychosis, depression, anxiety and or periodic self-harm. IoWD&ANA2013.doc Mar-13

57 7.9 Dual Diagnosis The majority of dual diagnosis commissioning is for people with drug problems, rather than alcohol problems, and within that the majority are people with opiate problems. However data is not currently accessible for dual diagnosis patients and for mental health levels within the Island. Dual Diagnosis Care Pathway/Flow Chart The referral route from Mental Health Teams into Substance Misuse Services for people misusing illicit substances, legal highs or alcohol is below. Mental Health Worker identifies a client with substance misuse problems during any stage of contact. Referral to Tier 2 Substance Misuse Services to be made dependant on outcome of DUST assessment YES NO If a client self refers and is in contact with any of the MH services then the whole procedure needs to be followed. No formal Substance Misuse Team involvement needed but information advice/consultation available; further motivational/health education work by CMHT if appropriate. Referral to Tier 2 (Cranstoun) for substance misuse triage completed: Include all minimum data (see notes), & preferably Client consent. If the person has a Mental Health Care Co-Ordinator forward the CPA. Is the person subject to CPA? YES NO Cranstoun will book triage in normal way Arrange triage assessment jointly with Care Co-Ordinator Does triage assessment reveal significant or severe level of substance misuse (Models of Care Criteria) requiring comprehensive assessment? No clear substance misuse problems or client does not want follow up from substance misuse services then referrer to be informed Referral made to Tier 3 Specialist Substance Misuse Team (IDAS) YES NO Substance misuse is mild/moderate, referral stays in Tier 2 (Cranstoun) Substance Misuse Services or is signposted to other substance misuse services i.e.; AA, SMART, RWT Care Plan to be formulated for substance misuse issues. If client under CPA, then CPA assessment Framework updated to include joint working with substance misuse team. MH worker remains Care Co-Ordinator with Substance Misuse Worker being a Care Contributor. IoWD&ANA2013.doc Mar-13

58 7.9.3 The Mental Health & Learning Disability Services have developed a Dual Diagnosis Integrated Care Pathway which provides guidance for the management of people with coexisting mental health and substance misuse needs. The Integrated Care Pathways (ICP s) describe the nature and anticipated course of action for a particular client and a predetermined plan of treatment. ICP s provide an opportunity to apply packages of care in a co-ordinated and integrated way promoting treatment efficiency, effectiveness and value for money. Working collaboratively capitalises on the skills and expertise of general mental health services and specialist substance misuse services, and by doing so, reducing the harm caused to those affected by mental health and substance/alcohol misuse needs, subsequently referred to as dual diagnosis within this document and promoting retention in treatment Isle of Wight Ambulance Service Drugs related call outs The following information has been collated from the Isle of Wight Ambulance Service for drugs overdose ambulance callouts. In the period 2010, 2011 and 2012 there have been 112, 108, and 107 drugs related call outs/incidents attended respectively. The table below shows where these callouts originated. Chart 15: Isle of Wight Ambulance Service Call outs by Post Code The post code locations with the highest level of call outs in the last three years were PO31, PO33 and PO30 respectively. IoWD&ANA2013.doc Mar-13

59 Chart 16: Isle of Wight Ambulance Services Drugs callouts by age The chart above shows the volume of drug related callouts by age. It is clear from this data that the groups with the highest level of Ambulance call outs for a drug related cause (often overdose) was the year old group, followed by the year old group. In 2012 there was a high point in the level of call outs for people from the 50+ group. What this suggests that drugs related call outs are related more to an older age group. Chart 17: Isle of Wight Ambulance Service Drug Call outs profile Unlike alcohol call outs the numbers of drug overdose call outs are far smaller. Additionally there does seem to be a decreasing trend line over the period of the last three years. IoWD&ANA2013.doc Mar-13

60 7.11 Criminal justice data This needs assessment has analysed relevant partner data sets from various partners within the criminal justice system (CJS). The section below describes the overall position of Isle of Wight in terms of drug related offences, within the context of antisocial behaviour and disorder, and drugs offences. Further data is provided by the probation service through its yearly OASys reports. Isle of Wight s strategic assessment priorities In headline policy terms, Isle of Wight s strategic assessment priorities for crime and disorder reduction for were: Alcohol related disorder Anti-Social Behaviour Burglary (residential) Domestic Violence Hate Crime Serious Youth Violence Under pinning priorities are improving community confidence, reducing re-offending and tackling drugs A review of the Isle of Wight s Strategic Assessment recommended that: Drugs and alcohol awareness and education programmes are coordinated and implemented to ensure that parents, key workers and young people are provided with information, advice and support. Education and treatment plans are reviewed in response to predicted needs identified through analysis of the emerging use of stimulants. Treatment providers continue to respond to Police Bronze Actions, offering fast-track referrals to individuals identified through intelligence. A review of the alcohol arrest referral pilot is undertaken by PTCG. A review of the alcohol harm reduction strategy is undertaken by DAAT It is clear that this top-level partnership has recognised the importance of addressing drugs misuse. This partnership has a clear understanding of the role treatment plays in addressing drugs misuse, and also the relationship between drugs and alcohol misuse and other priority crimes. Indeed, it is widely recognised that there is a close relationship between drug and alcohol misuse and other crime priorities in Isle of Wight - in particular domestic burglary, domestic violence, thefts from motor vehicles and antisocial behaviour and assault. This priority is critical to maintain the ongoing commitment to substance misuse treatment provision in the future. IoWD&ANA2013.doc Mar-13

61 7.13 Drug Offences (Hampshire Constabulary data sets) The data below is taken from the Hampshire Police s database. It describes the year on year trends for drug offences within the Isle of Wight (L) District. The data compares the 09-10, 10-11, and the year to date figures. The data was obtained using the Records Management System (RMS) of Hampshire Constabulary and extracted using ibase. Further manipulation of the data was completed using Microsoft Excel The data shows drug offences over this period broken down by the categories of Possession, Possession with the intent to supply (PWTS), Supply and miscellaneous. The data excludes these offences as they relate to the Isle of Wight Festival and the Bestival on the Isle of Wight. Possessions are by far the highest offence category. In the tables below these are broken down by class A, B and C drug offences as well as all drug offences. The final table identifies the top 10 police beats for drug offences. Chart 18: Total Drug offences Chart 19: Total Possession all classes April 09-to date IoWD&ANA2013.doc Mar-13

62 Chart 20: Isle of Wight Supply all Classes April 09 to date 7.14 The three Charts above show the total drug, possession and supply offences from 2009 to date; all show rates of decline since IoWD&ANA2013.doc Mar-13

63 Chart 21: Drug Offences drug offences by class and type April 09-to date It is clear that class B possessions account for the majority of drug offences, and that in classes A, B and C possession is the majority offence. However supply is a significant category of offence and one which the Police have been keen to target. Indeed there have been several campaigns in recent years targeting the manufacture, cultivation and traficking of drugs of all classes. The volume of crimes is high, however since 2009 this figure has been dropping quie considerably. IoWD&ANA2013.doc Mar-13

64 Chart 22: Isle of Wight Class A Offences year on year comparisons Class A offences are showing a rate of decline over the last four years. However there was a spike of supply offences in when a number of targeted covert arrests were made. Chart 23: Isle of Wight Class B offences year on year The chart above shows Class B offences. These still are showing a rate of decline although the level of possession is broadly consistent; once again there was a spike in supply offences in when intensive policing resulted in these arrests. However in the last year the trend shows that arrests for possession are in decline. IoWD&ANA2013.doc Mar-13

65 Chart 24: Isle of Wight Class C Drugs Offences Class C offences are at a far lower level than both Class A and B. Possession is still the main offence and supply is limited to single digit levels. Table 21: IoW Top ten beats for drug offences Beat Code Beat Name No of offences LW02 Pan & Fairlee 1690 LW01 Newport North & South 372 LE07 Ryde North/East/North West 270 LE03 Sandown North & South 189 LE01 Shanklin North/Central/South 133 LE08 Ryde St Johns East & West 126 LE09 Ryde South East & South West 107 LW06 East Cowes North & South Osborne 100 LW11 Carisbrooke East & West 93 LW04 Cowes Central & Medina The table above shows the top ten Police beats where drugs offences have occurred. The Pan and Fairlee have significant levels of Drug Offences although this is generated as a result of the Island s two music festivals. IoWD&ANA2013.doc Mar-13

66 7.15 Probation Service Data (Offender Assessment System OASys) The data below comes from the Probation Service s Offender Assessment System. This system measures the scores of probationers and classifies their assessments into a range of categories of client need/risks. For the purposes of this Needs Assessment data has been taken for the period 1 st January 2012 to 31 st December The table below identifies specific needs identified of the clients on the OASys system for the Isle of Wight. In 2012 there were 671 clients on the system. From this number we have extracted the profiles of the clients with drugs and alcohol needs as set out on OASys. Table 22: Drugs misuse in the IoW s probation service client base 2012 Drugs Misuse 2012 Frequency % No or don t know % Yes % Grand Total % Table 23: Alcohol misuse in the IoW s probation service client base 2012 Alcohol Misuse 2012 Frequency % No or don t know % Yes % Grand Total % The two tables above show that of the 671 clients on the system 24.6% show a drugs misuse and 47.7% show an alcohol misuse. Table 24: Isle of Wight Probation clients with Alcohol and Drugs needs Probation OASys need for IoW 2012 Number % Accommodation % Education, Training, Employability % Drug Misuse % Alcohol Misuse % Emotional Well-Being % The table above shows that Probationers have proportionately a high level of alcohol misuse (48%) and 25% have an identified drugs misuse need. Offence category The tables below show the offence categories of those with alcohol needs and those with drug needs. Both tables show a broad range of offences and in some cases more than one offence was committed by the same client. The main offences committed by alcohol clients included motoring offences 11%, followed by other offences 10% and theft and handling IoWD&ANA2013.doc Mar-13

67 7%. The main offences committed by drug clients included violence against the person and drug offences, both accounting for 26%, followed by theft and handling, 15%. This shows more serious offences. Table 25: IoW s Probation client offence categories by Alcohol Need 2012 I.O.W Offenders with Alcohol Need by Offence Category Offence Category Total % Burglary 1 1% Criminal Damage 3 4% Drug Offences 1 1% Other Indictable 2 3% Other Summary Offences 7 10% Robbery 2 3% Sexual Offences 4 6% Summary Motoring Offences 8 11% Theft and Handling 5 7% Grand Total % Table 26: IoW s Probation client offence categories by Drug Need 2012 I.O.W Offenders with Drug Need by Offence Category Offence Category Total % Criminal Damage 2 5% Drug Offences 10 26% Indictable Motoring Offences 1 3% Other Summary Offences 3 8% Robbery 3 8% Sexual Offences 2 5% Summary Motoring Offences 2 5% Theft and Handling 6 15% Violence Against the Person 10 26% Grand Total % The tables below show interesting relationships between drugs and alcohol client and their respective needs for housing, employment education and training and risks of domestic abuse and emotional well-being. Table 27: IoW Offenders (Alcohol Need) with accommodation, Domestic abuse and Employment Needs Alcohol Total % Total Offenders % Accommodation Needs 19 29% Domestic Abuse 36 55% Employment Education Training Need 13 20% Emotional Well Being 30 46% Those with Alcohol needs show higher levels of domestic abuse risk, and a high level of emotional well-being need. In the table below those with drugs needs shows IoWD&ANA2013.doc Mar-13

68 proportionately a higher proportion of clients with emotional well-being, employment education and training and housing need Table 28: IoW Offenders (Drug Need) with accommodation, Domestic abuse and Employment Needs Data Total % Total Offenders % Accommodation Needs 12 38% Domestic Abuse 9 28% Employment Education Training Need 14 44% Emotional Well Being 20 63% Probation client demographic profile Gender The table below shows the breakdown of offenders by gender for both the total population and those identified with a drugs problem. Table 29: Gender profile of probationers by Drugs and Alcohol misuse Gender Drugs Misuse Alcohol Misuse Frequency % Frequency % Female 5 16% 7 11% Male 27 84% 58 89% Grand Total % % The drug misuse profile of female probationers (16%) is proportionately higher than the 11% profile for the offender Population with an alcohol need although in actuality the numbers are smaller. Age groups This table shows the breakdown of offenders by age for both the total population and those identified with a drug problem. Table 30: Age profile of probationers by drugs misuse Age Drugs Misuse Alcohol Misuse Frequency % Frequency % % 6 9% % 19 29% % 33 51% % 5 8% 65+ 0% 2 3% Grand Total % % IoWD&ANA2013.doc Mar-13

