Nottingham Crime & Drugs Partnership. Treatment System Review Drug, Alcohol and Criminal Justice

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1 Nottingham Crime & Drugs Partnership Treatment System Review Drug, Alcohol and Criminal Justice

2 Contents Executive Summary 4 Proposed model 5 Key recommendations 9 1. Background Outcome Drivers Review process Equality and diversity Governance National guidance Local guidelines / research Consultation Drug treatment system Format of the report The treatment journey Four tiered treatment system Access & engagement National guidance and research Consultation findings Access & engagement provision in Nottingham Good practice Weaknesses Effectiveness Care pathways Client group Recommendations Structured treatment National guidance and research The local situation: structured drug treatment Consultation findings Good practice / system strengths Weaknesses Effectiveness Care pathways Client group Recommendations Aftercare / continuing care & wraparound National guidance and research Consultation findings Local aftercare and wraparound provision Good practice Weaknesses Effectiveness 66 2

3 5.7 Care pathways Client group Recommendations Criminal justice treatment system National guidance and research Consultation findings Criminal justice drug treatment provision in Nottingham Good practice Weaknesses Effectiveness Care pathways Client group Recommendations Families & carers National guidance and research Local situation: carer provision Consultation findings Good practice / system strengths Weaknesses Care pathways Client group Recommendations Equality & diversity practice and policy General Corporate commitment Data collection and analysis Access to services Workforce and recruitment Recommendations Alcohol treatment system Purpose of the review National guidance Interventions explained Effective interventions Key principles for commissioning local alcohol treatment systems Commissioning standards Learning from other areas Summary of consultation findings Current provision Current system overview Effectiveness of current treatment system Recommendations 110 Annex A Drug treatment services in Nottingham 112 Annex B Alcohol treatment services in Nottingham 146 Annex C - Record of activity undertaken for the treatment system review 159 3

4 1 Executive Summary The 2008/09 Adult Drug Treatment Plan for Nottingham made a commitment to review the city s drug treatment system to ensure compliance with national guidance, relevance to local need and increased effectiveness. Equally, the Nottingham Alcohol Strategy 2008/11 included an objective to review alcohol treatment provision in the city against national commissioning frameworks. This document sets out the conclusions of these reviews and makes key recommendations to improve Nottingham s existing drug and alcohol treatment systems. A new treatment model is proposed based on the findings of the review. Annual needs assessments have identified ongoing problems of underrepresentation of non-opiate users, Black and South Asian individuals, and under- 25s in the drug treatment system. Needs assessments have also highlighted gaps in treatment options and a lack of integrated care pathways. Radical action is needed to achieve stretching Local Area Agreement and drug effectiveness targets. A number of reports and guidance documents have been produced by Department of Health since 2004 to assist commissioners at a local level to develop and implement programmes of alcohol interventions that will benefit hazardous, harmful and dependent drinkers. The review will regain a strategic overview of alcohol services and examine current treatment provision against the guidance to identify gaps in local provision. The proposed new treatment model aims to address these problems by: Streamlining routes into treatment Delivering interventions in line with clinical guidelines Providing treatment options relevant to local need Developing stronger, more efficient care coordination Maximising client choice Developing integrated care pathways to create clear and effective pathways of care Expanding alcohol interventions for hazardous and harmful drinkers The review is informed by previous needs assessments and existing evidence, extensive consultation with stakeholders and clinical experts, and a wide range of best practice guidance and clinical guidelines. 4

5 Proposed Model The proposed model for the treatment system is as follows. The model is applicable to the criminal justice treatment system, the wider drug treatment system and the alcohol treatment system. Free-phone Abstinent Consortium Outreach / Criminal Justice / Generic Service Open Access Stable/Maintained No on top Brief Interventions Structured Treatment Assessment Care Plan Continuing Care Ongoing assessment Care Plan Care Co-ordination Care Co-ordination Menu of interventions Prescribing Psychosocial Psychological Inpatient Residential Complex Dual Diagnosis Self help Non-PDU Wraparound Leisure Mentoring Family therapy Carers referral Child referral Etc 5

