Foreword The public call for a detoxification provision located within the Derry and Strabane District has been gathering support for some time, beginning with a campaign led by the Quigley family in 2013-14 and manifesting more recently following the death of Louise O’Doherty and the awareness raised by her daughter, Tamzin White. The campaign has been supported by a range of support organisations that offer addiction support, families who have been affected by addiction as well as Derry City and Strabane District Council who affirmed its corporate position in favour of a local detoxification provision to complement other services such as community detox nursing services. In May 2021 the campaign met with Health Minister Robin Swann MLA and officials to convey the determination of local people to see a dedicated provision made available in the District as outlined in New Decade, New Approach. As part of that ongoing work, the campaign has sought clarity on funding priorities arising from the NDNA agreement and has sought a meeting with the Secretary of State, Rt. Hon. Brandon Lewis MP. In seeking to progress this commitment, the campaign has engaged with relevant agencies to determine the current state of Tier 4A detoxification services across the North, geographic provision and occupancy in order to complete this business case for a specific provision in the North West. We believe that it provides the basis for a local service as outlined in New Decade New Approach and commend it to you as a sound case for progressing this most important project for the people of Derry and Strabane.
Tamzin White
Cllr Emmet Doyle
Campaign Chair
Derry City and Strabane District Council
Contents
Current Services
Derry’s Case
Options 1: Status Quo 2: Altnagelvin Beds 3: Standalone Detox Unit
Recommendations
Appendices
Current configuration of Detoxification services In 2014, the Health and Social Care Board consulted on a plan to reconfigure Tier 4 – or in-patient services for addictions across the North.
As a result of that consultation, the ASHA centre in Omagh became the hub for the Western region encompassing Tyrone, Derry and Fermanagh, though open to referrals from across the North.
Two other services, in Downshire Hospital Downpatrick, or in the Carrick facility in the Northern Trust area in Antrim offer other regional T4 services. There are 30 inpatient beds in the North in total.
As of February, the Omagh centre was operating at 75% capacity due to the pandemic and had a waiting list of 25 patients. The Trust are currently working to increase that capacity.
There are a range of other services for less critical addiction support both across the North, and in the Western Trust specifically, and it is important that we highlight these.
The Western Health and Social Care Trust have outlined that the majority of detox cases can be addressed in the community as part of the Shared Care Detox Programme. The Alcohol Home Detox Service exists only in the Western Trust and is provided by a partnership including 2 (1 FTE) Alcohol Detox Nurses in the Northern and Southern sector of the Trust.
There are also two hostels, Damian House in Derry (men only) which provides three beds and Ramona House in Omagh which provides four beds.
Independently, the Northlands Centre provides a range of support for those with addictions and their families. Overall, the Western Trust addiction services see 2,500 referrals per year including the Opiate Substitution Service which had expanded in recent years with staff additions.
A regional review of services is due to be undertaken by the Health and Social Care Board in 202122. This proposal should feed into that review alongside the new Substance Misuse Strategy.
Addiction Service Tiers
Tier 1 interventions include provision of alcohol and/or drug-related information and advice, screening and referral to specialised drug treatment.
Tier 1 interventions are provided in the context of general healthcare settings, or social care, education or criminal justice settings where the main focus is not drug treatment.
Tier 2 interventions include provision of alcohol and/or drug-related information and advice, triage assessment, referral to structured alcohol and/or drug treatment, brief psychosocial interventions, harm reduction interventions (including needle exchange) and aftercare.
Tier 2 interventions may be delivered separately from Tier 3 but will often also be delivered in the same setting and by the same staff as Tier 3 interventions. Other typical settings to increase access are through outreach (general detached or street work, peripatetic work in generic services or domiciliary (home) visits) and in primary care settings.
Tier 3 interventions include provision of community-based specialised alcohol and/or drug assessment and co-ordinated care planned treatment and alcohol and/or drug specialist liaison.
Tier 3 interventions are normally delivered in specialised alcohol and/or drug treatment services with their own premises in the community or on hospital sites. Other delivery may be by outreach (peripatetic work in generic services or other agencies or domiciliary or home visits). Tier 3 interventions may be delivered alongside Tier 2 interventions.