69 7.16 Summary of alternative data sources Whilst described in this needs assessment as alternative data sources, this isn t strictly true. Indeed the data in this section from the Island s Health Services, the Ambulance Service, the Police and the Probation Service is rich in understanding the range and breath of drugs and alcohol abuse on the Island and in many ways identifies the critical impact drugs and alcohol has on the Island What is useful to this and future needs assessment is the establishment of reporting agreements and data sharing between the DAAT key partner services in health, the Police, the Ambulance Service and probation. These are the key players although moving forward data could also be accessed from the Fire Service, Housing and Social Services and key local authority departments However what the data we have collected shows is quite clear. Drugs and alcohol has an impact on the Health Service, emergency services, the Police and the Probation service. For example: At least 40% of females and 50% of males using the Islands Sexual Health Services have associated drugs and or alcohol consumption linked to their presentation to the service. Taking these proportions into account in 2012 at least 1,274 females and 536 males presented to sexual services with and associated alcohol and or drug use which was linked to their sexual health presentation. In several cases women have presented to services that are fearful of either becoming pregnant and or having a sexually transmitted disease (STD) but who were equally unaware of the causes as they we completely drunk or out of their heads at the point of sexual activity. Drug related overdose and deaths are relatively low on the Island in 2009 there were 6 Substance Abuse Deaths and in 2010 there were 5, this contrasts with Portsmouth and South East Hampshire with 43 and 30 Substance Abuse Deaths respectively. The Isle of Wight NHS Trust Mental Health Services in a service audit from 1 st January 2012 to 31 st March 2012 showed 66 admissions of which 22 (33%) presented with alcohol presentation often in association with a failed suicide attempt and 19 (29%) with a history of drug taking associated in some cases with a drug overdose, often at the same time as excessive alcohol consumption. This confirms the belief that there are strong links between alcohol and drug consumption either as a cause of or a factor in extreme psychosis, depression, anxiety and or periodic selfharm. The Mental Health Service have established an Integrated Care Pathway to address dual diagnosis with IDAS to ensure that working collaboratively capitalises on the skills and expertise of the Island s general mental health services and specialist substance misuse services. The Isle of Wight Ambulance Service callouts in 2010, 2011 and 2012 show that there were 112, 108, and 107 drugs related call outs/incidents attended respectively. Whilst these show a steady decline these call outs were distributed across the Island IoWD&ANA2013.doc Mar-13

70 however the highest levels of call outs in the last three years were PO31, PO33 and PO30 post codes respectively. The age with the highest volume of the callout requests were amongst the age group followed by the age bands. Interestingly in 2012 there was a significant growth in callouts from the 50+ age group, which may reflect the aging problematic drug using population on the Island. Hampshire Police Data on Drug offences (including possession, supply and PIWS and other miscellaneous offences) shows a steady decline since when there were 1,079 offences compared to 731 in NB this does not take into account drug offences during the Island s two music festivals. Possession and Supply the two largest offence categories have both declines over this period. Although in the case of supply there was a large spike of offences in Class B possessions (likely to be cannabis) have shown a decline since 2009 and are by far the highest recorded offence. There is an equal decline in the case of Class A and Class C possessions although when supply is reviewed it is clear that the Police can respond to increased drugs supply and have had success in a range of campaigns both to address dealing, supply and trafficking, as well as to address cultivation and manufacture of drugs. The top four beat locations for drugs offences are Pan and Fairlee 1690, Newport North and South 372, Ryde North/East/North West 270 and Sandown North and South 189. The probation Service s Offender Assessment System shows that in the period 1 st January 2012 to 31 st December 2012 there were 671 probation clients of which 25% had scores for drug misuse and 48% for alcohol misuse. The proportion of drug using probation clients that have accommodation issues 38%, domestic abuse 28%, employment, education and training needs 44% and emotional wellbeing 63% is high. The proportion that have an alcohol need have lower accommodation needs 29%, higher domestic abuse risks 55%, lower education and training needs 20% and lower emotional wellbeing needs 46%. Nonetheless this confirms this is a particularly difficult group to work with and getting these people to commit to treatment is traditionally extremely difficult In summary what this data suggests is that clients with alcohol and drugs problems present to other services on the Island both in health and emergency services, suggesting a relatively wide spread level of drug and alcohol misuse. The Police are active in tackling supply and addressing possession, although rates are in decline it is clear that there is still levels of criminality associated with drugs. The volume of probationers with drugs and alcohol needs is high at approximately 25% and 48% respectively. Collectively this suggests a relatively wide spread set of presentation and confirms the need for treatment provision for the Island s drug and alcohol misusers. IoWD&ANA2013.doc Mar-13

71 8 Alcohol 8.1 Alcohol is a growing component of Isle of Wight s treatment system. Increasingly substance misuse treatment providers are seeing more alcohol presentations. The NTA have advised of the need to include alcohol within a substance misuse needs assessment. To this end this needs assessment has analysed the National Alcohol Treatment Management System (NATMS) data held on alcohol treatment and has used the treatment mapping information to produce a comprehensive treatment map. The charts below describe in detail the treatment map journeys for IOW s Alcohol Service Provision is set out below: Tier 1 G.P Practices/Health Promotion specialists/ services able to deliver low level interventions Alcohol advice and information. Targeted screening and assessment for those drinking in excess of DH guidelines on sensible drinking and for those who may need alcohol treatment. Provision of simple brief interventions for hazardous and harmful drinkers. Referral of those requiring more than simple brief interventions for specialised alcohol treatment. Tier 2 Cranstoun/DAT/Get Sorted alcohol role Alcohol advice and information. Targeted screening and assessment for those drinking in excess of DH guidelines on sensible drinking and for those who may need alcohol treatment. Provision of simple brief interventions for hazardous and harmful drinkers. Referral of those requiring more than simple brief interventions for specialised alcohol treatment. Partnership or shared care with specialised alcohol treatment services. Tier 3 Cranstoun/IDAS/DAT/Get Sorted Comprehensive substance misuse assessment, care planning and review for all those in structured treatment, often with regular key working sessions as standard practice. Community care assessment and case management of alcohol misusers a range of evidencebased prescribing interventions, in the context of a package of care, including community-based medically assisted alcohol withdrawal (detoxification) and prescribing interventions to reduce risk of relapse. A range of structured evidence based psychosocial therapies and support within a care plan to address alcohol misuse and to address co-existing conditions, such as depression and anxiety, when appropriate. Structured day programmes and care-planned day care (e.g. interventions targeting specific groups) Liaison services, e.g. for acute medical and psychiatric health services (such as pregnancy, mental health or a hepatitis services) and social care services (such as child care and housing services and other generic services as appropriate). Tier 4 IOW Inpatient detox via IDAS/Tier 4 Rehab services via Care Manager (DAT) Comprehensive substance misuse assessment, including complex cases when appropriate care planning and review for all inpatient and residential structured treatment. IoWD&ANA2013.doc Mar-13

72 A range of evidence-based prescribing interventions, in the context of a package of care, including medically assisted alcohol withdrawal (detoxification) in inpatient or residential care and prescribing interventions to reduce risk of relapse. A range of structured evidence-based psychosocial therapies and support to address alcohol misuse. Provision of information, advice and training and shared care to others delivering Tier 1 and Tier 2 and support for Tier 3 services as appropriate. Chart 25: Alcohol Treatment Map. 8.3 In there were 150 referrals from a wide range of referral sources into the alcohol treatment system on the Island, almost twice the number of referrals compared to 69 in The highest volume of referrals came from self-referral, or family and friends 64 referrals or 43% of all referrals. The next highest was Health and Mental Health Services with 39 (26%), and Criminal Justice System with 25 (17%). 8.4 The table below shows the distribution of referrals sources for the 150 client referred into treatment. IoWD&ANA2013.doc Mar-13

73 Table 31: Alcohol Referral routes. Referral Source Number % Other 5 3% Community Based Care Services 6 4% Children & Family Services 4 3% Health & Mental Health Services 39 26% Substance Misuse Services 7 5% Criminal Justice System 25 17% Self, Family & Friends 64 43% Total New Presentations % 8.5 The table below shows there were 211 people experiencing treatment in the Isle of Wight in In total there were 211 different interventions and the range of interventions addressed is set out below. Table 32: Alcohol in Treatment interventions. Intervention Number % ALC Inpatient Treatment 5 2% ALC Residential Rehabilitation 6 3% ALC Community Prescribing 33 16% ALC Structured Psychosocial Intervention % ALC Structured Day Programme 1 0% ALC Other Structured Treatment 43 20% Adult Drug Intervention 6 3% Young Persons Intervention 0 0% Brief Interventions 1 0% Total % 8.6 In treatment transfers for alcohol services is completely non-existent on the Isle of Wight in This suggests that there is little cross partnership engagement and or that treatment and recovery planning reviews do not identify alternative local skills and expertise in which to pass clients on for further treatment, possibly more appropriate treatment. 8.7 The table below describes the range of treatment exits by type. It shows that 51% of those in treatment for alcohol exited the system as a successful completion which is a very strong level of treatment outcome. This suggests that the approach to treatment for just over half of clients has been appropriate at least to enable them to complete their treatment successfully either by reducing their consumption or by enabling them to complete alcohol free. The figure for un-planned exits for Alcohol at 48% which is high, as it would seem that just under half of clients have dropped out of treatment. Table 33: Alcohol Exit Categories. Exit Categories Number % Occasional User 24 22% Alcohol/Drug Free 33 30% Referred On 1 1% Unplanned Exit 53 48% Total Successful Completions 57 51% Total Exits (Including Successful Completions) % IoWD&ANA2013.doc Mar-13

74 8.8 It is important to assess how many people, out in the community, have an alcohol issue and hence may require treatment services. The only methodology currently being employed is the use of synthetic estimates generated from the Local Alcohol Profiles for England. This review was completed in 2008 and has since been updated annually. This provides an estimate which can generate a percentage profile for a local area, balanced by existing treatment patterns to assess the range of potential alcohol users in a local area. This data is also compared to England as a whole. 8.9 A clear focus of the estimation tool is to review the categories of alcohol abstainers, low risk drinkers, increasing risk drinkers, higher risk drinkers and binge drinkers. It can be seen from the table below that the Isle of Wight is below the national position in terms of abstainers and binge drinkers, and those at increasing risk of drinking. The Island however has slightly lower risk drinkers and high risk drinkers. Clearly this is being reflected in the increasing numbers currently entering treatment. Table 34: Estimation tool (Source: Local Alcohol Synthetic Estimates for England 11/12 Needs Assessment). IoW LB (00AE) England % of Total % of Total Lower Upper Lower Upper Population Population 95% CI 95% CI 95% CI 95% CI aged 16+ aged 16+ Abstainers 14.6% 9.7% 18.6% % of Drinking Population aged 16+ Lower 95% CI Upper 95% CI % of Drinking Population aged 16+ Lower 95% CI Upper 95% CI Lower risk Drinkers 73.5% 51.2% 86.5% 73.3% 51.1% 86.4% Increasing Risk Drinking 19.6% 10.6% 39.0% 20% 10.8% 38.5% Higher Risk Drinking 6.9% 2.4% 22.8% 6.7% 2.4% 21.8% Binge Drinking 12.8% 10.9% 14.8% 20.1% 19.4% 20.8% 8.10 The table above has been calculated using the 16+ Island population 2012 (177,679). This provides a profile of the population in these synthetic estimates as set out in the table below: Table 35: Estimation tool (Source: Local Alcohol Synthetic Estimates for England 11/12 Needs Assessment computes with ONS population profile 2012). Estimate Lower Upper 95% CI 95% CI Abstainers 17,181 11,415 21,888 % of Drinking Lower Upper Population 95% CI 95% CI aged 16+ Lower risk Drinkers 86,494 60, ,792 Increasing Risk Drinking 23,065 12,474 45,895 Higher Risk Drinking 8,120 2,824 26,831 Binge Drinking 15,063 12,827 17,416 IoWD&ANA2013.doc Mar-13

75 8.11 Using the estimate of the total population aged 16 the profile of the Island s alcohol drinking population is set out in the chart below. Inserted into the chart is the current number of treatment clients in the system. Chart 26: LAPE estimates converted to Isle of Wight Population profile What this suggests is that there is a very large proportion of low risk drinkers. Nonetheless there is a significant volume of increasing risk drinkers at 23,065 and 8,120 higher risk drinkers. Clients in treatment however is very low at 215 compared to the proportion of potential need set out in these synthetic estimates. Alcohol-related hospital admissions (NI 39) 8.13 Alcohol admissions to the treatment system are growing on the Island. There needs to be clear demarcation between drugs and alcohol services and the Island needs a clear alcohol strategy to support practitioners in their work The rate of alcohol related hospital admissions is a national indictor (NI 39). The value of this measure is reflected in the fact that it is also a Vital Signs Indicator (VSC 26) and Public Services Agreement Indictor (25.2) The rate of alcohol related admissions used for the national indictor is calculated using international best practice by the North West Public Health Observatory; it is calculated in several stages i : (1) Identification of hospital admissions with alcohol related diagnosis IoWD&ANA2013.doc Mar-13