6 Key points for the proposed treatment system model A consortium commissioning approach to be considered for generic assertive outreach provision across the city with no drug or alcohol specific assertive outreach Access to the treatment system to be streamlined through referral via generic outreach, generic services or the criminal justice system into open access, or by self referral to an open access centre base and/or free-phone number (available 24/7 and shared across drugs, criminal justice and alcohol) Brief interventions to be available in line with NICE Guidance for those not ready or suitable for structured treatment Seamless transition from brief interventions to the allocation of care coordinator, assessment and care plan in order to improve movement from access and engagement to structured treatment Clients to have one assessment, one care plan and one care co-ordinator throughout the structured treatment stage of their treatment journey Full range of treatment interventions to be available as menu of options for all clients, co-ordinated by care co-ordinator Continuing care to be available to those completing treatment and those stable on a treatment programme. Care co-ordination will be handed over at this stage in the treatment journey although clients will still be able to access the same menu of options 6

7 While adopting the same general principles as the drug treatment system model, the alcohol treatment model will follow the 4 tier framework as set out in Models of Care for Alcohol Misusers: Free phone Open Access Identification and Brief Interventions Primary care, health settings, Probation Hazardous Consortium outreach / Criminal Justice / Generic Services Extended Brief Interventions Harmful Community based structured treatment Moderately Dependant Inpatient & Residential Severely Dependant 7

8 Four-tiered framework for alcohol treatment Targeted and opportunistic screening to identify hazardous and harmful drinkers to be provided in primary care settings, A&E departments and a range of generic services, including Probation. Structured brief advice to be offered to hazardous and harmful drinkers to encourage a reduction in alcohol intake Extended brief interventions to be offered to those requiring further support and advice Specialised, care-planned structured treatment to be made available to dependent drinkers in a community setting Inpatient care and residential rehabilitation to be available for severely dependent drinkers A stepped care approach to alcohol treatment to be adopted in line with Models of Care guidance, where the least intensive form of treatment is offered to service users initially, progressing to more intensive forms if these are unsuccessful 8

9 Key Recommendations Based on the findings of the review the following recommendations are made in relation both the drug and alcohol treatment systems: 1. Access to treatment should be streamlined with clear access points. 2. Opening times should be extended in order to be responsive to client need with some level of 24/7 provision in order to respond in times of crisis. 3. To utilise existing generic assertive outreach provision within Nottingham City to identify, engage and refer problem drug and alcohol users into the treatment system. 4. There should be improved pathways into structured treatment, including further consideration of the benefits of having a single provider or co-located services for both open access centre base, care co-ordination function and some structured treatment interventions. 5. There should be a single care co-ordination function to act as an anchor for clients as they move through the drug and alcohol treatment systems. 6. All treatment options for clients should be made available, including abstinence. 7. Various self-help groups (including abstinence self-help groups) should be available. 8. Structured continuing care provision should be explicitly commissioned at the appropriate stage in the client journey and be accessible to those who are stable on a script or have achieved a controlled drinking goal. 9. Services that are culturally competent to meet the needs of the local problem drug using population. The following recommendations are made with specific reference to the drug treatment system: 10. Brief interventions should continue to be provided at the access and engagement stage of the treatment journey, but are to be aligned with the NICE Guidance definition of brief interventions. Activity above the definition of brief interventions to be counted as structured treatment. (The recommended role of brief interventions in alcohol treatment has been outlined below) 11. There should be rapid access to treatment for all drug users in line with accessibility through the criminal justice route 12. Gaps within structured treatment including psychosocial interventions (the mainstay of treatment for non-opiate users), psychological interventions (for addressing underlying issues), continuing care and wraparound / activities provision should be addressed. 9

10 The following recommendations are made with specific reference to the alcohol treatment system: 13. Ensure formal, effective care pathways between supported accommodation services and treatment services 14. All gaps in treatment provision should be addressed. In particular: 15. Targeted alcohol screening and the provision of brief and extended brief interventions for hazardous and harmful drinkers should be rolled out as a priority across primary care settings, A&E departments and a wide range of generic services 16. Expansion of structured alcohol treatment within community settings to meet demand 17. Investigate whether alcohol treatment should be incorporated into the Drug Intervention Programme 18. Commissioning arrangements to be considered as part of the implementation stage of the review, in line with the World Class Commissioning model 19. Clear alcohol treatment pathways to be established to ensure equitable and consistent systems of access to treatment for service users 20. Implementation of the stepped care model 21. A clear and unique remit should be established for each service and built into service level agreements to avoid confusion and guide service users and service providers through care pathways 22. Widespread advertising of alcohol services in community settings and awareness raising amongst staff and service managers 23. Standardised processes for screening, assessment and care planning should be created to facilitate referral between services and ensure high standards in line with national guidelines 24. Diversity data to be collected from all services across the six diversity categories to identify under-served groups 10

