Principles for commissioning a substance misuse treatment system

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1 Developing Recovery Communities: Treatment Plan Strategic Summary 2013/14 East Sussex Drug and Alcohol Action Team 1. The East Sussex Drug and Alcohol Action Team (DAAT) is the multi-agency partnership that addresses drug and alcohol issues locally. The DAAT includes East Sussex County Council, local NHS organisations, District and Borough Councils, HMP Lewes, Sussex Police, Surrey and Sussex Probation Trust and providers and users of services. The DAAT involves a wide range of stakeholders through special interest groups. 2. During the year ahead the DAAT will continue to focus on achieving the commitments it set out in the East Sussex health and social care commissioning strategy for substance misuse, Developing Recovery Communities: Additional needs assessment work has been completed in 2012/13 to develop the strategy. This document is the strategic summary that describes the DAAT s treatment plan for 2013/14. Detailed objectives are set out in the partnership s treatment planning framework. 3. These documents are published on the DAAT s website, - Developing Recovery Communities: Treatment Planning Needs Assessment (2012) - Treatment Plan Strategic Summary 2013/14 (this document) - Treatment Planning Framework 2013/14 (detailed objectives) The strategic context overall direction and purpose 4. The strategic framework for substance misuse services is described by the East Sussex Health and Social Care Commissioning Strategy for Substance Misuse. The strategy describes the DAAT s vision for a local substance misuse recovery system: Local people who need help for drug or alcohol misuse can quickly access effective treatment services and recovery communities that are shaped by the people they support. 5. The emphasis is on developing recovery capital, the internal and external resources that people draw on to initiate and sustain recovery. Achieving freedom from dependence on drugs or alcohol is critical, but only part of the story. People often need help to sort out practical issues like housing and employment, and develop new relationships with friends and family. We know that people value long-term support, provided through a recovery community of others who have travelled similar journeys. Principles for commissioning a substance misuse treatment system 6. The National Treatment Agency (NTA) was established in 2001 to improve the availability, capacity and effectiveness of drug treatment in England. Its functions will transfer to Public Health England from April The NTA suggests the principles for commissioning a treatment system that promotes successful recovery journeys are: 1. Drug and alcohol commissioners work closely with all relevant partners to commission services based on outcomes 2. Maintaining and Improving access to early and preventative interventions, and to treatment 1

2 3. Treatment is recovery-orientated, effective, high-quality and protective 4. Treatment delivers continued benefit and achieves appropriate recovery-orientated outcomes, including successful completions 5. Treatment supports people to achieve sustained recovery. 7. These principles have guided the development of the DAAT s 2013/14 treatment plan. Developing the 2013/14 treatment plan 8. The plan draws on the priorities described by the East Sussex Commissioning Strategy for Substance Misuse, Developing Recovery Communities The plan has been developed using the NTA s JSNA support pack for commissioners, which expands upon the principles set out in the 2010 Drug Strategy and provides local areas with prompts to guide their planning across community, residential and prison settings. 10. The ESCC Safer Communities Team has completed the Adult Drug and Alcohol Treatment Needs Assessment 2012 and identified any additional recommendations for improving treatment. 11. Priorities for have been included in the DAAT s treatment planning framework. The framework includes priorities, intended outcomes and detailed objectives and milestones. The framework is organised along the principles outlined above. Key findings of needs assessment Drug Treatment for Adults 12. There are an estimated 2,224 opiate and crack cocaine users (OCU) in East Sussex. We have calculated that there are 1,518 OCUs known to treatment, giving a treatment penetration estimate of 68.3%%. During 2011/12, 1,235 people received at least one structured treatment intervention. There are an estimated 706 OCUs who are treatment naïve, not known to treatment services`. About 9% of these people are likely to be injectors. Around 75% are expected to be male, and 16% will be under 25. The needs assessment provides a more detailed analysis of this population. 13. The population segments which have the highest proportion of treatment naïve users are: people aged (42.4% treatment naive, N=114) people aged (37.2% treatment naive, N=298) Non-injectors (48.2% treatment naive, N=627) Crack users (31.8% of OCU estimate in treatment, N=383) 14. The needs assessment reports a comparison of East Sussex and other South East partnerships, published by the Drug Treatment Monitoring Unit using 2010/11 data. Compared to other partnerships in the South East, people in drug treatment in East Sussex are more likely to be older than 50 (11.8%), have at least one child living with them (25.7%) and to be using opiates (86.9%). They are less likely to be younger than 24 (9.3%, lower than the previous year), and less likely to have an identified housing problem (13.8%). Compared to other partnerships, very few clients (5.6%) have alcohol 2