76 (2) Estimating alcohol attributable admissions (3) Standardised rate calculation The rate of alcohol related admissions have increased nationally and regionally. The rates on the Isle of Wight have also followed a similar trajectory as set out in the table below. Chart 27: Isle of Wight Hospital Admissions for alcohol related harm NI to 2012 Source: NWPHO The table above shows the rate of alcohol admissions to St Mary s Hospital as rising significantly since The last recorded rate in showed an increase to 1,193 alcohol attributable admissions, n.b these figures also include others who have been admitted because of someone else s alcohol inebriation i.e. victims of RTAs The percentage growth year on year is set out below and in this case the Isle of Wight s annual percentage change for hospital admissions is compared with the South East and England. One can see that the percentage change for the South East and England is still growing albiet at a slightly reduced rate. The Isle of Wight s rate of change of alcohol admissions annually is much more volatile, in some years the rate is reducing and in other cases the rate increases significnatly. This has been supported with a linear trend line for the Isle of Wight which compares to the rate of growth in the chart below. IoWD&ANA2013.doc Mar-13

77 Chart 28: Annual Percentage change of Hospital Admissions for alcohol related harm NI to 2012 IoW, South East and England Source: NWPHO Looking more closely at the trends for alcohol related admissions rates from to the following is evident: Isle of Wight has fluctuated below and above the average rate of alcohol related admissions for the South East and England, but currently is significantly higher. The rates of alcohol related admissions have risen sharply since and is now at its highest level in the last ten years What is abundantly clear is that there is a growing trend and this raises real concerns for the Island s alcohol strategy. It should be noted that the volatility of change in percentages of admissions makes it harder to plan services. The basic trend line is however growing and this growth is consistent in the analysis of NWHPO data used for this needs assessment Another comparison is set out below which describes the comparable profile of hospital admissions describing the rates of change. For this exercise the data has used a baseline of the same points on the y axis of the chart. The chart confirms that the Isle of Wight s rate of hospital admissions for alcohol has grown since 2003 as has been the case in the South East and England. The South East has a higher level of Hospital admissions for alcohol per 100,000 populations. IoWD&ANA2013.doc Mar-13

78 Chart 29: Standardised Hospital Admissions for alcohol related harm NI to 2012 IoW, South East and England Chart 30: Hospital Admissions for alcohol related harm NI to 2012 Directly Standardised Rate per 1000 population (NMPHO) 8.15 Interestingly when one looks at the age profile per 1000 population it is clear that the older one gets the alcohol related hospital admissions grows significantly and clearly the impact on alcohol on one s health is a greater concern the older one gets. IoWD&ANA2013.doc Mar-13

79 Isle of Wight Ambulance Service Alcohol related call outs 8.16 The following information has been collated from the Isle of Wight Ambulance Service for alcohol related ambulance callouts. In the period 2010, 2011 and 2012 there 329, 271, and 358 alcohol related call outs/incidents attended respectively. The table below shows where these callouts originated. Chart 31: Isle of Wight Ambulance Service Call outs by Post Code 8.17 The post code locations with the highest level of call outs in the last three years were PO31, PO33 and PO30 respectively. Indeed in alcohol callouts came from PO31. Chart 32: Isle of Wight Ambulance Services Drugs callouts by age It is clear from this data that the groups with the highest level of Ambulance call outs for an alcohol related cause in 2012 was the age group, followed by the 50+ age group and the age group. In 2012 there was a high point in the level of call outs for the IoWD&ANA2013.doc Mar-13

80 30-50 year old age group with 168 callouts. What this suggests that alcohol related call outs related more to the Island s older population. Chart 33: IoW Ambulance Service Alcohol Call outs profile Unlike drugs callouts the number of alcohol overdose call outs are far higher. Additionally there does seem to be a growing trend over the period of the last three years. Lack of clients moving into Treatment 8.20 The data we see in the tables above show an increasing trend in alcohol admissions to Hospital and an increasing trend in alcohol related Ambulance callouts. This suggests a worsening set of presentations to the Health service. This also is compounded by the fact that there is a far lower proportion entering the treatment system and clearly this is a reflection of the treatment naive population in the Island s high risk drinkers. Essentially there are problem drinkers on the Island that are not presenting to treatment and the overwhelmingly likely reason is that people do not believe they have a problem. Indeed this situation is consistent with other parts of the country where high risk drinkers simply do not feel they have an alcohol problem and they do not present for treatment until the problem becomes more serious for them, even life threatening. Alcohol TOPS reports What this next section reviews is the treatment outcome profiles for the clients that are in the treatment system. The reporting framework looks to assess the extent to which alcohol abstinence is achieved through treatment and as such is a clear measure of performance of the providers treating alcohol addiction on the Island. The TOP methodology is the same as was reported for drugs as set out in section 4 above. Alcohol Abstinence 8.21 The chart below shows the change in alcohol use at treatment review, this relates to the alcohol TOPS for clients cited alcohol as problematic at the start of their treatment. All 44 or 100% were using at the start of their treatment. Clients reported using IoWD&ANA2013.doc Mar-13

81 on average 15.3 days in the 28 days prior to treatment start, which is equal to the national average The RCI shows of those 44 using at the start of their treatment 15 or 34% were abstinent at the treatment review. This is within the expected performance range of between 27% and 43%. The remaining 29 or 66% did not abstain and continued using at the treatment review. 0 or 0% initiated using at treatment review compared to 33% nationally. Therefore the total number using fell from 44 at the start of treatment to 29 or 66% at treatment review. The average number of days also reduced to 11, less in comparison to the national average of This demonstrates better than national average performance The RCI further shows of the 44 using at the start of their treatment 7 or 16% had reduced their use by more than the boundary of 10 days thereby improving. Whilst 3 or 7% detriorated, that is their use increased to 10 days or more, nationally 7% deteriorated. Chart 34: Alcohol Abstinence (6 month review) TOP Planned Exit 8.24 The following outcomes are based on 43 clients that had a TOP start and exit completed in The table below shows the change in alcohol use from treatment start to treatment exit. The RCI here does not give an expected performance range and there are no national averages for comparison. The RCI provides the proportions that abstain, improve, deteriorate or initiate at treatment exit. IoWD&ANA2013.doc Mar-13

82 Substance Citing drug Table 36: Alcohol TOP (planned exit) Treatment START TOP Reliable Change Index Treatment EXIT TOP Using at start Days used in last 28 days Abstinent Improved Deteriorated Initiated Using at exit Days used in last 28 days IoW n. % IoW % % % % n. % IoW Alcohol % 13 33% 13% 13% 0% 10 63% cited alcohol as problematic at the start of their treatment; of this 15 or 94% were using at the start of their treatment. The RCI shows 5 or 33% abstained by treatment exit the remaining 10 or 67% continued to use at treatment exit. 0 initiated using at treatment exit. Therefore the total number using fell from 15 or 94% at the start of treatment to 10 or 63% at treatment review. Of those using 13% improved that is used for less than 10 days whilst 13% deteriorated, that is using increased to 10 or more days in the 28 days prior to treatment exit. Overall the change in the use of alcohol shows fewer clients using at treatment review and treatment exit compared to the start of treatment. Alcohol Treatment Data Executive Summary Report 8.26 These reports have been available since April The report contains data to monitor performance in relation to activity associated with the delivery of structured alcohol treatment. There are 5 key areas this report cover, treatment entry, length of time in treatment, successful completions and client information. The report produced quarterly for primary alcohol clients. This report covers quarter Quarter reports shows there were 297 clients in contact with treatment in last 12 months, with 71% in treatment starting a new treatment journey in the current year to date. The chart below shows the length of time clients are in contact with alcohol treatment for their most recent journey in the year to date. The majority of clients have been in treatment for between 2 to 4 months or 7 to 12 months, proportionately more than the national average. Chart 35: Alcohol Time in treatment quarter The overwhelming majority, 75% commenced a psychosocial intervention, compared to 49% nationally. Other interventions include 9% prescribing, 1% day programme and 14% other. Whilst no clients waited to start their first treatment journey, waiting time for any IoWD&ANA2013.doc Mar-13

83 intervention to start shows 86% waited 3 or more weeks to start a psychosocial intervention clients in alcohol treatment successfully completed treatment in the last 12 months. As a proportion of the total number in treatment 51% successfully completed their treatment in the year to date period. The chart below shows in the last 12 months the proportion that successfully completed treatment which sits below the baseline data of 59%. Chart 36: Alcohol Successful Completions quarter The chart below shows the units of alcohol consumed by clients in the Isle of Wight compared to the national average. This shows 63% consume units in the 28 days prior to their initial assessment, compared to 19% nationally, the next highest is 11% consuming units but lower than the national average of 16%. This also shows there are fewer clients consuming a high volume of units compared to the national average. Chart 37: Alcohol Units Consumed quarter IoWD&ANA2013.doc Mar-13

84 % of clients in treatment with alcohol as their primary substance reported other drugs as secondary or third problematic substance In summary this shows over half the clients have been in treatment between 2 and 6 months, with fewer in treatment for longer than 1 year, 9% compared to 18% nationally. Most treatment interventions are psychosocial, for which 86% have waited for more than 3 weeks to start. 51% are successful completing their treatment as a proportion of the total number in alcohol treatment; nationally this is higher at 60%. The majority of clients consumed between units per in the 28 days prior to initial assessment. Summary implications for Alcohol Treatment 8.33 Alcohol admissions to the treatment system are growing in Isle of Wight. In there were 150 alcohol referrals, with 215 in treatment and 111 treatment exits. The highest volume of referrals came from self-referrals and or referrals from family or friends with 64 referrals or 43% of all referrals. The next highest was Health and Mental Health Services with 39 (26%), and Criminal Justice System with 25 (17%) Isle of Wight is achieving a 51% successful completion rate for its alcohol users which is a solid achievement rate. This suggests that the approach to treatment for just over half of clients has been appropriate at least to enable them to complete their treatment successfully either by reducing their consumption or by enabling them to complete alcohol free. The figure for un-planned exits for Alcohol is 48% which is high as just under half of clients have dropped out of treatment Estimates from the North West Health Observatory have been used for assessing local alcohol profiles across England. For the Isle of Wight 14.6% of those over 16 are seen to be abstinent, 73% are lower risk drinkers, 20% increasing risk drinkers, 7% higher risk drinkers and 13% binge drinkers. Using the 2012 population profile this would suggest 17,181 abstainers, 86,494 lower risk drinkers, 23,065 increasing risk drinkers, 8,120 higher risk drinkers and 15,063 binge drinkers Clearly these estimates seek to place the whole population in one or more of these categories, however the presentation to service are low with 215 in treatment. Another indicator that is helpful is the IoW Hospital admissions for alcohol related harm (NI39). A review of this measure in the last 10 years has shown a growing trend in hospital admissions from 620 in 2002/03 to 1,193 in when the number has almost doubled Alcohol is clearly a growing concern and has a rightful place in the Island s drug and alcohol treatment system. However for some stakeholders alcohol services have been seen as being secondary to drug services, indeed the only budget for alcohol treatment comes from traditionally targeted drug treatment budgets. However both have significant substance misuse implications both for the social, economic and health and well-being of the Island and its population. Arguably it is important to maximise the outcomes form the Island s treatment system to procure effective treatment for both alcohol and drugs misuse and to maximise successful completions from all targeted substance misuse to provide drug and or alcohol free recovery for all clients. IoWD&ANA2013.doc Mar-13

85 9 Service User and Stakeholder Engagement 2011 and Introduction To support this needs assessment a series of stakeholder engagement exercises have taken place. This included an initial stakeholder questionnaire sent out electronically to all those it was felt important to engage in this assessment. These contacts were provided by Public Health and the DAAT at the commencement of the research programme. This was supplemented with a questionnaire of service users to access a different perspective on the treatment provision on the Island. This survey was a self-completed questionnaire and sought initially to engage circa 100 service users. To this end treatment providers undertook to recruit responses from within their client base. In addition we undertook stakeholder interviews of key partner agencies engaged more closely with the treatment services on the Island. Two focus groups were also held with service users to begin to drill down to the core perceptions of treatment and treatment services on the Island. Finally a workshop was held on the 28 th of February to discuss the findings of the needs assessment and to begin to review priorities for future treatment and priorities for improving services and to support the forthcoming treatment services tendering exercise being carried out by the DAAT The engagement activities set out above were identified within the needs assessment s research plan which was agreed with Public Health and the DAAT Commissioner in December The summary of which is set out below. Chart 38: IoW Drugs and Alcohol Needs Assessment Research plan IoWD&ANA2013.doc Mar-13