11 1. Background As set out in the 2008/9 Adult Drug Treatment Plan for Nottingham, the purpose of this review of the drug treatment system is to ensure compliance with national guidance, relevance to local need and increased effectiveness. The review of alcohol treatment provision to ensure compliance with national commissioning frameworks is set out as a key objective in the Nottingham Alcohol Strategy. The review aims to provide information about the general performance of the existing drug and alcohol treatment systems, their relevance to local need, fit with current strategic developments, in order to inform recommendations for improvements. A range of local data and analysis has been utilised alongside national guidance and policy, and the results of previous and current consultation with service users, carers and a range of other stakeholders. 1.1 Outcome The review has generated a new model for the drug and alcohol treatment system that is compliant with national guidance, relevant to local need and that should be in a better position to deliver against the 3 year effectiveness targets for the partnership. 1.2 Drivers Ongoing analysis of local need and the effectiveness and performance of the drug treatment system highlighted problems with the model for the local system, impacting on our ability to meet the needs of local problem drug user populations. Several key drivers for the review were identified prior to its inclusion as a key objective in the Adult Drug Treatment Plan and the Nottingham Alcohol Strategy: 1 Address underperformance against Local Area Agreement (LAA) targets and meet drug treatment effectiveness targets for 2008/9 and beyond The LAA includes stretching and ambitious targets for improving the effectiveness of drug treatment over the next 3 years. In order to deliver the proposed 3 year targets in increased effectiveness (08/09 6%, 09/10 9%, 10/11 12% on the baseline year) the treatment system must deliver the following steps: Increase treatment penetration into PDU population of heroin and/or crack users this will require improving pathways to treatment and ensuring full range of treatment interventions as required to meet local need are available Increase effectiveness (improving retention and successful completion performance) this will require improvements in treatment quality alongside better integrated treatment delivery and reduction in duplication. The Nottingham Crime and Drugs Partnership Board have risk assessed LAA targets relevant to the CDP and have identified that delivery of the treatment effectiveness target is a high risk to the partnership. 11

12 2 Ensure the treatment system is appropriate to meet local need Annual drug treatment needs assessments highlight important issues indicating problems within the current drug treatment system that require attention from a system wide commissioning perspective. In particular needs assessments over the past 3 years have highlighted that certain groups of problem drug users are underrepresented in treatment, in particular nonopiate users, users of Black and Minority Ethnic background and those aged under 25. Annual needs assessments and consultation conducted as part of needs assessments indicate gaps in the treatment system and a lack of integrated pathways relevant to these underserved groups. 3 Ensure compliance with a new suite of drug & alcohol clinical guidelines New clinical guidelines for drug treatment were launched in Models of Care for Alcohol Misusers was produced by the Department of Health in 2006, consolidating research into best practice in delivering local alcohol treatment systems. All partnership areas should ensure that commissioned systems and service delivery are aligned with the full range of guidelines. A summary of relevant national guidance and references of where to obtain the full documents from is included in section Maximise cost effectiveness The Pooled Treatment Budget will not see significant increases over the next three years and previous budget streams from Neighbourhood Renewal Fund and Local Public Service Agreement will now need to be picked up. The treatment system review will enable a review of cost effectiveness of the current treatment system. 5 Alcohol treatment system The purpose and remit of the review of alcohol treatment services in the city differ slightly from those of the review of drug treatment services. There is a lack of clarity and clear understanding about the city s alcohol treatment system that does not exist in comparison to the drug treatment system. There is no current and complete map of alcohol services in the city and misunderstandings and confusion about the range of treatment options and services available are common. The purpose of the alcohol treatment system review is to regain a strategic overview of alcohol services in Nottingham City and consider the existing structure against national guidance and local need, and with regard to stakeholder feedback. 12

