How To Provide Community Detoxification

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1 Summary Forty individuals attended the consultation event on 24 June 2010, and 16 individuals returned their views through the consultation response form. Respondents included GPs, practice nurses, service users, alcohol practitioners and providers in the statutory and voluntary sector and other stakeholders. This report encompasses a summary of both the feedback provided through the consultation event and other responses returned (consultation questions can be found at the end of the document). Information gleaned from this feedback report will be used as the foundation for making decisions on the nature and shape of future services. However, at the point of commissioning, if there are substantial changes to services there will be a need for additional formal consultation processes to meet statutory obligations. Community Detoxification Respondents identified the need for additional provision for alcohol detoxification. It was identified that there were waiting lists for home and in-patient alcohol detoxification. Community detoxification was supported. However, it was highlighted that the clinical risks associated with detoxification need to be managed and there is also a need for good pre and post detoxification support to ensure that detoxification is successful, especially as alcohol dependency is a highly relapsing condition. Experienced staff (doctors and nurses) will need to be available to prescribe, monitor and mange alcohol withdrawal. Suggestions for how community detoxification may be provided included a stand alone 24 hour supported provision, eg based on the model of the mental health Recovery House, or through New Cross or Penn Hospitals; incorporated or attached to a rapid access clinic/ community health centre or GP surgery; or through a peripatetic/ community alcohol liaison nurse who would supervise detoxification in the community. (It is not within the remit of this work to develop additional in-patient provision (24 hour alcohol detoxification provision), although it is recognised that there is an issue within the City, which will need to be addressed. The provision of community detoxification has to be integral to and integrated into alcohol treatment systems and referral pathways, because providing detoxification on its own without a range of pre-during and post support is not going to work. 1

2 Alcohol LES There was support for improving the provision of IBA (Identification and Brief Advice) in the community. However, respondents gave tentative support for the provision of an alcohol LES, they identified other aspects needed to be in place for it to be effective, including GP and practice staff commitment and buy-in; staff need to be trained to deliver IBA; and there has to be a robust alcohol treatment system and referral pathways in place to ensure individuals receive appropriate support if they have been identified with serious alcohol problems. Having control over and access to alcohol counselors and support and advice from alcohol practitioners was identified as ways which would improve the provision of an Alcohol LES. Suggestions for high risk groups the LES could target were varied, included those in most need, eg with physical and mental health problems, people from disadvantaged groups (eg BME communities /the unemployed/ those living in deprived areas and vulnerable groups (eg the homeless/ victims of domestic violence). The provision of support, training in IBA and financial reward were identified as incentives that would support the take up of the alcohol LES with GPs. It was highlighted that IBA could be provided in a variety of settings and by a variety of workers/ professionals in the community eg in voluntary or community organisations. It was suggested that rather than having an Alcohol LES, the shared care arrangement for drugs was cited as a model that could be effective applied to alcohol for GPs. Designated GPs, who are specialists in alcohol misuse, could provide support and services. Motivational therapies The provision of motivational therapies was supported and identified as a necessary part of the whole treatment package. The delivery of motivational therapies as part of the treatment interventions offered through rapid access clinic(s) was endorsed as it was recognised as a way of maximizing the effectiveness of treatments offered. It was highlighted that there was a range of therapies available; therapies identified included motivational interviewing, motivational enhancement therapy, behavioural family therapy, group work, and CBT (cognitive behavioural therapy). Decisions about which ones should be delivered must be based on the needs of the individual (the seriousness of their alcohol problems, their culture and other experiences they may have had). 2

3 Which ever therapies are delivered it is imperative that practitioners are competent to deliver them, they need to be qualified or trained and have on-going training to maintain their skills. It was identified that it would be useful to use make links with other mental health services for the provision of motivational support. Although not necessarily motivational therapy respondents identified that providing peer or buddy support might also be beneficial to supporting individuals to address their drinking problems. Rapid Access Clinic The provision of rapid access clinic (s) was supported, because it provided the opportunity to start treatment quickly when individuals were motivated and ready to address drinking problems. However, respondents did question how rapid was rapid, how quickly services and treatments could be delivered. It was highlighted that there needs to be clarity about what level/category of alcohol misuser rapid access clinic (s) provided services to and what those services would be. Respondents identified a range of services which could be provided within clinic(s) including, motivational therapies, alcohol harm reduction services, beds for community detoxification, initial assessments, assessments, provision for prescribing, onward referral and sign posting to other services. It was suggested that clinic(s) should take a holistic approach providing wrap around services - advice and spport on benefits, debt and housing. The provision of information on alcohol harms, and health checks were also identified as possible activities clinic(s) could be involved with. With regard to the establishment of rapid access clinic(s) respondents viewed that clinics could be developed as a stand alone provision or attached to existing provision in the community eg a GP surgery or community health centre. Respondents stated that clinics could be located in up to three locations in the City, ranging from an easily accessible central location to being located in areas of high alcohol needs (hotspots) or in the 3 PCT localities. At a minimum clinics should be open Monday Friday, 9.00am 5.00pm, but respondents also mentioned the need for evening and weekend provision to address issues of rapid accessibility. How clinics should be staffed was dependent upon the services provided, but they called for a range of clinicians and possibly other support staff. To be successful clinics had to take a multi-agency approach, be able to work and make links with other services and they have to be an integral and seamless part of existing alcohol services. (Alcohol treatment systems and referral pathways.) 3