86 9.2 Stakeholder questionnaire This survey was designed as an introductory questionnaire in part to illicit general views of the substance misuse system and model on the Island as well as to engage key partners and agencies in the needs assessment and to provide some understanding and context to the needs assessment. The survey was sent out to 110 people on a database of key contacts provided by the Public Health Unit and DAAT team. The survey was sent out just after Christmas 2012 and was completed by 51 stakeholders by the time the questionnaire closed at the end of January The Lines of inquiry within this short questionnaire were: The prioritisation of Drugs and Alcohol Services on the Isle of Wight Satisfaction with current Drugs and Alcohol treatment provision on the Isle of Wight Outcomes expected of the treatment services Interest in finding out more from the Needs Assessment Other key issues respondents felt they wanted to raise which they specifically saw as priorities for the needs assessment. This was an open ended question and analysis was not sought as these were essential qualitative responses to this question Findings 90.2% of respondents see the treatment and prevention of Drugs Misuse on the Isle of Wight as being either a High Priority or a Very High Priority 86.3% of respondents see the treatment and prevention of Alcohol Misuse on the Isle of Wight as being either a High Priority or a Very High Priority 31.4% of respondents are dissatisfied with Drugs and Alcohol treatment provision on the island 51% of respondents are neither satisfied nor dissatisfied with Drugs and Alcohol treatment provision on the island 17.5% of respondents are satisfied with Drugs and Alcohol treatment provision on the island With respect to the outcomes expected of the treatment services: o 84.3% see managing addictions as a high priority treatment outcome o 82.4% see reducing and minimising harm as a high priority treatment outcome o 92.2% see providing resources to address addiction as a high priority treatment outcome o 79.8% see reducing crime and disorder associated with drugs and alcohol as a high priority treatment outcome o 96.1% see supporting behavioural change as a high priority treatment outcome o 92.1% see establishing a journey towards drug and alcohol free recovery as a high priority treatment outcome 92.2% of respondents wanted to find out more about the effectiveness of treatment services on the Island 80.4% of respondents wanted to find out more as to the level to which services penetrate need IoWD&ANA2013.doc Mar-13

87 70.6% of respondents wanted to find out more about the prevalence of drugs and alcohol addiction on the Island 68.6% of respondents wanted to find out more as to the cost impact of drugs and alcohol misuse on the Island and the levels and trends in drugs and alcohol misuse on the island The table below shows the range of interests respondents had for information the Needs Assessment could illuminate. The highest priority focus is effectiveness of treatment services followed by the level to which current services penetrate need. Chart 39: IoW Stakeholders priorities to emerge from the needs Assessment Additional issues raised by the 12 respondents who took up this open ended section of the questionnaire have been summarised below, they include: A better understanding of the 6 year plus long term service users Focus on young people and alcohol and specific care pathways for this important group Issues of harm reduction, maintenance prescribing and the recovery agenda Treatment services need to link with other partnerships stakeholders in particular the Police, NHS and Ambulance services Holistic linkage of Drugs and Alcohol Services with mainstream health provision and in particular mental health, domestic abuse, sexual harm and family services Interest in integrating treatment services with primary care, community and social care services and 3 rd sector organisations. IoWD&ANA2013.doc Mar-13

88 Summary It is abundantly clear from this survey that there are some extremely committed stakeholder to the drugs and alcohol treatment system on the Island. There is equally a strong sense that people are passionate about the services that the Island provides and that they are committed to ensure that the services are as effective as possibly in delivering benefits to their clients. It is interesting that there are differing views as to the priorities of these services however there are some clear indicators for priorities in particular to support clients on their journey to drug or alcohol free recovery as well as the commitment to supporting behavioural change for treatment clients However it is equally clear that the local drugs and alcohol partnership needs to work to build a consensus with this stakeholder group to ensure that there is a common approach to supporting referrals to the treatment provision and to ensure that the partnership has clearly defined priorities for treatment and for tackling drug and alcohol addiction and to preventing substance misuse. To this end the needs assessment will attempt to identify core priorities for the Island to take the drugs and alcohol services forward locally and to begin to define the targets within the drugs and alcohol treatment plans for IoWD&ANA2013.doc Mar-13

89 9.3 Service User questionnaire This service user Survey was supported by IDAS and Cranstoun who disseminated the questionnaires amongst their service users and collected the self-completion questionnaires and posted them using the Freepost addressed envelops provided. The questionnaire had 27 separate questions including 5 demographic sampling questions Essentially Section one of the survey sought to identify the substances being misused by the cohort, their length in their current treatment episode, how they were referred into treatment, and their service provider. Section two of the survey identified client perceptions of their substance misuse and their entry into treatment. Section three identified questions about the clients care plans. Section four asked questions about the client s perception of treatment and their treatment provider. Section five asked questions about after care services and concluded with an open ended questions offering the opportunity for the client to make comments about treatment provision in general In total 120 questionnaires were distributed as part of this exercise and 65 were returned which represents just over 50% of the sample. Indeed based on the number of clients in treatment in (438) 65 returns represents 15% of the total treatment population Findings Question 1 asked respondents to inform the survey of the form of substance misuse and they were given the option to respond to as many options as they saw fit. Opiate and Crack users made up 53.8% of the respondents, Alcohol accounted for 43% of respondents, Cannabis 31%, Diazepam 20%, Cocaine 14% and Amphetamines 11%. Interestingly there were no clients who used crack only which seems to concur with the view that crack use is directly associated with opiate use for a proportion of the opiate taking population. Indeed opiate users, who use crack as well, make up 40% of the OCU respondents. The high level of alcohol use also describes the volume of alcohol drunk in association with other substance. Question 2 sets out the profile of respondents in terms of when they started their current treatment episode. The majority of respondents (58%) started their treatment within the last year although 23.4% have been in treatment for more than 4 years. Chart 40: Q2. When did you start your current treatment episode? IoWD&ANA2013.doc Mar-13

90 Question Three shows the referral source for each client in the survey. What is interesting in this table is the number of clients that state they were referred to treatment by their GPs; however this is likely to include Alcohol clients as well as drugs that will have been referred by their GPs. Table 37: How were you referred for treatment? Answer Options Q3. How were you referred into treatment? Response Percent Response Count Self-Referral 43.8% 28 GP 21.9% 14 Drug Services 9.4% 6 Arrest Referral (DIP) 6.3% 4 Probation 9.4% 6 CARAT 0.0% 0 Other Health Services 3.1% 2 Other Criminal Justice Services 10.9% 7 Other 7.8% 5 answered question 64 skipped question 1 Question 4 identified the respondent s treatment provider. 66.7% were with IDAS, 47.6% were with Cranstoun and 7.9% other. In some cases treatment had been through more than one provider which suggests that there is a fair amount of informal referrals between providers. This also challenges the data that suggests that there is a low level of in treatment transfer between clients. Several respondents stated they were at both IDAS and Cranstoun and some identified other providers as well including the Real World Trust, Mental Health Services and their GP. Question Five sought to identify the most important reason for respondents wanting to change their substance misuse behaviour. Desire to improve their health was the most significant response with 79.4% of respondents stating this was the most important reason. This is followed by both enjoying and reducing the stress for their family, children and friends (57.1%). The nest most important reason is to help improve their chances of living longer with 47.6%. This is followed by improving their ability to work (46%), stopping getting into trouble with Police 34.9% and to gain more money 31.7%. The priority from this group therefore is about health gain, followed by feelings for their families, children and friends, longevity of life, employment, reducing trouble with the police and generating more money. IoWD&ANA2013.doc Mar-13

91 Chart 41: Q5. What is the most important reason for you wanting to change your substance use behaviour? Question Six set out a series of statements which respondents were asked whether they agreed or disagreed with. Chart 42: Q6. Please indicate the extent to which you agree or disagree with the following statements The highest levels of agreement (90%) came from the statements I think my substance IoWD&ANA2013.doc Mar-13

92 misuse negatively impacts on my ability to lead a full and active life and 83% from I feel optimistic about my ability to reduce my dependency on substances. The highest levels of disagreement came from the statements I don t think I have that big a problem with 65% disagreeing, and I think more could be done by services to better help me with 57% disagreement. Question 7 gave respondents the chance to think back to when they entered treatment to see if any of the following applied. Table 38: Q7. Thinking back to when you first considering coming to a support service on the Island, did any of the following apply: Answer Options Yes No Not Sure Response Count I didn t think I had a real problem I missed appointments and failed to turn up I thought the others attending were worse off than me I didn t want anyone to see me going to a service because I was ashamed I felt pressurised by health professionals to have to come answered question 62 skipped question 3 The responses show that there is a similar response to the first four statements. Interestingly only a small proportion felt they were pressurised by health professionals to have to come. Section Three of the survey sought to identify the use of care/recovery planning to support clients in their treatment journeys. Question Eight confirms 77% of respondents have a care/recovery plan and 14.8% did not and 8.2% were not sure. Question Nine asked those who answered yes to Question 8, did they completed their care/recovery plan jointly with their key worker. 70.5% (31) said yes, 11.4% (5) said no and 18.2% (8) were not sure. Question Ten asked if clients have a copy of their care/recovery plan. 34.4% said yes, 55.7% said no and 9.89% were unsure. Question Eleven asked if their Care/Recovery Plan has been reviewed in the last 3 months. 55.7% said that it had been 29.5% said it hadn t and 14.8% were unsure. Question 12 asked if their care/recovery plan had positively contributed to their treatment. 63.8% said that it had, 13.8% that it hadn t and were unsure. Some respondents were keen to state that their care/recovery plan provided focus, offers goals and helps record achievement and progression. IoWD&ANA2013.doc Mar-13

93 Question Thirteen asked if clients were given choices about treatment options available to them on the island. 73.3% said that they had, 23.3% said they had not and 3.3% were unsure. Question Fourteen asked how clients judged their current or most recent treatment in terms of meeting their needs. 85% said it was good, 13.3% average and 1.7% said it was poor. Question Fifteen asked clients how they would relate their existing or most recent treatment provider in terms of their relationship with them. (96.7% said it was good, 1.6% average and 1.6% poor. This is a very positive result for all providers. Question Sixteen asked clients how they would rate their treatment provider on their skills and abilities in interpreting their needs. 91.5% stated they were good and 8.5% stated that they were average, none stated they were poor. Questions Seventeen asked how clients would rate their treatment provider on their support for them. 88.1% stated it was good, 8.5% stated they were average and 3.4% stated they were poor. Question Eighteen asked clients whether treatment experience so far has helped to change their drug and or alcohol use. 89.7% stated that it had, 3.4% stated it had not and 6.9% stated not really. Section Five addressed aftercare provision. Question nineteen, asked clients if they have had access to any aftercare services to help with their reintegration into the community, such as support for education, training and employment. 48.2% stated yes, 42.9% sated they had not and 8.9% were unsure. Respondents identified Goal Mapping, Result+, benefits advice, Hep C testing, and Gum clinic as positive options, employment support and training were also identified by some clients. Question Twenty asked clients if they thought they have benefitted from Aftercare services. 61.1% stated that they had, 8.3% stated they had not and 30.6% stated they were not sure. Question Twenty One asked clients if there are any services that they think would better help them work towards recovery that have not been offered to them on the Island. 20.7% stated there were, 53.4% stated they were not and 25.9% were unsure. This suggests that Service users are not clear about alternative options for treatment and or alternative provision. Some felt there needed to be better after care, employment support, and more access to GPs, in patient detox on the island, a Hep C clinic on the island, one to one buddy systems and mentor schemes where as others were keen to say they were satisfied with IDAS. In general summary clients were asked if they have any other comments to make or improvements to suggest to the provision on the island. Interestingly there was a strong volume of supportive responses stating that current drug and alcohol treatment was good, IoWD&ANA2013.doc Mar-13