13 Summary of drivers for the review To address underperformance against LAA target and meet effectiveness targets for 2008/9 and beyond To ensure compliance with new suite of drug & alcohol clinical guidelines To address gaps in the drug and alcohol treatment system and ensure appropriate services are available in line with Models of Care [NTA] and Models of Care for Alcohol Misusers To ensure the drug treatment system is well placed to deliver relevant objectives within the 10-Year Drug Strategy [Home Office] To ensure cost effectiveness of the drug treatment system To ensure the treatment system is easy to navigate To address ongoing issues identified in annual needs assessments over a 3 year period To reduce duplication between services To regain a strategic overview of alcohol treatment provision 1.3 Review process The review has been led by Nottingham Crime & Drugs Partnership (CDP) on behalf of the Board with full involvement and support from Nottingham City PCT. The review process has been broken down into a three-phase development programme as follows: Stage 1: Stage 2: Stage 3: Establishing the framework Review of the current treatment system and development of the function and general principles for a new treatment system model Planning Developing the form of the new model including full risk assessment Implementation Implementation of the revised model Stage 1 of the review process began in June 2008 and is now complete. Stage 1 focused on three key objectives in order to establish a framework for the new model: 1. Reviewing the current treatment system A range of existing information sources was considered in reviewing the current system including but not limited to service level agreements, contract monitoring information, performance management information, service review minutes and file audits. New information was also obtained via consultation, bespoke information requests, file audits and reviews, interviews and shadowing opportunities. 13

14 2. Ongoing consultation with a wide range of stakeholders and experts A wide range of existing consultation has been collated and included in the review including records of service user and carer forum meetings, speak-out events and expert panels conducted as part of the annual needs assessment process. There has also been considerable consultation taken specifically for the review including two stakeholder events (which focused on visioning for the new treatment system) and questionnaire consultation with a wide range of stakeholders including services users, carers, service managers, workers, other stakeholders and the wider community. 3. Development of functions and general principles for the new model The development of the function and general principles for the new treatment system model was undertaken by the CDP commissioning team and PCT commissioning team with reference to: National clinical guidelines Findings of the review of the current system Stakeholder/consultation feedback Local needs assessment Models of care (alcohol and drugs) Annex C provides further detail on the consultation and audits that have been undertaken in stage 1 of the review. Section 1.7 contains further detail on the consultation process and headline findings. 1.4 Equality and diversity Equality and diversity has been considered in detail in stage 1 of the review, and the CDP Equality and Diversity Manager has been fully involved in the review process. Section 8 of the report contains a detailed review of equality and diversity policy and practice within the current drug treatment system. A full Equality Impact Assessment will be undertaken on the proposed model during stage Governance Appropriate governance mechanisms for the treatment system review have been embedded throughout the process with the JCG fulfilling the function of Treatment Review Board. The regional National Treatment Agency has been involved in the treatment system review by providing governance and guidance on the process. The Treatment Review Board took responsibility for: Monitoring the progress of the review against the project plan Informing and guiding the review process from a partnership perspective Representing the views of partner agencies Reporting into the CDP Board Making recommendations for the proposed treatment model Communicating on the review to partners and stakeholders Making financial decisions (within the scope of decision making responsibilities of the JCG) on the proposed treatment model 14

15 1.6 National Guidance A summary of the key national and local guidance considered in the review is included in this section. More detailed references are made throughout the main body of the report as relevant. Models of care for the treatment of adult drug misusers (2006) Models of Care is the national framework for the commissioning of adult drug treatment for drug misuse in England. Models of Care sets out the treatment interventions and pathways that all partnership areas are expected to have available to meet the diverse needs of the local population. As such, Models of Care is a crucial piece of national guidance that must be considered when evaluating current structured treatment provision in the City. The Models of Care Update 2006 document can be found in full at: 3.pdf Drug misuse and Dependence: UK guidelines on clinical management The Department of Health issued Drug Misuse and Dependence: UK Guidelines on Clinical Management in 2007 (hereafter referred to as 2007 Clinical Guidelines ) to replace the 1999 Clinical Guidelines addition. The most recent edition provides guidance on the treatment of drug misuse in the UK and is intended for all clinicians providing drug treatment to individuals (including non-medical clinicians). The full guidelines can be found online at: NICE Suite of Clinical Guidelines The National Institute for Health and Clinical Guidance launched a new suite of guidelines for drug treatment in 2007 which must be worked to in all partnership areas. They provide a range of detailed guidance relevant to prescribing interventions including detoxification, and also useful guidance on psychosocial interventions. The NICE guidelines and clinical guidelines are purposefully linked and cross reference one another. The full suite of guidelines can be accessed online at: National Drug Strategy The Home Office launched the new 10 year national drug strategy, Drugs: Protecting Families and Communities this year. The strategy aims to restrict the supply of illegal drugs as well as reducing demand. The four strands of the strategy are: 15

