1. Residential Rehabilitation Services in Brighton and Hove

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1 24 Although a formal committee of the city council, the Health & Wellbeing Board has a remit which includes matters relating to the Clinical Commissioning Group (CCG), the Local Safeguarding Board for Children and Health Watch. Papers come from a variety of sources. The format for Health & Wellbeing Board papers is consequently different from papers submitted to the city council for exclusive city council business. 1. Residential Rehabilitation Services in Brighton and Hove 1.1. The contents of this paper can be shared with the general public This paper is for the Health & Wellbeing Board meeting on the 20 th October Author of the Paper and contact details Kathy Caley, Lead Commissioner for Substance Misuse, Brighton and Hove City Council kathy.caley@brighton-hove.gov.uk 2. Summary 2.1 Until April 2015, residential rehabilitation services were jointly commissioned by Public Health and the Housing Related Support team. In April 2015 the budget and commissioning responsibility transferred to Public Health. 2.2 Existing contracts for residential rehabilitation will expire on 31 st March This paper makes recommendations for the process of awarding future contracts. 3. Decisions, recommendations mendations and any options 3.1 That the Board agrees for the commissioners to seek to negotiate contracts with the current providers, with the option of moving to a competitive process if negotiations fail; 25

2 3.2 That the Director of Public Health be granted delegated authority to conduct the negotiations on the Council s behalf, and to run a competitive procurement in the event that negotiations fail; 3.3 That the Director of Public Health be granted delegated authority to award the contract after negotiations with the current providers or competitive tender process has taken place. 4. Relevant information Substance Misuse Services in Brighton and Hove 4.1 Adult community based substance misuse services (drug and alcohol treatment services for people aged 18 and over) are provided by Pavilions, a partnership of organisations led by Cranstoun, which began providing services in Brighton and Hove on the 1 st April A range of treatment interventions are offered to support service users to work towards recovery in a community setting. Each person entering treatment services is allocated a care co-ordinator to work specifically with them around their needs. Some service users will benefit from the more intensive, structured support that can be provided in a residential programme. Residential rehabilitation can be defined as a programme to establish a state in which clients remain alcohol/drug free and physically, psychologically and socially capable of coping with the situations encountered. Residential rehabilitation generally involves communal living with other alcohol/drug misusers in recovery, and can include group and individual relapse prevention, counselling, individual key working, improving skills for daily living, training and vocational experience, housing and resettlement services and aftercare support Residential rehabilitation aims to reduce substance misuse and associated homelessness by providing treatment and support to enable individuals to achieve abstinence and recovery, independent living and to take part in work and learning opportunities. Individuals are required to give up their current accommodation to move into full time residential rehabilitation. It is vital that service users understand the commitment this requires. 1 Simoens S, Matheson C, Inkster K, Ludbrook A, Bond C (2002) The Effectiveness of Treatment for Opiate Dependent Drug Users: An international systematic review of the evidence. Effective Interventions Unit, Scottish Executive, Edinburgh. 26

3 Evidence of Effective Practice 4.3 NICE guidance supports the provision of residential treatment for people who are seeking abstinence and who have significant comorbid physical, mental health or social problems 2. In 2012 the National Treatment Agency (now part of Public Health England) stated that service users who need residential rehabilitation should have access to it, and partnerships should not inappropriately restrict availability. The NTA also commented that because of the high cost of residential rehabilitation, the focus should be on high complexity cases 3. Residential Rehabilitation Provision in Brighton and Hove 4.3 In the last ten years Brighton and Hove has consistently been ranked in the highest three DAAT (drug and alcohol action team) areas (out of 159) for the proportion of all clients in treatment accessing residential rehabilitation. Data for 2013/14 shows Brighton and Hove as the area with the highest proportion of clients, with 9% of all clients in treatment attending residential rehabilitation. 4.4 Brighton and Hove is unusual in the approach to residential rehabilitation provision. The majority of Local Authorities rely on out of area providers of residential rehabilitation to meet their clients needs and clients could be placed a considerable distance from their home 4. Whilst for a small number of individuals this can be helpful (if a client is fleeing domestic or sexual violence, or if a client has considerably high needs that cannot be met locally), high numbers of individuals will want to continue to live in Brighton and Hove after completing treatment. It is therefore considered beneficial to support these individuals to build recovery capital in their own home city, so that when they do complete treatment they are able to re-integrate with the local community. They will also continue to have access to the support network they will have established during treatment and recovery. 2 Drug Misuse: Psychosocial interventions and opioid detoxification. Quick reference Guide. July National Treatment Agency. The Role of Residential Rehabilitation in an Integrated Treatment System There are 159 DAAT areas. 65 responded to a survey asking about the model used in their area. 37 use only out of area providers. The remaining areas use mainly out of area, with a small amount of incity provision. Only two other areas that responded said they use only in-city provision. 27