94 IDAS is brilliant, I am very happy and keep things the same, and it works for me. Others state they have experienced services elsewhere and treatment provision on the island is the best provision they have experienced, some referred to the need for more out of hours provision, better information and communication of what s available, a full time doctor, the friendliness of Cranstoun and how Cranstoun have helped with everything needed. The profile of respondents showed that 73.2% were male, 26.8% female; the age profile was spread relatively evenly with 8.6% (18-24), 37.9% (25-23), 20.7% (35-44), 24.1% (45-54) and 8.6% (55-64). The ethnic profile of respondents showed 98.3% White British and one White other. 75.9% stated they did not consider themselves as disabled and 24.1% stated they had a disability. This is relatively high and of this group 17 felt they had a mental health condition, 5 had learning difficulties and 6 a physical impairment and 2 a sensory impairment In summary Service Users are particularly supportive of current treatment providers, supporting their providers in this way shows a positive relationship and clear commitment to working on this relationship In terms of the priority motivation to enter services the survey s respondents highlighted improvement to their health (79%), enjoy more the company of families, children and friends and reduce the stress caused by substance misuse with families, children and friends (Both 57%), followed by increasing longevity of life, employment, reducing trouble with the police and generating more money In highlight terms 97% felt they had a good relationship with their treatment providers. 91.5% stated that their treatment provider s skills and abilities in interpreting their needs are good. 87% felt their treatment provider was good at meeting their needs. 77% of respondents stated that they had a care /recovery plan and 70% of these had developed their care/recovery plan with their key worker. These are generally strong responses and this clearly shows the close and strong links with these client s treatment providers With respects to recommendation for the future, several referred to the importance of after care, after hours services and general service access across the island. There were also concerns that several services needed to be accessed on the mainland and convenience and cost was seen as a factor in these concerns. Specific provision related also to greater GP access through treatment and better information and communication about what s available Essentially the survey has provided a strong set of returns confirming the general support clients have for the way services are currently run. IoWD&ANA2013.doc Mar-13

95 9.4 Stakeholder interviews Interviews took place throughout January 2013 and it was clear that there were people coming to the interviews from different parts of the drugs and alcohol treatment services, partner agencies and concerned individuals who want to see effective and efficient interventions to address drugs and alcohol use and treatment on the island To put these interviews in context it seemed that there was a range of different levels of understanding of people and stakeholders as to the issues that relate to drugs and alcohol and as to the different types of interventions and in particular treatment. Each clearly knew their area of expertise but as individuals and organisations coming to the Drugs and Alcohol treatment environment from differing positions and organisational priorities, they seem to want to have a greater sense of what collectively they were doing to address needs and to resolve the problems associated with drug and alcohol use Interviews ranged from between 30 and 40 minutes and several were made by phone although the majority were face to face. Who had been engaged? Bryan Hurley DAAT Commissioner Gille Bergeron Service user Engagement Scott Carter Get Sorted Gaby Buday Get Sorted Gary Castle Get Sorted John Marsek Get Sorted (Transitional) Zoryna O Donnell Safer Families Fleur Gardiner Domestic Abuse Simon Bryant Public Health Consultant Carol Foley Public Health Team Georgia Tuckey IDAS Elaine Baxendale IDAS Felicity Young Sexual Health Unit Kay Marriott Sexual Health unit Christina Skipper Prison Detox Mo Smith Mental Health Services Chris Smith IoW Ambulance Service Dr. Andreas Lehmann GP Shared Care Scheme Mandy Brown Cranstoun CDA Laura Brock Alcohol Counselling Mental health Nikki Shave Probation Service David Stewart Lead Councillor Drugs and Alcohol Jayne Bell Obelisk Training (Goal Mapping) Tracey Goodhew National Treatment Agency Nicholas Heelan Hampshire Constabulary Matt Lockear Hampshire Constabulary John Prickett Real World Trust Findings A range of findings emerged from the interviews that have taken place to support this needs assessment. It is clear that they are important issues for those interviewed and to this end the key finding have been clustered below: There is a general sense that the island s drugs and alcohol work lacks coordination Lack of infrastructure, strategy and policy to support interagency activity Lack of effective cross partnership communication, although there was a realisation that this is something that needs to be two way Information sharing and data support is lacking although all who were asked offered and provided data to this needs assessment Performance management is reliant on DOMES reporting but the partnership is not reviewing up-to-date data and hence affect localised pressure for change and improvement IoWD&ANA2013.doc Mar-13

96 Establishment of the island s problem family programme and project plan indicates a strong likelihood that there will be good opportunities in the future for consolidated partnership working to support these families. (Note: the Families with Children section in the DOMES report will be useful to identify those users with children already in the treatment system, by assessing their outcomes and representation to treatment. The report also identifies pregnant females in the treatment system) Strong commitment from Sexual Health Services to partner treatment providers and make their contribution to the Isle of Wight drugs and alcohol treatment partnership Managing the wide range of partnership inputs is critical to the support of the achievement of the partnership Police have undertaken specific campaigns on drugs seizures and in working to reduce drugs supply and cultivation/manufacture, particular campaigns have been delivered in partnership with the DAAT Historic provision of drugs and alcohol education by partnership but due to reprioritisation this seems to have declined. Police priorities in developing partnerships and engagement of interagency support to reduce the supply of class A drugs. Several felt that services and activities currently feel fragmented, with a lack of effective coordination, awareness and often poor communications and information Critical value to support the health and mental wellbeing of the clients both through and at the end of their care process. There is a clear view supporting the value of Goal Mapping which is provided on the island and which supplements the tier three interventions drugs and alcohol treatment provider s offer. Crisis services for Mental Health clients have strong drug and alcohol associations and presentations Strong relationship to the use of cannabis and legal highs being seen in presentation to Mental Health Services Particular need to link Mental Health Services in with local health promotions services in particular with respect to legal highs and non-opiate drug and alcohol use General concerns with legal highs and cannabis, alcohol presentations have significant impact on wider service provision Commitment to better support drugs and alcohol treatment provision and to widen local referrals which many felt were in need of reinvigorating Real local problems associated with training, education and employment and desperate need for supported housing for drugs and alcohol service users Strong hope that the Integrated Offender Management approach will better support drugs and alcohols probationers Critical need to address the disjointedness of treatment provision and to consolidate a clear understanding of what everyone is doing. Summary The interviews carried out as part of this needs assessment were extremely helpful in establishing the context and history of local services and perceptions of need. What is extremely encouraging is that all the stakeholders wanted to ensure that the whole approach to drugs and alcohol is addressed collectively with each partner agency and local commissioned provider agency are pulling together preferably through a stated drugs and alcohol strategy. IoWD&ANA2013.doc Mar-13

97 9.4.6 A variety of points in the needs assessment have been embellished through these interviews and whilst it is not right to transcribe them in detail the essence of their findings have been extremely useful in clarifying the needs locally and understanding the way in which the Island s treatment system can support improvement, growth its achievements and adapt to change effectively. In short we would like to thank those for taking part in these interviews. IoWD&ANA2013.doc Mar-13

98 9.5 Focus groups Context The main purpose of these two focus groups was to establish an opportunity to give service users and ex-service users the time and the space to explain what it is and or was like for them in the treatment system on the Isle of Wight. The exercise took 1 ½ for each focus group and they were attended by the Result+ group followed by a group of service users from both IDAS and Cranstoun. The groups were recruited through the membership of the Result+ group assisted by Gilles Bergeron the Council s Service User Engagement Coordinator, who invited the group to attend and through the management and staff from both IDAS and Cranstoun Specifically each focus group followed the same format and included activities to: Introduce the group and the rationale of the focus groups Run a warm up exercise reviewing attitudes to treatment Review users experience of entering the treatment system Review users experiences in treatment Consider the role and approach to Care Planning/Recovery Planning Establish whether treatment provision on the Isle of Wight meet their needs Identify what in the eyes of the user has been critical in their progress in treatment on the Isle of Wight Every effort was made in the focus groups to elicit views that were born of the experiences of these people and commitment was given in each to the confidentiality of the sessions and the integrity of the views being expressed. Throughout each focus group effort was made to review discussion and to note the session accordingly. RESULT Plus Focus Group This focus group took place at Cranstoun CDA s offices in Newport on Wednesday 30 th January at 1.00pm. The group was made up of 8 participants, four women and four men. Between them there were people who came to treatment to address, alcoholism, and drug misuse including opiate, crack, cocaine and a range of poly substance misuse. Attenders had been in the treatment system from between 20 and 2 years at an average of 9.2 years in some form of treatment. Most had had the majority of their treatment on the Island and all had experienced treatment on the Island The group collectively had had experiences of IDAS, Cranstoun, Mental Health Services, Ambulance Services and A&E. Several had had Detox both in house in the community and with Real World Trust and several confirmed the benefits they got through Goal mapping. There were three women who were also members of Power which is a service users group focused on women. Essentially this was a group of recovering drug and alcohol users, all of whom have experience of the treatment system and most of which have completed journeys to drug and alcohol free existence. IoWD&ANA2013.doc Mar-13

99 9.5.6 After initial introductions the group started to review four statements and each were asked to state whether they agreed or disagreed with the statement. This was done to warm the discussion up and to start to set the parameters of the focus group. The first statement was: Statement One: Isle of Wight Drug and Alcohol treatment services are fit for purpose and delivers the goods for its clients Five disagreed and 2 agreed with one not sure, between them there were a range of views emerged including: it depends funding for alcohol was not there before but its better now with it present in the system For Alcohol I got more support from my GP and Power who supported me through a community detox which Cranstoun arranged alcohol beds are scarce it was better at the Real World Trust Unclear what the selection process for detox is, however once it's done there is no aftercare Now recovery is the aim but it s not right for everyone, maintenance has its place as you can t detox until you have reduced down your methadone and or Subutex to a point where detox is more successful Statement Two: My service provider/key worker understands what I need and works to support my journey to recovery Most agreed with this statement however: Several respondents felt they had had numerous key workers. However their overwhelming view was that they are fantastic, they do their bit some keep in contact since treatment but essentially once you have been through to detox that it. The discussion then took a different tack. Clearly the group are strong advocates for the role that Result+ and Power undertake to further support clients in and post treatment. There was an underlying concern that this is not recognised and that this voluntary work is unsupported. There was a feeling that the commitment to service user engagement is being driven by the DAAT and not by clients for clients. This is a concern as it is equally clear from information gathered through the DAAT that the work of the Service User Support Officer is extensive and driven. In the longer term issues of structure, reporting lines, roles, responsibilities, governance, planning and coordination of activities with Result+ must be reviewed through effective dialogue and joint working. In this review the issues of support and acknowledgement must feature to address these perceptions. Statement Three: My treatment experience has assisted me in changing the level of my drug and alcohol usage. All agreed with this statement and hence the group moved onto the next statement. IoWD&ANA2013.doc Mar-13

100 Statement Four: I feel stabilised through the treatment I receive/d and this is more important than achieving full recovery The group were quite unanimous in their view that total abstinence is what Result+ and Power seek to achieve. There is recognition that there are different trigger points for different people that would challenge their abstinence approach, but that the group felt that keeping busy and working to enhance the success rates for other people is critical for them and that service users are best placed to support these clients completing their treatment. Many were extremely supportive of Goal mapping and the value that has had for them. Several are still in contact with their former key workers but that this is recognised as something these committed staff are keeping up rather than something that is part of any formal after care. Many felt that the group was increasingly supporting people and that several felt there was a need to continue to support the group both in terms of service user training and in terms of the group s development The group then considered a series of questions about their experience of entering the treatment system on the Island. It took so long, remember being passed from pillar to post with people and professionals not really knowing what the best solution was. (notably this was an experience of clients that had been in the system for a long time) Many remembered the sense that they were entering into something quite confusing and complicated Several felt that IDAS had their hands tied by their previous management, there wasn t any real direction There was limited information and whilst the one to ones were good they didn t seem to get to the bottom of things Goal Mapping has made things much more clearer since exiting the treatment system Several felt that as they wanted to access detox quickly, but there are no spaces for in patient detox apart from the Severn Acres Mental Health Ward and this is a real concern. There are no detox beds on the Island for drugs, apart from Butler Gardens run by Southern Housing and the Real World Trust Several were supportive of IDAS whop were seen as flexibly building up trust for things like fortnightly pick-ups, goal setting and how the nurse pointed to Result+ as a solution to their aftercare The group then considered their experiences whilst in treatment. Several had been in treatment with IDAS and Cranstoun and as mentioned the Real World Trust and through Jane Bell s and Bethan Stretting s Goal Mapping support. In terms of rating they would give IDAS they were between 4 out of 10 and 8 out of 10, Cranstoun was 5-7 out of 10 and the Real World Trust much higher but from those who had used that service, as not all had. All felt that the goal mapping work is crucial and several felt that would have helped earlier in their treatment, whilst other recognised that they weren t previously ready to get benefit from Goal Mapping. All had has some level of psychosocial interventions with behavioural therapy, motivational interviewing but essentially heroin users got most value from their scripts and most alcoholics gained from their one to one work with key workers. IoWD&ANA2013.doc Mar-13