3 recorded as a secondary problem. The Treatment Outcomes Profile data also reports that the proportion of clients completing treatment abstinent from alcohol use is lower than expected. 15. Treatment is effective. During 2011/12, 425 people left treatment. 62% of these people completed their treatment journey and left in a planned way. For comparison, the England rate is 47%. People whose primary drug problem is cannabis or cocaine are more likely to complete treatment in a planned way (cocaine, 90% and cannabis 80%) than heroin users (41.3%, N=104). 16. For most people, treatment is relatively quick. 65.3% of all discharges in 2011/12 were of people in treatment for less than a year. 9.4% of people who were discharged in 2011/12 had been in treatment for more than 4 years, which is more than 2010/11 (5%). All of these longer-term clients were opiate and/or crack users. This increase reflects a focus on enabling longer-term clients to leave treatment. 17. The National Treatment Agency s Recovery Diagnostic Tool has identified a relatively high number of people in treatment with a long history of opiate use and multiple treatment episodes. In the most recent twelve months, 314 people have had drug using careers of 21+ years. 209 have had 4 or more previous treatment journeys, and 165 have had 4 or more previous treatment journeys ending in unplanned exit. These people are likely to require particularly focused support to achieve successful treatment outcomes. 18. Almost one in five adults in treatment (19.9%, N=246) was referred via a criminal justice route. Compared to the whole in treatment population, these referrals are more likely to be male (79.3%, N=195). Male clients are more likely than female clients to complete treatment transferred in custody. Offenders are also more likely to have a housing problem (20.6%, N=51). The proportion of these criminal justice referrals who report has reduced over the past three years, from 59% in 2009/10, to 28.7% in 2010/11 and 16.3% in 2011/ Introducing test on arrest in Hastings has increased arrest referral activity. The referral pathway is well established, with 82% of clients who are contacted by the Drug Intervention Programme (DIP) being triaged and starting treatment within six weeks. This is upper quartile performance, comparing favourably to the national average (63%). The approach is identifying a significant number of powder cocaine users who were not previously known to services. This referral route is effective. 30% of all DIP clients successfully completed treatment (15% nationally), and only 3% re-presented (13% nationally). 20. Transmission of blood-borne viruses remains a risk. Services in Hastings are involved in the Health Protection Agency (HPA) unlinked anonymous monitoring survey. In the 78 samples used in the most recent test, Hepatitis C prevalence was 56.4%, Hepatitis B prevalence was 20.5% and HIV prevalence was 2.6%. There is a risk of transmission through unprotected sex only 11 of the 78 people involved in the survey said that they always used a condom during sex. Although the percentage of injectors who report sharing has reduced each year since 2008/9, sharing injecting equipment remains a high risk activity for 42.9% (N=350) of the injectors in treatment. 21. The treatment system is generally good at ensuring that people who start treatment are offered hepatitis B vaccinations and injecting drug users are offered hepatitis C testing. During 2012/13, services have focused on reducing the proportion of people who refuse the offer. The needs assessment notes that the proportion of people assessed as not appropriate to offer has increased for Hepatitis B (9.7%) and Hepatitis C (51.3%). 3

4 22. The NTA has produced a recovery diagnostic report. The report uses three years of data to analyse factors that are known to impact on the likelihood of successfully completing treatment. The report identifies relatively high levels of complexity, with particularly high rates of daily use, injecting, hazardous drinking, crack use, housing difficulty and referral from criminal justice. 23. For many of those at the 6 month review, these same issues persist. Physical and psychological health improvement scores at the six month review aren t as good as they should be. These persisting negative factors are likely to undermine or prevent successful recovery. 24. The report provides some insight into those who have been in treatment a long time. A high proportion of opiate users have had drug using careers of 21+ years (314 people in the most recent 12 months), a high number (209) have had 4 or more previous treatment journeys, and a high number (165) have had 4 or more previous treatment journeys ending in unplanned exit. This highly complex patient group are likely to require additional support to ensure treatment is effective. Alcohol Treatment for Adults 25. Whilst this strategic summary focuses on treating people who are dependent on alcohol, there are inter-relationships between treating dependent drinkers, and supporting people who are drinking at increasing and higher risk levels to reduce their drinking. 26. From a health improvement perspective our focus is engaging with people before they require treatment. Current prevention work includes targeted behaviour change interventions and Identification and Brief Advice training for professionals. Prevention and treatment are part of a continuum of interventions to reduce alcohol harm. 27. Work to address the needs of increasing and higher risk drinkers is co-ordinated through the alcohol steering group and currently includes: supporting professionals to undertake brief interventions with their clients; using social marketing approaches and targeted communications to enable all those at risk of harm from their drinking behaviour to understand the consequences and to make changes ; providing in-depth 1:1 behaviour change support to enable people to make changes to their lifestyle including reducing their alcohol use; and systematically identifying increasing and higher risk drinkers through the NHS health Check Service (for people aged 40-74). 28. Health improvement interventions that support the continuum between prevention and treatment have been included in the treatment plan with other actions that will maintain and improve access to early and preventative interventions and to treatment. 29. The needs assessment estimates that there are 6,635 dependent drinkers across East Sussex (aged 18-75) in East Sussex. During the year, 1 in 8, or 13% of these people were engaged in structured treatment. There were 1,132 people who received treatment in 2011/12, an increase of 24% on the previous year. 30. Compared to the profile of people in treatment across England, the in treatment population in East Sussex is more likely to be drinking at lower levels of harmful drinking (less than 200 units each month). 31. The proportion of people in treatment who are aged 60 or older has increased slightly, from less than 8% in 2010/11 to just over 10% in 2011/12. More focused activity during 2012/13 is expected to increase this further. 4