4 4.5 In Brighton and Hove residential rehabilitation is provided by two in-city providers; Brighton Housing Trust s Addiction Service, and CRI s St Thomas Fund. For 2015/16, the total spend on residential rehabilitation services is 690,739. This funds a total of 79 units of accommodation. 4.6 The Community Care Budget is accessible for local residents who would benefit from an out of area placement. The substance misuse budget is approximately 94,000 and this funds roughly ten placements per year. Referrals to out of area placements are overseen by the specialist substance misuse social workers, working within treatment services 4.7 Brighton and Hove has a long history of working with BHT and CRI to ensure that residential rehabilitation services are available for Brighton and Hove residents with addiction problems. Services have been provided by both organisations, initially via contracts with Housing Related Support (since approximately 2003), until Public Health took over commissioning responsibility in 2015/ Both services work to support clients to achieve a detoxification followed by abstinence, however, the overarching philosophy of the two providers differs slightly. BHT Addiction Services are based on a 12 step treatment model integrated with CBT treatment interventions. The use of illicit drugs or alcohol is a breach of license, leading to eviction. This is made very clear to clients at both assessment and start of treatment induction. If a client is evicted, providing they show motivation to change the behaviour that put their recovery or the recovery of others at risk, staff work with their care coordinator for a fast track re-referral back into treatment with the service. Treatment outcomes in the service have demonstrated the value of the consistent use of this approach. 4.9 CRI use interventions based on Cognitive Behavioural Therapy (CBT). Abstinence is still the end goal for service users, but there is a greater degree of flexibility as to how this is achieved. If a service user does have a lapse, they will initially be supported to address this, rather than evicted immediately. The distinction between the two services is an important one for service users to understand, and certain individuals may be better suited to one approach than the other. However, the overall aim of both services is the same, in that they support a wide range of individuals to recover from addiction. Improvement work 28

5 4.10 A programme of service improvement work is underway with the current providers, based on a review of residential rehabilitation provision undertaken in A number of areas were identified for development that will support the greatest number of service users to successfully complete treatment. These are: - Development of eligibility criteria - Since assuming commissioning responsibility for residential rehabilitation services, eligibility criteria have been developed by the Public Health team, to allow transparency for service users and ensure that the most appropriate individuals are referred to the most appropriate service. A guidance document on eligibility has been jointly developed by BHT and CRI, in partnership with commissioners. Clients who are motivated to change, who are high risk and have complex needs will be prioritised. - Ensuring that appropriate preparation work is undertaken by client Potential clients are expected to show their commitment to residential rehabilitation by attending preparation drop-in groups. The programme of work offered by providers in this stage of treatment has been developed to ensure that clients are fully informed about what to expect once they are in residential rehabilitation, and are aware of the requirements that will be put upon them to change. - Development of a consistent and fair lapse/relapse policy BHT and CRI have slightly different approaches to this element of service delivery, and a guidance document to support this, and to ensure that clients understand what is required of them, has been developed. - An approach to frequent returners research literature acknowledges that clients are likely to need to undergo more than one treatment episode before abstinence is achieved. This is the case locally for 34% of those who have undertaken residential rehabilitation since 2003, who have had more than one episode 5. Providers have developed personalised approaches to support these 5 Figure taken from Nebula, data recording system used to capture all activity. Data from 21/09/2003 to 31/03/

