Contact for further information: Chris Lee, , Adult Services, Health and Wellbeing Directorate,

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1 Report to the Cabinet Member for Health and Wellbeing and the Cabinet Member for Adult and Community Services Report submitted by: Director of Public Health Date: 16 September 2014 Substance Misuse Tier 4 Review (Appendix 'A' refers) Part I Electoral Divisions affected: All Contact for further information: Chris Lee, , Adult Services, Health and Wellbeing Directorate, chris.lee@lancashire.gov.uk Executive Summary As part of the Adult Services, Health and Wellbeing Directorate's approved savings programme, the Tier 4 review is required to deliver savings of 500,000 from the Tier 4 pathway for Substance Misuse Services by April The key strands of this project are to: Review and re-commission inpatient detoxification services via open tender; Review and re-commission residential and non-residential rehabilitation services via open tender; Consolidate budgets for inpatient detox and rehabilitation services so that the whole treatment system can be managed in a more integrated way; Review the role and function of the County Council provided assessment process for substance misuse rehabilitation services (currently carried out via Social Workers within the Directorate's Personal Social Care team) and make recommendations for change if required; Approval to reallocate resources from the Tier 4 budget to support the development of supported housing for those with substance misuse problems if required. This is deemed to be a Key Decision and the provisions of Standing Order No 25 have been complied with.

2 Recommendation The Cabinet Member for Health and Wellbeing and the Cabinet Member for Adult and Community Services are recommended to approve the proposals for the project and the key strands as set out in the report including the tendering of services and the consolidation of the relevant budgets across Public Health and Adult Social Care to create a joint resource to fund future service provision. Background and Advice This report outlines the purpose of the Substance Misuse Tier 4 Review and seeks approval to: Re-commission via open tender services for inpatient detoxification; Re-commission via open tender services for residential and non-residential rehabilitation; To consolidate budgets for inpatient detox and rehabilitation services so that the whole treatment system can be managed in a more integrated way; To review the role and function of the County Council provided assessment and funding agreement process for rehabilitation services with a view to ensuring the best process is in place to meet the needs of service users; and to make recommendations should change be required; In order to support the wider substance misuse agenda and the Tier 4 review, commissioners seek approval to re-direct Tier 4 resources to support the development of supported housing opportunities for those with substance misuse problems. Definition of Tier 4: The National Treatment Agency (NTA) defined Tier 4 services as Tier 4 interventions include provision of residential specialised drug treatment, which is care planned and care coordinated to ensure continuity of care and aftercare. (Models of care for treatment of adult drug misusers: Update 2006). The key examples of Tier 4 services include: Inpatient specialist drug and alcohol assessment, stabilisation, and detoxification/assisted withdrawal services. A range of drug and alcohol residential rehabilitation units to suit the needs of different service users. A range of drug halfway houses or supportive accommodation for drug misusers.* * The County Council already commissions supported housing via the Supporting People team. It is accepted that a lack of housing is the weak spot in the treatment system nationally, Lancashire included. If the engagement work regarding the Tier 4 review highlights supported housing to be a key issue then this will need to be

3 developed as part of the core critical challenge Tier 4 review; the project PID will be updated as required. As such approval is sought to transfer resources if required from the Tier 4 budgets to support the development of supported housing either via supporting people contracts or to support providers outside of Supporting People, as is now being done around the UK. This provision can be funded via enhanced housing benefit. Additional top up may be required to ensure a significant level of support to ensure both tenancy and recovery is maintained. The key drivers for this project are as follows: Commissioning for substance misuse in Lancashire now largely sits with the County Council (NHS England is responsible for prison based services which are currently jointly commissioned with the County Council as part of an integrated approach). It provides the opportunity to integrate residential (and non-residential day care) rehabilitation services more closely with the community treatment system. It provides a chance to review County Council provided services (assessment) in light of comprehensive treatment provision by adult substance misuse services. Residential (and non-residential day care) rehabilitation services have been managed but not market tested in Lancashire. The Inpatient detox contract, held by Blackpool is due for review by The Directorate's savings programme requires 500,000 to be saved from Tier 4 Substance Misuse services. This provides an opportunity to rationalise the Tier 4 pathway. National Priorities: Tier 4 services have been a long standing focus of the National Treatment Agency prior to the move of this function into Public Health England. Tier 4 services play a key role in the recovery agenda in the UK. The National Drug Strategy, 2010 (NDS) is built on three main strands: o o o Reducing Demand, Reducing Supply and Building Recovery in Communities; This project is a key element in Lancashire s response to the third strand. A key statement in the NDS is to ensure more people are tackling their dependency and recovering fully (National Drug Strategy, 2010, p 2). The NDS (p 19) also recommends local commissioned solutions:

4 'As part of their new role we will also look to Directors of Public Health, along with local partners, to ensure that the drug treatment and recovery services, and those for the more severely alcohol dependent, are delivered in line with best practice. We would view this as: - Aligned and locally led local areas will be free to design and jointly commission services to ensure they meet local needs, including for those in the criminal justice system (CJS). - Competitively tendered and awarded with transparency of performance and money following success. Local areas and providers that succeed will be rewarded. - Transparent about performance local accountability is key. We will not prescribe to local areas what they should deliver or how and we will move away from bureaucratic performance mechanisms focused on activity and outputs. We will instead focus on supporting local accountability for delivery of the key outcomes through the provision of consistent data, updated clinical protocols, allocation of funding and development of skills. This will enable variations in factors that affect recovery such as local housing and job markets to be taken into account.' Local Priorities for Lancashire: Significant elements of the eligible population are less likely to access rehabilitation services (e.g. women, families, users of New Psychoactive Substances). Changes in the substance misuse markets (growth in alcohol demand, aging opiate population, emergence of New Psychoactive Substances) Community treatment services have undergone significant change in recent years, this project will allow that learning to be applied to the Tier 4 agenda and ensure that Tier 4 services are fully integrated with community services to enable seamless treatment transition. Therefore there is a need to ensure that Tier 4 services match the developments in community treatment and are responsive to need. The scope of service specifications for residential (and non-residential day care) rehabilitation services have not been reviewed in light of the modernisation to community service and inpatient detox services and changes in drug markets, demographics and the growth of the recovery agenda. Housing remains a critical issue for the substance misuse treatment system in Lancashire. Public Health business plan: Substance misuse is integral to the Public Health business plan and the review of Tier 4 services included in the Public Health business plan. Existing business: Inpatient detox provision for Lancashire is considered currently to be cost effective and providing good value for money.