101 9.5.9 With respect to care planning/recovery planning, almost 50% recognised that they had had a care plan, some simply did not know nor indeed remember this being part of their treatment regime. Others that did felt they were engaged in their treatment plans and some even had seen copies of them. None had ever seen and information about the treatment system from a performance perspective The group then discussed what has been critical in your progress in treatment in Isle of Wight and to this end the following points were raised: Peer support Keeping busy Actively working to support others to get the most from the treatment system, this is why the peer mentoring component was seen to be so important for the group Goal mapping is highly valued and this has helps many who have gone through this process. Several felt that the methadone and Subutex dosages were well considered and that their scripts were much improved through IDAS. Two felt that the Hostels through the Real World Trust, the Salvation Army, and Riverside were critical in supporting their treatment Finally with respects to improvements to the treatment system on the Island: Several felt there needed to be more done to address legal highs Most felt that there is a real need to improve access to detox and aftercare, especially if the commitment to the recovery agenda is meaningful Funding for user groups and support for life skills Several also felt that needle exchange on the island is inadequate At this point the group concluded, several members completed the service user questionnaires and all felt the focus group was valued and they thanked each other for the strong levels of participation. One impression the group gave was that they cared for the improvement to the treatment system and all had benefitted from working together to support other treatment clients on their journeys to recover drug or alcohol free. Current Treatment Client Focus Group This group was held on Wednesday 30 th January at 3.00pm at Cranstoun CDS. The group had been selected by treatment providers with the requirement that they were general clients, but that where feasible those that came from IDAS were longer term clients who had been in the system for a while. The group was made up of eight people seven men and one woman, although there was another woman in attendance, being the mother of one of the men present. This enhanced the group both in terms of gender balance but also in having a slightly different view from a parental perspective There were four heroin and crack users and four who abused alcohol. What was clear was that all the heroin users had been in treatment for over 10 years where as the alcohol users were more recently in treatment i.e. all less than 5 years. Six of the clients were clients of IDAS and two from Cranstoun. IoWD&ANA2013.doc Mar-13

102 After initial introductions the group started to review the four statements previously used in the first focus group and each were asked to state whether they agreed or disagreed with the statement. This was done to warm the discussion up and to start to set the parameters of the focus group. The first statement was: Statement One: Isle of Wight Drug and Alcohol treatment services are fit for purpose and delivers the goods for its clients Almost unanimously the group agreed: the fact that I m here is testament to the work of the treatment providers they are thoughtful caring and committed to my needs The programme is working for me My medication is well measured and I ve been coming off methadone since I been going to IDAS Statement Two: My service provider/key worker understands what I need and works to support my journey to recovery Most agreed with this statement: My key worker is great she regularly contacts me to remind me of my scripts and appointments Key workers give you time on the Island, having used services elsewhere it simply doesn t come close to the time they give you here They are sympathetic and caring, they don t pigeon hole you and make you feel bad like some providers in other places They are friendly, their reception (IDAS) is much better than it used to be. It used to feel like a prison They have given me a lot of support, but I recently lost their trust Statement Three: My treatment experience has assisted me in changing the level of my drug and alcohol usage. All agreed with this statement and hence the group moved onto the next statement. Statement Four: I feel stabilised through the treatment I receive/d and this is more important than achieving full recovery The group had slightly different views, the majority felt that the drive to total abstinence is a goal but they all felt that they needed to be in the right place to enable treatment to be successful. This they argued needed to be accompanied with a clear period of maintenance treatment particularly for opiate users to ensure that they were stabilised to benefit from treatment and reducing dosage of substitute proscriptions to ensure that could move onto abstinence. Those alcohol misusers in the group were committed to abstinence but recognised that they have potential trigger issues which would bring alcohol back into their lives. In essence there was recognition that this works hand in hand and that you can t get to full recovery without firstly being stabilised. IoWD&ANA2013.doc Mar-13

103 The service users present then looked at their experiences of entering the treatment system on the Island. Several felt it was all very easy, with clear referrals from their GP and or the criminal justice system. In many cases these clients knew of treatment provision and brought themselves into treatment themselves. Some had had some chaotic starts to treatment but all felt that it was easy to enter into treatment and that there were no waiting lists. Several of the longer term clients in treatment felt that services have changed in particular since IDAS was under special measures and when the new management have been in place some 4-5 year ago. In fact some of the redesigns at IDAS were done in conjunction with service user group. Indeed several felt that things had drastically improved. Those who used IDAS felt that it was doing a superb job. However there seemed to be a lack of cohesion with IDAS and St Marys Hospital, moreover this opened up views that clients felt they were being judged at St Marys Hospital and that they were unsympathetically seen at the A&E ward, especially a view from those who has been in alcohol related A&E situations With respect to the groups view of their providers and key workers they felt that they: Identified their needs and addressed their concerns Supported them in their treatment plans Listened Gave time and commitment Responsive Supported with things like housing and benefits Came to visit and were active in giving their time and support With respect to their current treatment service users in the group felt: They had to ask in the past but now things were offered Detox is still a real problem and there is less, although several of the long term heroin clients were now working to complete community detox, which is something that the providers have recently been offering Scripts are better now with the right levels, Georgia is good at prescribing They are super friendly, super-fast, but services don t seem to be advertised and perhaps this could be done more Waiting at IDAS is not clean of dealing and access to drugs, remember in the past being able to score off other clients down the road. It would be good to get a bit more face time with GPs at IDAS With respect to care planning, most drugs users were aware of their care plans and one had even brought theirs to the session, the alcohol users less so, but their view was that one to one sessions were critical to their health and well-being and that these had been instrumental to their drive to alcohol free recovery The critical features of the services from the service user perspective were: The quality of the one to one work for alcohol clients Quality of key working for drug clients Getting the scripts right and ensuring that you had the right amount of dosage for you Strong sense of care from all providers Community detox IoWD&ANA2013.doc Mar-13

104 Effective detox for alcohol on the Island, some had heard of the Real World Trust, two had been to the trust and one had been there as a client for a heroin detox Being in the right place myself, I recognise that I need to be fit to recover and to this end I m eating better doing exercise and this should be generally supported by providers At this point the group closed, there was a strong view from that group that the session had been valuable and that in some respects they had learnt something about the treatment provision on the Island. Moreover others felt the value of the discussion and hoped that this would support provision, which they were all concerned would be maintained and supported financially. Summary It is clear that the two focus groups were made up from different sets of people at different stages of their substance misuse recovery. The Result Plus group seemingly had a clearer focus on the whole journey enhanced by their commitment to support people through this and onto recovery. In particular they are driven to support the provision of group support towards aftercare many of whom from a personal perspective were benefiting from this approach to joint working However the current treatment clients were far more immersed in their treatment experiences and their position on their journey to recovery. Indeed it was clear from this group that they had strong support for their treatment providers and that they were benefitting from this experience. In essence they were currently engaged in making the system work for them and in most respects this was being fully supported by their service providers It was also abundantly clear that there are different perceptions of treatment provision by alcohol and drugs clients alike. Essentially drug users were preoccupied with substitute prescribing from a stabilisation and then recovery perspective. Whereas alcohol misusers were more aware that they needed one to one support to exercise their alcohol addictions, indeed some had previously been prescribed alcohol reactive medication which was deemed awful and quite repugnant In summary the two groups felt that: There is real support for providers particularly from current service users A general concern as to the adequacy of detox provision on the Island Strong perception for the need for stabilisation before recovery Ongoing support of provision for aftercare Support for service user groups and provision of resources to maintain this critical aftercare support work. IoWD&ANA2013.doc Mar-13

105 9.6 Summary Primary Research and Engagement The levels of engagement of stakeholders and service users in this needs assessment has been targeted to maximise the opportunity for key people to inform the needs assessment and to support the future direction of the treatment system on the island. The key finding from this primary research has been: Stakeholders are keen to see the needs assessment effectiveness of treatment provision on the island and the extent to which services are penetrating need. 90.2% of Stakeholders see the treatment and prevention of Drugs Misuse (Alcohol 86.3%) on the Isle of Wight as being either a High Priority or a Very High Priority Both these highlights serve to suggest that Stakeholders are interested to support improvement to the treatment system and see the value in so doing. There was very strong support from Service users with regards to their treatment providers particularly the strong and positive relationships that support the recovery agenda. General recognition by all partiers of the need for detox and after care on the island Concerns with regard to housing and employment and in particular the sofa surfing culture of some of the island s substance misusing population Service users and Stakeholders have stated that information and access to services could be improved, as could the widening/expansion of referral pathways into treatment Strong sense from stakeholders and service users that there is a need for a drugs and alcohol strategy for the island Particularly strong support for Result+ and Power as service users groups helping clients to recover. This is a critical resource and one which needs to be harnessed effectively to maximise the benefits this peer led approach can offer. IoWD&ANA2013.doc Mar-13

106 10 Partnership Review and Performance 10.1 Performance in delivering substance misuse treatment is critical, especially in current times where public funding is limited. Successful outcomes are a reward element which account for 20% of the drug treatment budget. A successful completion is defined where a client exits drug treatment and is recorded as either treatment complete drug free or treatment complete occasional user (although this latter category is not used for heroin or crack). To this end one measure of treatment achievement is the volume of successful completions and successful completions as a proportion of the total number in treatment. This meets the Government s National Drugs Strategy commitment to ensure achievements against the recovery agenda. The measure of successful completions as a proportion of the total number in treatment is performance indicator 2.15 of the Public Health Outcomes framework. The assessment has taken NDTMS Successful Completion Performance data (Partnership and Provider) and looked at Isle of Wight successful completions since April 2011 to October 2012 using a month on month and year on year comparison. Isle of Wight performance against its cluster partnerships, South East and national averages are also used as comparators The chart below shows the number of successful completions for Isle of Wight DAAT based on a count (month on month) of individual exits for opiates and non-opiate clients. Chart 43: Opiate and Non-opiate number of successful completions Apr10/Mar11 Nov11/Oct12 IoW Opiate and Non-opiate Number of sucessful completions (Apr10/Mar11 to Nov11/Oct12) M A M J J A S O N D J F M A M J J A S O N D baseline 10/ Opiates Non-opiates 10.3 There is clear evidence of the growth in the number of opiate successful completions since quarter 2 of With the most current performance showing the highest volume of successful completions achieved, 40 in Oct11/Sep12 and a slight dip to 38 in the following month. Non-opiates on the other hand have seen a stark decline, from baseline where the highest 41 non-opiate successful completions were achieved this continued to decline with 18 in Sep11/Aug12, non-opiate successful completions being the lowest, IoWD&ANA2013.doc Mar-13

107 However the recent 2 month reporting periods are showing growth with current numbers of non-opiate successful completions at The chart below shows the trend in the number of successful completions for all drugs (opiate and non-opiate). As the change in opiate and non-opiates successful completions travelled in opposite directions of growth the impact can been seen on the overall number of successful completions for all drugs with a general trend of decline as the growth in opiate successful completions has not been enough to compensate for the decline in nonopiate successful completions. Chart 44: All drugs number of successful completions Apr10/Mar11 to Nov11/Oct Comparing performance against baseline data shows, for opiate successful completions fell to 25 (6 or 19% less) in compared to (31 opiate successful completions) and with current performance showing growth of 13 or 52% from at 38. Nonopiate successful completions fell to 24 (17 or 41% less) in compared to (41 non-opiates successful completions) and with current performance Nov11/Oct12 is 0 or 0% change from at The declining number of opiate successful completions has been a national trend, with a national decline of 3.6%. The South East has also seen the same level of decline in the number of opiate successful completions, compared to the baseline data. Nationally there has been a 3.7% growth in the number of non-opiate successful completions; the South East has seen a slightly higher level of growth to 4.3% compared to baseline data The charts below compare South East performance for opiate and non-opiate successful completions. Isle of Wight features at the lower end of the table for both the volume of opiate and non-opiate successful completions for all clients exiting drug treatment. However it is important to note that the volume of both opiate and non-opiate clients in IoWD&ANA2013.doc Mar-13

108 treatment varies between partnerships and where the volumes are high more opportunities exit for successful completions. Chart 45: South East Opiate number of successful completions Nov11/Oct12 Chart 46: South East Non-opiate number of successful completions Nov11/Oct During the course of DAAT partnership were grouped into 1 of 5 clusters that presented with similar client complexities for their opiate using populations, allowing benchmarking against similar drug using populations. This was extended to the non-opiate clients in April Clusters range from A to E, with A presenting the least level of IoWD&ANA2013.doc Mar-13