6 frequent returners, to ensure that the reason they left treatment unsuccessful previously is addressed in their next treatment episode. The aim is to reduce the number of people who frequently return to treatment. Benefits accrued from In-City Provision 4.11 The benefits of in-city provision include: - Enabling the essential pre-treatment contact or preparation work, including visits to the residential rehabilitation unit to be undertaken, and with it, a better understanding of what residential rehabilitation will bring. - The intensive support needed to link service users with local physical health treatment providers to obtain the care they need. - Being taught skills to manage the risks to their recovery that are specific to Brighton and Hove, where they will still be living post treatment. This will include learning to live a crime free life in Brighton and Hove. - Integrating with the recovery support network already available in Brighton and Hove, which will be vital to their ongoing recovery on leaving treatment. - Being supported by volunteers/recovery mentors who have already been through local services and recovered, which empowers individuals in their own recovery. - If they are a parent, being able to have ongoing contact with their children, and therefore being able to commit to residential rehabilitation. - Established links in the supported housing pathway, a crucial stage post treatment. Current Provider Outcomes 4.12 Providers are monitored against the percentage of successful completions from treatment services. The Public Health Outcome Framework defines this as the number of individuals that leave treatment successfully (free of drug/s of dependence) who do not then re-present to treatment again within six months The majority of people accessing substance misuse treatment services require support for their opiate addiction. The most recent 30

7 data set indicates that there were 1241 opiate users in treatment compared to 262 non-opiate users, 757 alcohol users, and 251 alcohol and non-opiate users (categories set by Public Health England) Residential rehabilitation services contribute significantly to successful completion rates for opiate users, with 37% of all opiate successful completions coming from individuals who have been in residential rehabilitation at some point 6. Individuals with opiate dependence issues are often the most complex users of treatment services, and residential rehabilitation can offer them the intensive support they need to overcome their addiction. These individuals will also be linked into community treatment services, where referrals for residential rehabilitation will originate from, and they may have initially received interventions in the community. However, the causal role of residential rehabilitation in their successful recovery should be acknowledged. Since assuming commissioning responsibility, the Public Health team has put in place a quarterly performance monitoring system that will allow variance in performance between the two residential rehabilitation providers to be identified, and focused on in improvement plans. The aim is to ensure that the opportunity for successful completion from treatment is the same for individuals regardless of which residential rehabilitation service they access As documented above, clients accessing substance misuse services are likely to undergo more than one treatment episode before abstinence and recovery is achieved. The majority of individuals accessing residential rehabilitation only have one episode (66% of all individuals accessing services since 2003). A further 21% have had two episodes of residential rehabilitation treatment. A small number, 9%, had three episodes of residential rehabilitation treatment. See appendix 1 for the full breakdown of episode numbers. The programme of service improvement work outlined earlier provides detail on how service users are given enhanced support to reduce the number of attempts needed to achieve full recovery. Recommendation for Service re-design with existing providers 6 Data is taken from the National Drug Treatment Monitoring System (NDTMS) and is for the period of 01/10/2013 to 30/09/2014, with re-presentations up to 31/03/

8 4.16 There are a number of practical reasons for the recommendation to undertake a service re-design with existing providers in the first instance. These are as follows: - Desire to continue with in-city provision model given the benefits of this service model, documented above, the Public Health team wish to continue with in-city provision. Service users have voiced their support for this model, and as demonstrated, residential rehabilitation contributes significantly to overall outcomes. Should there be the need, there is also provision for individuals to attend an out-of-area placement if required. - Premises requirements any organisation providing residential rehabilitation services in the city would be required to have access to appropriate buildings to provide the required treatment. Recent experience of the community substance misuse services seeking appropriate accommodation has highlighted the difficulties in acquiring buildings. BHT and CRI already have appropriate buildings in place, some of which have been recently upgraded using Public Health England Capital Grants funding. - Extensive improvement work already underway as detailed above, extensive improvement work is underway with existing providers. This work will help to ensure that the right individuals are accessing residential rehabilitation, and that they are receiving appropriate support and interventions. Future contractual position 4.17 The proposal is to negotiate three year contracts with existing providers, with the potential to extend for one further year. This will tie in with Brighton and Hove City Council s current four year budgetary planning cycle. As part of the service re-design, commissioners will work with providers to develop the most clinically and cost effective service delivery model. In line with required Public Health budget reductions, it is anticipated that a twenty percent saving will be made across residential rehabilitation services from 2016/17 onwards. This will reduce the spend on residential rehabilitation services from 690,739 to 552,591 per year. Community Engagement and Consultation 32