16 Protecting communities through tackling drug supply, drug-related crime and anti-social behaviour Preventing harm to children, young people and families affected by drug misuse Delivering new approaches to drug treatment and social re-integration Public information campaigns, communications and community engagement The strategy advocates a new approach to treatment with the ultimate goal of treatment for all clients to achieve abstinence from their drug - or drugs - of dependency. The strategy emphasises that this should be achieved by better end-toend management through the system and by developing more personalised approaches to treatment. The strategy also has a renewed focus on helping drug users successfully integrate with the community through providing effective continuing care and better support for those leaving or planning to leave treatment with packages of support to access housing, education, training and employment. The full strategy can be accessed online at: Scottish Drug Strategy: The Road to Recovery The Scottish Drug Strategy is a useful document for consideration in drug treatment commissioning and delivery with a focus on the concept of recovery. The full strategy can be accessed online at: Models of Care for Alcohol Misusers Models of Care for Alcohol Misusers (MoCAM) provides a best practice model for the commissioning of alcohol services based on the commissioning model established for drug treatment services in Models of Care for Drug Misusers. MoCAM describes best practice interventions and treatment for four main categories of alcohol misusers: hazardous drinkers, harmful drinkers, and moderately and severely dependent drinkers. MoCAM establishes a quality framework and minimum standards for the management and provision of local alcohol services. Guidance/DH_ Review of the effectiveness of treatment for alcohol problems The Review of the effectiveness of treatment for alcohol problems provides guidance on delivering effective interventions at a local level. This document summarises a wealth of international and national research into effective alcohol treatment modalities and determines which interventions are likely to deliver the best outcomes for people with alcohol disorders. eatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf 16

17 Alcohol misuse interventions: guidance on developing a local programme of improvement (Department of Health, 2005) This document provides guidance on developing and implementing programmes of interventions for hazardous and harmful drinkers, including alcohol screening and brief interventions. Guidance/DH_ Local guidelines/research Adult Drug Treatment Plan for 2008/9 The Adult Drug Treatment Plan is the commissioning action plan for the adult drug treatment system which each partnership area is required to complete annually by the National Treatment Agency (NTA). Nottingham City s Treatment Plan for 2008/9 has a clear focus on the aims and objectives for the Treatment System Review and has been used to guide the review process. Adult Drug Treatment Needs Assessment 2007/8 Local needs assessments are undertaken on an annual basis as part of the treatment planning cycle. They provide an insight into the types of people who use drugs and alcohol problematically in Nottingham and what types of drug and alcohol use they engage in. The information available from needs assessments is vital in identifying how well the treatment system is equipped to meet local need and has been a key consideration in the review of current provision. The full needs assessment is accessible online at: Nottingham Alcohol Strategy The Nottingham Alcohol Strategy 2008/11 outlines the next steps in the local response to alcohol-related harm. The strategy identified a need to review the city s alcohol treatment system against Models of care for alcohol misusers to ensure effective treatment for alcohol disorders. Nottingham Harm Reduction Strategy The Nottingham Harm Reduction Strategy 2008/11 outlines the strategic objectives related to reducing drug related harm for drug users, their families and the wider community. The strategy is supported by several action plans. Strategic Review of Supporting People funded Drug and Alcohol Related Accommodation in Nottingham This review has been completed to inform the Options Appraisals process being undertaken by Supporting People with the aim to provide information on the 17