109 complexities and E the highest. The Isle of Wight is grouped in cluster A for opiates and cluster A for non-opiate using clients There are 21 DAAT partnerships in cluster A for opiates with similarly grouped opiate clients; there are only 5 South East partnerships in this cluster. The chart below show the number of successful completions achieved for cluster A. In the Nov11/Oct12 reporting period the number of successful completions for cluster A ranged from 16 to 88 with an average of 41 for the cluster. Isle of Wight achieved the 9 th highest volume of successful completions in its cluster placing the Isle of Wight mid table but below cluster average. Chart 47: Cluster A Opiate successful completions Cluster A non-opiates has 23 DAAT partnerships with similarly grouped non-opiate clients; the majority which make up one third are South East partnerships. The chart below show the number of successful completions achieved for cluster A non-opiates. In the Nov11/Oct12 reporting period the number of successful completions ranged from 91 to 102 with an average of 37 for the cluster. Isle of Wight achieved the 18 th highest volume of successful completions in its cluster placing the Isle of Wight in the bottom quarter of the table with performance below cluster average. IoWD&ANA2013.doc Mar-13

110 Chart 48: Cluster A Non-opiate successful completions As well as the volume of successful completions partnership now have to demonstrate movement of clients in the treatment system. The volume of successful completions as a proportion of the total number in treatment is the measure for this. It is important to point out that the total number in treatment differs to the numbers in effective treatment, as it is a count of anyone in treatment for any length of time, whereas numbers in effective treatment is where a client has been in treatment for a minimum of 12 weeks or completed successfully within this time Both opiate and non-opiate clusters have top quartile performance ranges for successful completions as a proportion of the total number in treatment. The chart below shows that Isle of Wight performance for opiates has not been within the top quartile performance range, although in recent reporting periods has managed to get closer at 11.4%. If this performance continues it is likely to achieve the top quartile performance status. IoWD&ANA2013.doc Mar-13

111 Chart 49: Cluster A opiate top quartile performance range The chart below shows that Isle of Wight performance for non-opiates too has not performed within the top quartile performance range and since Nov10/Oct11 has further fallen behind with 30.4% non-opiate successful completions as a proportion of the total number in treatment. Chart 50: Cluster A non-opiates top quartile performance range The chart below shows Isle of Wight opiate successful completions as a proportion of the total number in treatment from Mar10/Apr11 to Oct11/Sep12, at quarterly points in the reporting period. This makes comparisons to the South East and national average. The Isle of Wight is represented in green and performance in the main has been below South East (red) and national (blue) average performance. However in recent months this IoWD&ANA2013.doc Mar-13

112 performance has improved and since quarter the Isle of Wight is performing above South East and national average performance. Chart 51: Opiate successful completions as proportion of the total number in treatment, South East and national comparisons Apr10/Mar11 to Oct11/Sep The chart below compares Isle of Wight non-opiates successful completions as a proportion of the total number in treatment. Isle of Wight started with very high performance at baseline data with 55.7% but since has seen a rapid decline currently with 25.3%; this is significantly below South East and national average performance which has remained consistent at around 40%. Chart 52: Non-opiate successful completions as proportion of the total number in treatment, South East and national comparisons Apr10/Mar11 to Oct11/Sep Another way of addressing performance would include the levels of re-presentations to treatment. The re-presentation data compliments the successful completion numbers by monitoring the number of clients that complete treatment and re-present within 6 months. IoWD&ANA2013.doc Mar-13

113 The charts below show this on a rolling year period. The data is displayed for the number of clients recorded as successfully completing treatment in the first half of November 2011/October 2012 and then monitored for re-presentation to treatment in the latter 6 months of the same reporting period From 19 opiate successful completions recorded 2 or 10.5% re-presented to treatment, which places Isle of Wight just beneath the top quartile performance range, between 11% and 0%. Of 12 non-opiate successful completions 1 or 8.3% re-presented to treatment this places Isle of Wight outside of the top quartile performance range, between 2% and 0%. The table shows how soon after leaving treatment, clients re-present. Of the 3 clients that have re-presented 2 did so in the first month of completing treatment and the remaining 1 re-presenting within three months. This is relatively soon after treatment, as most client are likely to relapse in the latter part of the 6 month monitoring period. However the successful completion and low level of re-presentation suggests that the providers in Isle of Wight are effective at supporting sustainable treatment completion but due to low numbers and corresponding percentages non-opiates re-presentations are high. Table 39: IoW Re-presentations to treatment Nov11/Oct12 Completions 0 month 1 month Re-presentations to treatment 2 month 3 month 4 month 5 month 6 month Total representing Total not representing Opiates Non-opiates All Drugs Another way of assessing successful completion is through the drug treatment exits and the proportion that exit treatment in a planned way that is successfully completing their treatment. The chart below shows opiate successful completions as a proportion of the total number of exits from treatment, and compares this to the cluster average performance. The data is cumulative year to date from April 2012 to October Isle of Wight has a higher volume of opiate planned exits in the first few months of when compared to cluster average, this then evened out with Isle of Wight still seeing a higher proportion of planned exits compared to cluster A. IoWD&ANA2013.doc Mar-13

114 Chart 53: Opiate planned exits from treatment (Cluster A) The chart below shows the breakdown of all opiate exits from treatment from April 2012 to October Following planned exits the next highest volume of 18% exits were recorded as dropped out of treatment (red). Chart 54: Breakdown of all opiate exits from treatment The chart below shows planned exits for non-opiate clients displaying a similar pattern of high proportion of planned exits in the initial months than the cluster average but has since declined and now sits equal to the cluster average of 57% of all treatment exits. Nonetheless Isle of Wight has a good ratio for planned exits from treatment. IoWD&ANA2013.doc Mar-13

115 Chart 55: Non-opiate planned exits from treatment (Cluster A) The chart below shows the breakdown of all non-opiate exits from treatment. Again following planned exits, the next highest proportion of exits, 30% clients dropped out of treatment, this almost twice the opiate volume of clients dropped out of treatment. Chart 56: Breakdown of all non-opiate exits from treatment Compared to current exit data shows a 33% (28) increase in the number of exits from treatment, with 30% (14) more planned exits. However there were only 6 clients who dropped out of treatment compared to 19 in The volume of clients recorded as dropped out of treatment could be present opportunities for successful completions. IoWD&ANA2013.doc Mar-13

116 Chart 57: Exit data compared with Treatment Exit Outcomes (Apr - Oct 2011 & Apr - Oct 2012) All Drugs Apr11-Oct11 All Drugs Apr12-Oct12 No. % No. % Treatment completed - drug-free 18 32% 33 39% Incomplete - dropped out 6 11% 19 22% Treatment completed - occasional user (not heroin or crack) 14 25% 13 15% Transferred - not in custody 4 7% 5 6% Transferred - in custody 12 21% 4 5% Incomplete - treatment withdrawn by provider 2 4% 3 4% Incomplete - client died 0 0% 3 4% Transferred to another partnership 0 0% 3 4% Incomplete - retained in custody 0 0% 1 1% Incomplete - treatment commencement declined by client 0 0% 1 1% Transferred - not in custody (within 21 days of end of month) 1 2% 0 0% Total % % Successful achievements in terms of completions are based on a greater number of people in the treatment system. The chart below shows change in both opiate successful completions and numbers in treatment. Since Apr10/Mar11 baseline the volume of opiate clients in treatment has declined by 5%. The volume of opiate successful completions however has seen a steady growth since Apr11/Mar12. Whist the volume of outcomes are low for the numbers in treatment, the outcomes show positive direction for performance. Chart 58: Opiate number in treatment and number of successful completions The number of non-opiate clients in treatment has fluctuated since the Apr10/Mar11 baseline, the lowest numbers of 57 recorded in Oct10/Sep11, since then however the number of non-opiate clients in treatment has increased and currently at its highest of 79. Successful completions for non-opiate on the other hand have declined since the Apr10/Mar11 baseline from 41 to 18 and then a slight increase in the last two month IoWD&ANA2013.doc Mar-13

117 reporting period. As the gap between the two widen it only follows that successful completions as a proportion of the total number in treatment becomes less. Chart 59: Non-opiate number in treatment and number of successful completions The numbers in treatment are as important as the numbers who successfully complete treatment. The chart below shows OCU new treatment episodes and compares this over three years, to The table shows year on year growth or decline in the number of new treatment episodes. Using April November reporting periods for comparison (green) showing growth of 31% compared to (red) with showing 21% decline compared to (blue). Chart 60: OCU new treatment episodes Apr10-Mar11 and Apr11-Nov12 IoWD&ANA2013.doc Mar-13

118 10.26 The chart below shows the overall growth for all drugs new treatment episodes, growth in % compared to (red) and 22% decline between (red) and (blue). Chart 61: All Drugs new treatment episodes Apr10-Mar11 and April11-Nov Whilst the new treatment episodes have seen growth, decline and then growth in the past three years the overall numbers entering treatment has seen a decline, it is worth noting the count of new treatment episodes is a crude number that does not take account of the measure for in effective treatment, which makes it necessary for a client being retained in treatment for a period of 12 weeks to become counted as in effective treatment. As a partnership Isle of Wight has always achieved 85% retention for 12 weeks for the OCU clients and 87% for all drugs. This growth in the new treatment episodes will have a positive impact on the numbers in effective treatment as these clients mature into treatment. It is also encouraging that a good proportion of OCU to non-ocu clients are entering treatment, 60% and 40% respectively The chart below shows the trend month on month and year on year for both all drugs (red) and the proportion that are OCU (blue) baseline data compared to for all drugs shows 6% reduction in the numbers in effective treatemtnt, whilst compared to shows a 3% increase. Whist baseline data for OCU compared to shows 4% reduction the compared to shows less than 1% reduction. What this suggest is the proportion of OCUs in effective treatment has seen greater decline than non-ocus in treatment, this in part could also be due to the hgiher proportion of OCUs exiting treatment. IoWD&ANA2013.doc Mar-13

119 Chart 62: OCU and All drug numbers in effective treatment Apr10-Mar11 and Sep11-Aug12 Summary The partnership has not achieved the baseline volume of successful completions for opiates and non-opiates. Whilst non-opiate successful completions have seen a continuous downward trend, opiate successful completions have since baseline shown growth. As the numbers in treatment have not changed significantly the lower volume of successful completion has had an impact on the measure of successful completions as a proportion of the numbers in treatment, placing the Isle of Wight outside of the top quartile performance range. This is a particular concern for the non-opiate cohort Planned exits from treatment are above Cluster A average for opiates and equal to Cluster A for non-opiates. There are 30% more treatment exits in compared to last year, with a higher proportion of planned exits, however there has also been an increase on the number recorded as having dropped out of treatment There has been a growth in the number of new treatment episodes compared to however the low level of new treatment episodes during means the overall numbers in effective treatment have declined. What is encouraging is the partnership has had growth in the volume of new treatment episodes and has maintained a good ratio of OCU and non-ocu clients new to treatment in , 60% and 40% respectively. The partnership is good at retaining clients in treatment and as these clients mature into treatment this will have a positive impact on the numbers in effective. IoWD&ANA2013.doc Mar-13

120 11 Provider Review and Performance 11.1 Successful completions and the numbers in effective treatment are the two key performance areas for the Isle of Wight DAAT. The charts below show the change in the number of successful completions for the main drug treatment providers since April 2010 to March 2011 baseline data The charts show IDAS has generally experienced growth in the number of opiate successful completions, whilst saw 4% less successful completions compared to baseline data, current performance Nov11-Oct12 shows 24% growth. This is good performance given that IDAS is the main opiate service provider and accounts for the majority of outcomes for opiate clients. Whist IDAS does not have many non-opiate clients in treatment in it achieved 1 non-opiate successful completion Cranstoun on the other hand has seen a downward trend in the number of successful completions for both opiate and non-opiate clients. This is a concern as this is bringing down the overall partnership performance. The highest volumes of successful completions for both opiates and non-opiates were achieved at the baseline data, 35 and 24 respectively. Since then there has been a 46% (11) reduction in the number of successful completions in compared to and a 36% (15) increase in compared to The number of non-opiate successful completions has seen a 23% (27) reduction compared to and a 30% (19) reduction in compared to Get Sorted have outcomes for non-opiate clients and due to the specific nature of their service provision have only a few treatment outcomes, however since the baseline they have shown growth in volume. Chart 63: Provider Growth in Successful Completions from Baseline IoWD&ANA2013.doc Mar-13

121 11.5 Successful completions as a proportion of the total number in treatment are increasing and this is important for those providers who carry a large opiate and or non-opiate caseload as this demonstrates movement through the treatment system. In the table below IDAS (purple) has the highest number of opiate clients in treatment and an average rate of 8.4% successful completions as a proportion of the total numbers in treatment. This sits at around the same level as the partnership. Cranstoun (blue) has a very high ratio of successful completions to numbers in treatment 44%, it is important to note Cranstoun have much fewer opiate users in treatment and successful completions. IoWD&ANA2013.doc Mar-13