5 32. Comparing the estimated populations of dependent drinkers with the people who access treatment, more needs to be done to ensure that people in rural districts engage in treatment. An estimated 3.8% of people aged 16+ are alcohol dependent. A larger proportion of this estimated population entered treatment from Eastbourne (11.2%) and Hastings (13.4%) than from Lewes (3.3%), Rother (5.9%) or Wealden (3.6%). Priorities for 2013/ The priorities for 2013/14 are: 34. Commissioning for positive outcomes: Market-test community drug and alcohol treatment services Include treatment for alcohol misuse as part of a wider Alcohol Harm Reduction Strategy Evaluate the impact of alcohol liaison workers at local acute hospitals 35. Maintaining and improving access to early and preventative interventions and to treatment: Introduce test on arrest at Eastbourne custody centre (also a Safer Communities Business Plan priority) to: o o Increase the number of younger, non-injecting opiate users who access treatment Increase the number of people using drugs other than opiates who access treatment An alcohol diversion scheme funded by Penalty Notice of Disorder (PND) payments (also a Safer Communities Business Plan priority) Target Identification and Brief Advice (IBA) training towards staff in specified professional groups Increase the number of people from rural areas who access alcohol treatment 36. Delivering recovery-oriented, effective, high-quality and protective treatment: More sustained investment in residential rehabilitation Develop services to respond effectively to the needs of older drug users Community alcohol detoxification needs to be expanded across GP surgeries in Eastbourne, Hailsham and Seaford CCG and High Weald, Lewes Havens CCG There is an effective response to the risk of serious harm in cases of domestic abuse 37. Achieving outcomes and successful completions Improved focus on a long history of opiate use and multiple treatment episodes 5

6 A programme of clinical audit will routinely identify opportunities to improve outcomes and successful completions More housing support for offenders and people with more complex needs 38. Treatment supports people to achieve sustained recovery Enabling the East Sussex Recovery Alliance (ESRA) to develop as a strong, sustainable, independent recovery organisation Community engagement work to develop recovery communities Demand for community-based services, including open-access, abstinence based, harm-reduction interventions, alcohol brief interventions and structured drug and alcohol treatment interventions 39. Across England, fewer drug users are entering treatment for heroin and/or crack dependency. The needs assessment estimates that more than 90% of local injecting opiate users are already known to treatment. The test on arrest service in Hastings and Rother has particularly identified powder cocaine users who had not previously sought help from treatment services. Introducing the test on arrest approach in Eastbourne is expected to identify a similar cohort. These users tend to have relatively short treatment episodes. Effective treatment pathways are available for users of all drugs. 40. The prevalence service user ratio the proportion of dependent drinkers who were in treatment in the previous year is 13%, or 1 in 8. In Signs for Improvement, the Department of Health recommends that capacity is available for and utilised by 15% of dependent drinkers. 41. Demand for alcohol treatment is likely to increase. The Community Alcohol Team has become more established in primary care. Public health interventions are increasing the ability of front line services to identify alcohol misuse and refer people into treatment. Social marketing is highlighting alcohol misuse as a problem and raising awareness about the help that s available. Demand for in-patient and residential services 42. In-patient treatment is provided via specialist beds at Mill View Hospital, Hove. The resource available for drug misuse is two beds, which meets current demand. The resource available for treating alcohol misuse is also two beds. There are no waits caused by lack of capacity. 43. Residential treatment is purchased using a combination of Adult Social Care community care budget and DAAT pooled treatment budget. The partnership s commissioning strategy describes the intention to increase recurrent allocations from the DAAT pooled treatment budget to increase access to residential care throughout the period of the current strategy. Improvements to be made in outcomes 44. The National Treatment Agency has reported that during 2011/12, 18% of the adults in treatment in East Sussex completed their treatment journey and left in a planned way. This is similar to national performance (15%). A significantly higher percentage of nonopiate using adults completed treatment (65%). This activity was driven particularly by 6