18 performance of existing accommodation and support projects and their strategic relevance. Nottingham Standard Assessment Framework Nottingham City Standard Assessment Framework is a common assessment and care planning framework for use across all drug treatment services launched in January The supporting guidance document provides information on referral pathways, interventions, need, hidden harm, equality and diversity and harm reduction among other things. Crack Down: Tackling Drugs and Community Harm in Nottingham A local report making recommendations for the improvement of prevention, treatment and after care services in Nottingham. The report was developed following a local conference delivered by The African-Caribbean and Asian Forum, Nottingham CDP and Local Implementation Groups. The report makes 5 key recommendations: Increasing opportunities for peer support Using community involvement and empowerment methodologies Raising the aspirations of young people Reducing stigma around drug treatment Person centred care delivered by joined up services: holistic treatment for the individual including a whole family approach to support St Anns Week in Action Report An evaluation report following work undertaken as part of a Week of Action in St Anns prepared by the African Caribbean & Asian Forum and Community. The report makes some recommendations relevant to drug treatment focused on: Cultural competence of drug related services Peer driven/peer led services After care and support 1.7 Consultation As stated above, extensive consultation has been undertaken as an integral part of the treatment system review. As well as reviewing an exhaustive list of pre-existing consultation information and undertaking to consult with services and partners on an individual basis, two additional stakeholder consultation exercises were undertaken: Questionnaires Questionnaires were distributed amongst various stakeholders in order to gain feedback on the current drug and alcohol treatment systems and gather ideas for the new model. The stakeholder groups consulted via questionnaires included: drug and alcohol service managers, the drug and alcohol treatment workforce, service users, carers, wider partner agencies, and the local community. Questionnaires were distributed as widely as possible through existing networks and then cascaded even further through the local press and the CDP website. There was a significant response with over

19 questionnaires returned relevant to the drug treatment element, and over 160 relevant to the alcohol treatment element. Stakeholder events Two stakeholder consultation events were held. The first event was held in June and was attended by around 50 delegates from across the field including service users, carers, the CDP Independent Advisory Group, the community, the drug and alcohol treatment workforce, service managers and wider partners. The first event focused on visioning ideal drug and alcohol treatment systems based on local need, national best practice and national guidance. Delegates invited to the first event were invited to the second in September where the findings, recommendations and proposed new model were presented and then debated. Delegates had a window of a week to provide any additional feedback and comments to inform the final proposal. Copies of blank questionnaires or outcomes from the stakeholder events can be made available on request to the CDP. Clinical consultation has been available through Dr Stephen Willott, Clinical Lead for the CDP, and Dr. Phil McLean and Dr David Rhinds, Consultants with Nottinghamshire Healthcare Trust, have also been consulted. 19

20 2. Drug Treatment System As stated in the introduction to this report, the objective of the review of the drug treatment system is to ensure that the treatment system model is able to deliver effective and evidence based drug treatment that will meet the needs of our local drug using population. In order to establish this and make recommendations for any changes, a detailed review of the current drug treatment system has been undertaken in stage 1 of the treatment system review. The following chapters provide a comprehensive summary of the findings and recommendations of stage 1 of the review in relation to the drug treatment system. These findings and recommendations are based on the review of current treatment provision in the city and consultation feedback against a backdrop of national guidance (in particular Models of Care, National Clinical Guidelines, and the NICE suite of guidance) and local need. In order to be service user focused, the review of the drug treatment system has been undertaken within the context of the client journey through the treatment system (see 2.2 below). 2.1 Format of the report Sections 3-5 contain analysis of national guidance, consultation findings, review findings and recommendations for the various elements of the treatment system in line with the treatment journey: Access and engagement Structured treatment Aftercare and continuing care (combining the community integration and treatment completion stages of the treatment journey see below) There is a separate section for the criminal justice treatment system (section 6) in order to capture the different delivery mechanisms and experience for clients whose treatment journey is directed through the criminal justice route. Sections 7 and 8 look at cross cutting issues: Families and carers Equality and diversity policy and practice Section 9 contains analysis of alcohol treatment provision in Nottingham. It is equally important to acknowledge what has not been considered in the review of the current drug treatment system: Tier 4 in-patient and residential rehab provision has not been included as this agenda is being considered as part of a regional commissioning framework. Further work to understand the level of need for such provision in Nottingham will be undertaken as part of the treatment system review. The hidden harm and needs of the children of adult drug misusers is not considered in this review as it does not directly impact on the treatment system model. However, information on hidden harm has been obtained 20

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