4 Systematic Follow- up The provision of systematic follow up was supported, as the process would ensure individuals received appropriate referrals, on-going support and would prevent duplication of services. It would also address some of the gaps in existing alcohol treatment systems by making sure follow up could happen after a hospital discharge or A&E attendance with an alcohol related condition, for example. However, some respondents had their doubts about whether systematic follow-up was the right approach. Issues identified were whether it might create additional waiting lists, others felt if clients had previously received alcohol services the follow up role should be the responsibility of clinicians or key workers known to them. The existence of clear alcohol treatment systems and referral pathways is essential to the success of the system. In addition clear communication strategies and processes between the system and alcohol and other services was vital. It was mentioned that there would be a need for a good technology system to keep track of patients. It was noted that an additional benefit of a call and recall system is it would provide a monitoring function. A central resource would allow statistics and information to be built up on the needs of alcohol misusers and track the take-up and effectiveness of alcohol treatment services. Other Needs and Issues Questions about additional needs and services formed part of the consultation document response form, but not the consultation event. Questions were asked about what was missing and what was needed in alcohol treatment provision in Wolverhampton. There was insufficient current provision to meet the needs presented. Inadequate provision identified, included services for those with poly/multiple substance misuse problems, those with complex mental health and alcohol problems, in-patient detoxification for severely dependent drinkers with complex physical and or mental health needs. It was highlighted that there was a lack of tier 1 provision, preventative and early intervention services, tier 3 provision for dependent drinkers and access to tier 4 provision (detoxification and rehabilitation). There was a need for culturally appropriate provision and services for young people, especially improved early identification and intervention work. Many respondents wrote about the importance and need for wrap around or other support services eg housing, debt & benefit advice, and employment and education. Meeting these needs supported the success of alcohol treatment interventions. 4

5 It was identified that there is no commissioned housing /hostel provision specifically for alcohol misusers, currently those with serious alcohol problems are difficult to manage in accommodation provided for other client groups. In a similar vein another respondent stated there was need for provision of a wet house for street drinkers/ the homeless or those in hostel accommodation (and who may not have a GP) where they can also receive support during the day including psychological/social and medical interventions to meet their needs. Staffing levels and resources for current services was identified as insufficient, as evidenced by waiting lists. Services were described as being insular, they had poor links with other services and there was poor communication between services. It was stated that services need to be more joined up and holistic to meet the needs being presented, if this happened service provision would be improve. It was highlighted that collecting better quality information and data on patients alcohol misuse would uncover higher levels of needs. 5

6 Proposal Rapid Access Clinic It is proposed that rapid access clinic (s) be established to provide immediate or quick access to clinicians, diagnosis and treatments for people with more serious alcohol misuse problems. We suggest that motivational therapies should also be provided in clinics as it has been identified that the provision of motivational therapies increases the effectiveness of any treatment regime. Motivational therapies It is proposed that motivational therapies are made available in the community for those with moderate alcohol misuse problems, including those with problems of alcohol aggravated violence and domestic violence. Evidenced based motivational therapy addresses the underlying causes of alcohol misuse and supports problematic drinkers to change their drinking behaviours. Systematic follow-up It is proposed that a central administrative team/hub is established to coordinate the referral process and systematic follow-up services for people identified with serious alcohol problems. Community Detoxification It is suggested that alcohol detoxification is provided in a community setting. This offers the opportunity to mimimise the risks of detoxification for those were home detoxification is not a viable option, because of inadequate social support. A detailed model for such a service in Wolverhampton has not been determined, however this could be provided in a central or day unit for example. Alcohol LES We support that an Alcohol LES (Locally Enhanced Service) could be established within Wolverhampton targeting those at highest risk of developing alcohol misuse problems. Consultation Questions b) What treatment services and interventions should be provided? c) How many and where should it (they) be located? Times available? Staffed? d) What relationship should clinic(s) have with other alcohol services? b) If Yes/No Why? b.) How should this unit be provided and staffed? (Attached to a current community service out-patient clinic or as a stand alone service.) Suggested models are welcome. c) What would its relationship be with other alcohol services? b) Which higher risk groups should be included in the LES c) What support/incentives would be required to get GPs to sign up to this LES? 6