9 4.18 An independent Substance Misuse Service User Involvement Worker is commissioned by Public Health and employed by MIND in Brighton and Hove, to undertake all relevant community engagement and consultation. As part of the review of residential rehabilitation services in 2014, extensive service user consultation was undertaken. In total 63 service users took part in the consultation. The views obtained were used in the improvement work programme. The feedback from people using the services was extremely positive. Areas where improvements could be made centred on ensuring that all clients were aware of the choice of services available to them more generally, and in making informed decisions regarding their care. These are addressed in the residential rehabilitation review actions discussed earlier The Involvement Worker undertakes an annual service user consultation, and from the responses generates treatment priorities for the year ahead. Residential rehabilitation, as well as recovery and reintegration support, with housing and wraparound services for sustained abstinence are consistently high on the list of service user priorities 7. Conclusion 4.20 The continuation of the in-city service model for the provision of residential rehabilitation is the preferred option. Negotiating new contracts with current providers is the most suitable way of ensuring this. The extensive improvement work underway will ensure that the quality of services continue to improve A competitive tender process will be commenced should it not be possible to negotiate new contracts. 5. Important considerations and implications Legal: 5.1 Residential rehabilitation services fall within Schedule 3 of the Public Contracts Regulations 2015 and are required to be awarded in accordance with Section 7 of the Regulations (except where the value of the proposed contract is less than 625k, in which case only the general obligations of transparency and fairness apply). 7 Residential rehabilitation extract summary paper from Rick Cook, SU Involvement Worker, August

10 5.2 For Schedule 3 contracts with a value in excess of 625k the Council is required to publish a contract notice in OJEU setting out the process by which it is intended to award the contract. 5.3 There is currently some uncertainty about the extent to which is necessary to run a full competition prior to the award of such contracts, however the Council has previously taken the view that this is not strictly necessary for this type of service; and that the requirements set out in the 2015 Regulations and the EU Procurement Directive can be satisfied by advertising an intention to negotiate with existing providers, moving to a full competition only where such negotiations are not successful. The EU Directive recognises that there will not always be an established market for Schedule 3 services, and the intention of the Directive and the UK Regulations is to stimulate the development of such markets, not to force unnecessary competition where no genuine cross border market exists. 5.4 If and when terms are agreed with the current providers, the contracts entered into will need to be in a form approved by the Head of Law, and executed as Deeds. Legal Office consulted: Natasha Watson Date: 5 th October 2015 Finance: 5.5 The 2015/16 budget for residential rehabilitation services is 0.691m and the proposals set out in this paper seek to reduce the level of funding by at least 20% ( 0.138m) from 2016/17 onwards. It is considered that the preferred option to deliver this level of saving is by negotiating with existing providers and the outcome of these will help inform current service and financial planning across Public Health. Finance Officer consulted: Mike Bentley 2015 Date: 15 th September Equalities: 5.6 Equalities, and the reduction of health inequalities, are considered in the service specification development of any Public Health service. Services will be developed to ensure that all individuals have equal access. Sustainability: 34

11 5.7 The continued provision of in-city residential rehabilitation is the preferred approach of commissioners. Reducing the overall budget in line with budget pressures should allow the service to be provided in a sustainable way. Health, social care, children s services and public health: 5.8 This is covered in the body of the report. 6 Supporting documents and information 6.1 Appendix 1 Number of episodes of residential rehabilitation 35

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