5 The current Inpatient detox contract is hosted by Blackpool Council and is in scope for review and re-commissioning within the next 2 years. Residential (and non-residential day care) rehabilitation contracts are held by the County Council but have never been market tested in Lancashire. County Council social workers (from the Personal Social Care team) currently provide the assessment of clients for residential (and non-residential day care) rehabilitation, decision making over placement, funding and review during the rehabilitation process. Tier 4 Review Project Objectives: Greater integration of the whole Lancashire substance misuse treatment system by directly linking access to rehab into existing community services, alongside access to inpatient detox service. To reassess the model of residential (and non-residential day care) rehabilitation for substance misuse via consultation and review of the evidence base, with an initial view to shifting towards a spectrum of provision from traditional residential services to community based provision and recovery housing (Oxford model). To review the input from County Council provided services (Social workers) for the assessment for residential (and non-residential day care) rehabilitation services and to consider if this can be provided via existing community substance misuse services. To review the process for authorising rehabilitation placements and strengthen the links to community substance misuse services. To review the process for authorising inpatient detoxification placements. Refresh service specification and provider framework for inpatient detoxification services via open tender. A new service specification for residential (and non-residential day care) A new provider framework for residential (and non-residential day care) Reduced costs across the whole Tier 4 pathway through finding efficiencies in process as described above and in potential cost reduction by re-tendering. To achieve savings of 500,000 by April The project delivers an integrated approach to Tier 4 services that is clearly connected into existing community substance misuse services. Project outcomes: There will be a number of key outcomes for this project as follows: 1. Greater integration of the whole Lancashire substance misuse treatment system, including financial alignment of budgets. 2. Revised input from County Council provided services for assessment of, and authorisation for, 3. Review the process for authorising rehabilitation placements. 4. Review the process for authorising inpatient detoxification placements. 5. Refreshed service specification and provider framework for inpatient detoxification services.

6 6. A new service specification for residential (and non-residential day care) 7. A new provider framework for residential (and non-residential day care) 8. Potential investment in and/or support for supported housing for those recovering from substance misuse. 9. Reduced costs across the whole Tier 4 pathway. 10. Savings totalling 500,000 from three project streams: a. Inpatient detoxification b. Residential (and non-residential day care) rehabilitation c. County Council Social Worker costs Consultations The project team is currently undertaking an engagement process with service users, the recovery community, families and carers, community substance misuse treatment providers in Lancashire and will engage with providers of inpatient detoxification and residential rehabilitation prior to any procurement process. The project group has also held discussions with both Blackpool and Blackburn with Darwen Councils about joining this process. The rationale for this is that the current inpatient detox framework is jointly commissioned by all three authorities and continuing this in the future for inpatient detox and residential rehabilitation would improve the purchasing power of all partners and therefore improve value for money. As it is envisioned to commission a framework of provision each authority would retain control of its own budget. Implications: This item has the following implications, as indicated: Risk management This project is part of the Directorate's savings programme. Simply reducing funding would not address the need to re-commission residential rehabilitation services and the impending need to re-commission inpatient detoxification services from April Whilst efficiency savings in the inpatient detoxification services had already been achieved when the services were part of the NHS, a new contractual framework could give stability to the treatment system for years to come, dependent upon the contract length. Residential rehabilitation services have never been market tested in Lancashire, as such there is a clear opportunity to refresh the service specification and expectations that Lancashire demands from service providers and experience tells us that quality improvements can be made with opportunity to drive further financial efficiencies. Such opportunities will not be realised to their full potential if the procurement exercise is not conducted. The outline plan as discussed with procurement is to have a two stranded cost structure for detox (medically managed and medically monitored, in line with NTA definitions) and a three stranded cost structure for rehabilitation (24 hour staffing,

7 non 24 hour staffing and day programme/community rehabilitation). The move towards more day programme/community rehabilitation support, underpinned by supported housing should enable further efficiency savings, improve patient choice and social value and support sustainable recovery as part of the whole Lancashire treatment system. Spend will be monitored and further efficiencies will contribute towards the efficiency savings required in the longer term. The project has a risk management plan in place. Financial Based on expenditure in 2013/14 the total fund for inpatient detox ( 1.4m), residential rehabilitation ( 1.6m) and non-residential day care ( 0.1m) is 3.1m. The in-patient detox service is currently funded by the Public Health grant. The residential rehabilitation and non-residential day care services are currently funded by the Adult Social Care budget. The project is expected to secure savings of 0.5m per annum by April Legal Existing contracts for residential rehabilitation are dated Existing contracts for inpatient detoxification are due to expire in April Equality and Diversity An Equality Analysis has been completed and is set out at Appendix 'A'. List of Background Papers Paper Date Contact/Directorate/Tel National Drug Strategy 2010 Chris Lee, Adult Services, Health and Wellbeing Directorate, Reason for inclusion in Part II, if appropriate N/A