7 the Hastings test-on-arrest service. Following a positive evaluation, this intervention will be rolled out at Eastbourne custody centre. 45. The needs assessment identifies groups of opiate and crack users that are underrepresented in treatment people aged less than 34, non-injectors and crack users. Introducing test-on-arrest will increase the number of people from these groups who start treatment. It will also increase the number of non-opiate users completing treatment successfully in Eastbourne. 46. The NTA recovery diagnostic report has identified a cohort of patients with complex needs whose treatment outcomes are poor. Services should identify patients with long histories of use and multiple treatment episodes to ensure they receive targeted support to improve treatment outcomes. 47. The Treatment Outcomes Profile for drug users in treatment tells us that the majority of people describe continued alcohol use at reviews and at discharge. The number of people reporting abstinence is below the expected rate. Interventions that address alcohol misuse by people reporting a primary drug problem will improve treatment outcomes and reduce re-presentations into the drug and alcohol treatment system. 48. A Payment by Results approach will be introduced to incentivise providers to enable people to leave treatment free from dependent drug and alcohol use. 49. Further development of peer-led mutual aid will increase visible recovery. Additional support will be provided to ensure that the peer-led organisations developing in East Sussex are sustainable. Key priorities for access to accommodation, education and employment 50. Immediate access to accommodation for service users with an acute housing need remains challenging. The needs assessment tells us that 4.5% (N=56) of drug misusers presented with no fixed abode, and a further 8.1% (N=100) with a housing problem. At the point of review, the proportion of people reporting an acute housing problem had risen to 17.3% (N=61). For comparison, the England figure is 11.8%. Almost 1 in 10 people who are discharged describe an acute housing risk. 51. People presenting to alcohol treatment were slightly less likely to have a housing problem. Fewer than 3% (N=33) were of no fixed abode and 6.8% (N=77) had a housing problem. 52. The partnership has agreed to extend its agreement to joint-fund (with Surrey and Sussex Probation Trust) the Preventing Offender Accommodation Loss project to March The partnership will work with Probation and Supporting People to establish a jointly commissioned housing support service for offenders. 53. Job Centre Plus is an active strategic partner, and has worked with local services to develop referral pathways. Training for Job Centre Plus staff has included recovery champions. Job Centre Plus has commissioned an employment support project that targets people with a drug, alcohol or offending history. 54. More opportunities to develop skills through volunteering are being established with the development of the local peer-led organisations. 7

8 Integrating local treatment services with peer-led mutual aid and other community assets, and establishing local recovery communities 55. The partnership continues to use the SMART Recovery approach to develop peer-led groups. The partnership has adopted a community development approach to enable the development of the East Sussex Recovery Alliance (ESRA), a peer-led recovery organisation. ESRA provides peer-led SMART Recovery groups alongside other support groups and recovery oriented activities. SMART Recovery groups have been established in community drug and alcohol treatment services and in the local prison. A directlyemployed community engagement post will focus on increasing involvement in peer-led recovery activities in 2013/14. Arrangements for commissioning fully-integrated, recovery-focused substance misuse provision at HMP Lewes 56. HMP Lewes is represented at the DAAT Board and joint commissioning group. A new Drug and Alcohol Recovery Team was established in October 2012, utilising the Building Skills for Recovery accredited programme. Plans are in hand to develop a drug recovery wing, subject to any population changes required following the recently announced prison closure programme. From April 2013, the NHS Commissioning Board (Kent and Medway Area Team) will be accountable for healthcare provided within the prison, including the substance misuse service. The partnership intends to work closely with the NHS Commissioning Board to ensure there is a strategic fit between drug and alcohol treatment in the community and the local prison. Robust continuity of care arrangements for service users moving between custody and community settings 57. There is a well-established Criminal Justice Integrated Team (CJIT) in East Sussex. Good links with HMP Lewes, the local male prison for Sussex, ensure that care for service users moving between the local prison and the community is continuous. Female prisoners are located outside East Sussex, generally at HMP Bronzefield in Surrey. 58. The needs assessment reports that 83% of referrals from prison drug treatment were picked up by the local Criminal Justice Integrated Team (CJIT). This compares favourably to national performance (48%) and follows a sustained programme of improvement. 59. People who are referred to treatment via the CJIT are quickly engaged in effective treatment. The needs assessment tells us that 82% of referrals to the CJIT started a structured intervention within six weeks compared to 63% for England. This performance places East Sussex in the upper quartile of all partnerships nationally. 30% of all CJIT referrals completed treatment successfully, twice the England average (15%). Only 3% re-presented to treatment, compared to 13% nationally. Version 4 Final Draft for DAAT Board 11 March 2013 Author Jason Mahoney Joint Commissioning Manager Contact details / Version date 1 March

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