122 Chart 64: Provider opiate successful completions as a proportion of the total number in treatment 11.6 The chart below shows from the main providers of non-opiate treatment, Cranstoun (blue) has the highest number of non-opiate users in treatment and the highest volume of successful completions. However since using baseline data one can see a downward trend of successful completions as a proportion of the numbers in treatment, from its highest point of 63% to current performance of 30%. As the main provider of nonopiate treatment the partnership performance has mirrored this. Get Sorted who also provide non-opiate services have on the other hand seen an increase to 37% successful completions as a proportion of the total number in treatment. Chart 65: Provider non-opiate successful completions as a proportion of the total number in treatment IoWD&ANA2013.doc Mar-13

123 11.7 The table below shows the data for the number of clients recorded as successfully completing treatment in the first six months of November2011 to October 2012 and then monitored for re-presentation to treatment in the latter six months of the same period. The data shows IDAS with 12% re-presentations for opiate successful completions and Cranstoun with 11% re-presentations for non-opiate successful completions. The table also shows that clients re-present early on in the six month period preceding treatment exit. Opiates Completions Table 40: Re-presentations to treatment Re-presentations to treatment Month Total representing Total not representing % representation s IDAS % Cranstoun % Non-opiates Completions Month Total representing Total not representing % representation s Cranstoun % Get Sorted % 11.8 The charts below set out the outcomes for all opiate clients leaving treatment. At a provider level it is clear both IDAS and Cranstoun have a good proportion of planned exits (either drug free or occasional users) from treatment. IDAS had from a total 32 exits 50% planned exits, of this 44% (14) drug free and 6% (2) occasional user and 4% (2) dropped out. Cranstoun had from a total of 12 exits 58% planned exits 50% (6) drug free and 8% (1) occasional user, however proportionately a large volume of 33% (4) dropped out. Chart 66: Provider Opiate exits from treatment Apr12 to Oct12 IoWD&ANA2013.doc Mar-13

124 11.9 The charts below set the outcomes for all non-opiate clients leaving treatment. At provider level it is clear both Cranstoun and Get Sorted have a good proportion of planned exits (either drug free or occasional users) from treatment. Cranstoun had from a total of 23 exits 52% planned exits, of this 22% (5) drug free and 30% (7) occasional user. However a large proportion of 35% (8) dropped out. Get Sorted has a total of 7 exits with 72% planned exits, of this 29% (2) drug free and 43% (3) occasional user. 14% (1) dropped out. Whilst the volume of exits for Get Sorted is small the outcomes are good nonetheless. Chart 67: Provider Non-opiate exits from treatment Apr12 to Oct12 IoWD&ANA2013.doc Mar-13

125 11.10 Movement though treatment system can be measured through the proportion of the caseload that successfully complete and the proportion who successful transfer to another provider within 21 days. The volume of clients recorded as transferred to another provider (transferred not in custody) are low, of these there no clients recorded as having successfully continued their treatment with another provider. This could highlight inaccuracies in the recording of data as clients transfer but essentially any break in a client s treatment journey has a negative impact on both the numbers in effective treatment as well as potential successful outcomes Whilst clients will not necessarily end their treatment journey with the same provider, the partnership shows a low level of movement of client s between providers. The opiate using population is mainly treated by IDAS and as a proportion of the total number in treatment less than 1% successfully transferred and continued their treatment, (that is 3 from 319 clients). Similarly Cranstoun who provide treatment to the majority of non-opiate clients have 0% successfully transferred and continued their treatment, (that is 0 from 27) The numbers in effective treatment is another key performance measure; in order to achieve this, providers will need to increase the volume of clients who enter treatment as a new treatment episode and then follow through to become counted as in effective treatment. The charts below show the volume of new treatment episodes by provider for the past 3 years The charts show the main providers with OCU clients, IDAS and Cranstoun. Both saw the highest number of new treatment episodes in IDAS saw 28% less in (red) compared to (blue), and 26% growth in (green) compared with Cranstoun saw 29% less in (red) compared to (blue), and 30% growth in (green) compared with Whilst there has been growth in the best performing year has been IoWD&ANA2013.doc Mar-13

126 Chart 68: OCU Main Provider New Treatment Episodes to The charts show the main providers performance for all clients new treatment episodes. As all IDAS clients consist of OCU s this is the same information as above. Cranstoun has seen a higher proportion of non-ocu client new treatment episodes and shows 30% growth in , compared to and 19% growth in compared to Get Sorted saw 10 new treatment episodes in , in there were 1 and in the current period there have been 0 new treatment episodes. IoWD&ANA2013.doc Mar-13

127 Chart 69: All Drugs Main Provider New Treatment Episodes to IoWD&ANA2013.doc Mar-13

128 11.15 The following 2 charts map the trend of the overall numbers in effective treatment for the main treatment providers. As IDAS and Cranstoun are the main providers of opiate and non-opiate treatment respectively, the trend for individual providers follows that of the partnership, showing steady decline since April 2010 to March 2011, and in the recent few months a steady growth. Chart 70: OCU numbers in effective treatment IoWD&ANA2013.doc Mar-13

129 Chart 71: All drugs numbers in effective treatment Alternative treatment provision on the Island Goal Mapping This service is being provided by two counsellors on the island through Obelisk training. Their service is to provide Goal Mapping for clients in the Treatment sessions and they are contracted by the DAAT commissioner to do so. Essentially they work as wellness coaches, in the field of drug and alcohol addiction, offering an alternative to a 12-step programme. This work entails a one day Goal Mapping seminar followed by a twelve week programme in Positive Perspective Therapy. Their role is to help client's improve their lives on a variety of fronts, dealing with the whole person as opposed to focusing on the addiction. They specialise in enabling clients to gain clarity about what their goals are; improving selfconfidence; understanding loss and learning to deal with stress. Once the client has a clear idea of their goals, then they work together to formulate and develop action plans which ensure they reach their goals. Information from the service users engaged in this needs assessment suggest that this service is extremely well received and that the service has a supporting value to aftercare and has the potential to prevent relapse and to mitigate representation into the system. On average the services sees 5 groups of clients a year, with from starting each programme. Details of the performance of the programme and statistical information about them have been provided to the DAAT although at this stage this information is not available. Butler Gardens - Real World Trust Butler Gardens is a ten-bedroom supported housing scheme, which provides an abstinence-based environment for people committed to tackling their substance misuse. It is a modern detached building owned by Southern Housing Group but staffed by The Real World Trust. Butler Gardens operates under the Supporting People framework and access IoWD&ANA2013.doc Mar-13

130 to Butler Gardens is via a referral process from social services or health agencies providing that a room is available or likely to be so within the foreseeable future Length of stay is dependent upon needs and availability of other accommodation; however, an average length of stay would be between 4-6 months. Residents are allocated a support worker from the Butler Gardens team who meet regularly with each resident to work on a "Support Plan" and assist with any issues which may arise and offer advice to help people to achieve their potential. this might include accessing treatment for substance abuse and voluntary work, training, education or employment later on - in addition to discussions regarding future housing opportunities Two beds are set aside for Clients undertaking community detox and these are referred through IDAS and funded by the Hospital Trust. Former residents have supported this service through service user engagement. Data has been provided by the Real World Trust that relate to the use of these two rooms from April 11 through to March 12. It confirms that 52 clients and used these rooms for alcohol detox purposes, this breaks down to 23 women and 29 men all for alcohol detoxes. All clients are aged between 24 and 61 with the majority being The Trust have also worked with clients on detox who are using substitute medication of Subutex and some Methadone although whilst the Subutex can be provided on site they cannot currently administer Methadone and this the client still needs to attend IDAS It should be noted that housing is a critical factor for the Island s substance misusing population and the stability of an environment for community detox is critical to the overall treatment provision and outcomes locally. Summary The volume of clients being recorded as dropped out of treatment is high, particularly with Cranstoun, for whom clients that have dropped out account for 30% of all exits, higher still for non-opiate clients. There have been low number of clients referred between providers and none have successfully continued their treatment. In both instances this could be a result of inaccurate data recording processes and the lack of outreach and re-engagement of clients into treatment. Addressing this could have a positive impact on successful outcomes and number in effective treatment performance, as those who clients that leave treatment in an unplanned way could have successfully completed or retained in treatment. IoWD&ANA2013.doc Mar-13

131 11.22 An additional consideration needs to be made when looking purely at successful completions. In essence these charts show growth and or decline in performance in the volumes achieved since In the last 12 months IDAS has maintained a pattern of growth in the volume of opiate successful completions whilst Cranstoun has maintained a pattern of decline for both opiate and non-opiate successful completions, with the a more rapid decline for the non-opiate. Overall however the pattern is one of decline. There is evidence of growth in the new treatment episodes for the majority of providers. This would indicate as the new clients mature in treatment the potential for higher volumes of successful completions exist However there are some strong influences to the ability for treatment providers to succeed in growing year on year. Firstly staff capacity is critical, providers need to have the capacity to maintain growth, secondly and most importantly clients need to be available to engage and this suggests an increase in numbers entering treatment and a prevailing commitment of new treatment entrants to see their treatment through to completion. This is critical to any successful scenario. IoWD&ANA2013.doc Mar-13

132 12 Analysis of Long Term Client in the Island s Treatment System 12.1 A critical concern identified both through this needs assessment and through the NTA s walk through carried out in 2012 is the high volume of long term opiate users in particular those who have been in the treatment system for 6 or more years A review of clients in treatment shows that in there were 437 people in treatment with Isle of Wight providers, 61 had been in treatment from between 2 and 4 years and 169 had been in treatment for more than 4 years. Those clients in treatment for more than 4 years make up 39% of the Isle of Wight profile and this is significantly higher than the South East (15%) nationally (17%). This has also increased from 34% in The only provider to have any clients for more than 4 years is IDAS and this figure makes up 52% of its clients Clearly long term clients by their very nature are far more difficult to support to successfully complete their treatment. Indeed for many their reluctance to move on in their treatment journey suggests a level of comfort in their current treatment situation and that their treatment is based on maintaining their opiate use and supporting their health and wellbeing through substitute prescribing. Normally clients undergo a clinical review of their treatment and their prescriptions quantities periodically to establish their need for clinical prescribing and to support a reduction of substitute consumption and a normalisation of their often chaotic lifestyles Clearly every client has his or her own treatment experiences and personalised needs. Each will have their own pathway to a successful completion, however in some cases this can be hampered by the consolidation of their lifestyle in a treatment environment in which they become stabilised as a recipient of substitute prescriptions and this maintenance of their well-being oddly becomes a contributing barrier to moving on through to successful drug free existence. However clinicians have a real balance to make, as in some cases the use of substitute prescriptions is the right course of action for clients who need to be stabilised to maintain a broadly normal lifestyle In order to get a better picture of the long term client group this needs assessment has accessed data through the NTA from NDTMS that separates out the 6 years + group of long term clients. At present there are 120 clients that have been in treatment for 6 years and longer The span of long term clients ranges from clients who have been in treatment for 6 years through to clients who has been in treatment for 20 years. This span has a high point in terms of volume with clients that have been in treatment for 7 years which is 42% of this group of long term clients. What is particularly interesting is that there are large volumes of clients that have been in treatment for 7, 8, 9 and 10 years. Providers will need to maintain their review of these clients to ensure that this treatment is still the best option for the client s overall well-being and long term recovery The table below shows the gender profile is split between one third women and two thirds men. It is interesting that more women are represented in this cohort than in the overall treatment population, where women represent 28% of the treatment population. Heroin is IoWD&ANA2013.doc Mar-13

133 the primary drug representing 95% of this cohort although other opiates, methadone and amphetamines are also primary drugs in this group but to a far lesser extent. Table 41: Profile of Long Term Clients 6 years + Length in treatment number % Primary Drugs number % 6 years 27 23% Heroin % Other Opiates Methadone and 7 years 50 42% Amphetamines 6 5% 8 years 9 8% 9 years 13 11% Total % 10 years 10 8% 11 to 20 years 11 9% Gender number % Female 40 33% Male 80 67% Total % Total The chart below shows from an age perspective the largest cohorts of clients are in the 30-34, 35-39, and age groupings. This would suggest that for some, treatment started in their mid-twenties and has put them on a programme of treatment which is stabilising and supporting their ability to maintain their lifestyles. In some cases these users are still using although in other cases their reliance on the substitute prescription may be a problem in itself. Chart 72: Ages of Clients who have been in treatment for 6+ years 12.9 A key question that needs to be asked is: what can be done to support this group of long term clients on through their treatment journey to a successful completion? The NTA in Drug Misuse and Dependence: UK Guidelines on Clinical Management 2007 sets out the IoWD&ANA2013.doc Mar-13