Tier 4 interventions include provision of residential specialised drug treatment, which is care planned and care coordinated to ensure continuity of care and aftercare. Ideal settings to provide inpatient alcohol and/or drug detoxification and stabilisation are specialised dedicated inpatient or residential substance misuse units or wards.
Derry’s case Patient Profile The ASHA centre in Omagh remains the closest T4A unit for those in need of inpatient detoxification services in the North West. The geographic profile of its users since 2017 shows that 36% of all those admitted to the service has been from the Derry City and Strabane District. When compared with the provision in the Northern Trust area, the same profile does is not correlated, as five geographic localities share a distribution of the admissions, which includes admissions from outside of the Trust area.
Mental Health services It is widely accepted that mental health and addictions often intertwine. Since the opening of the Grangewood Unit in Derry, the bed occupancy and length of stay has steadily increased. In 2018/19, bed occupancy stood at 78% with the average stay in the facility 13 days, rising in 2020/21 to 87% occupancy and a 15-day average length of stay. Whilst figures are not available for the reason for admission to Grangewood, other figures of utilisation of addiction support throughout the City and Trust would support a hypothesis that a high proportion of patients in Grangewood entered due to some form of substance abuse either arising from a mental health crisis or vice versa.
Alcohol Statistics received from Altnagelvin Hospital also indicate a worrying upward trend of the impacts of alcohol and drug abuse on our health service. From 2016/17 to 2020/21, 3,277 individuals attended Altnagelvin Accident and Emergency arising from alcohol abuse. 10,233 persons were admitted to Altnagelvin due to alcohol abuse in the same period between 2016-17 and 2020/21. Again, this follows a concerning upward trend and when we consider there is only one FTE alcohol nurse in the Trust area, it is clear that the services are not adequately resourced to address what is a clearly growing problem and there are those represented by these figures that could benefit from a Tier 4 presence.
Drug abuse In the same period relating to attendances at Altnagelvin Accident and Emergency arising from drug abuse or overdose, the upward trend continues from 2016/17-2020/21 with dataset 5 demonstrating the total numbers of those attending, a total of 2,501. 3,139 persons were admitted to Altnagelvin in the same period arising from drug or substance abuse including overdose. Clearly there are those represented within these figures that could have availed of a range of tiered addiction services.
Repeat presentations In determining a growing problem with chronic alcohol or drug abuse in relation to Altnagelvin patients, we have received information outlining how many people have attended Accident and Emergency more than twice in a month for alcohol-related reasons. An upward trend is evident, and from the same period as the other datasets, indicates 204 persons have presented in this way.
Equally, those presenting more than twice in a month to Altnagelvin Accident and Emergency as a result of drug abuse or overdose presents a picture of a problem in the community – 97 people, though it is fair to say that it would seem from the recorded data provided by the Trust, the numbers may have been reflecting access to other tiered services which is a good news story though there is no way we can verify this.
Home Alcohol Detox Service Yhe HADS is aimed at those who are in need of support to detoxify, yet are not in need of inpatient services and it is the belief of medical professionals that they are capable of receivingn care at home. Since the inception of the programme in 2017 in the Western Trust, Derry has consistently had the highest number of male users. Female users follow that trend except from 2017 when Omagh has slightly more users. Locality total (F) Derry Fermanagh Limavady Not recorded Omagh Strabane Other NHS Trust Total
2017 43 26 13 36 47 11 0 176
% 2018 % 2019 % 2020 % 2021 % 24.4 206 43.6 152 40.4 137 58.8 83 14.8 86 18.2 83 22.1 33 14.2 0 7.4 4 0.85 14 3.7 3 1.3 0 20.5 3 0.6 0 0 0 0 0 26.7 141 29.8 87 23.1 39 16.7 0 6.3 31 6.6 37 9.8 14 6 7 0 2 0.4 3 0.8 7 3 0 473 376 233 90
92.2 0 0 0 0 7.8 0
Locality total (M) Derry Fermanagh Limavady Not recorded Omagh Strabane Total
2017 % 2018 % 2019 % 2020 % 2021 % 126 35 330 37.5 251 38.2 195 58.7 117 67.6 69 19.2 190 21.6 143 21.8 38 11.4 4 2.3 16 4.5 35 4 32 4.9 0 0 38 10.6 24 2.7 0 0 0 90 25 241 27.4 189 28.8 68 20.5 36 20.8 20 5.6 61 6.9 42 6.4 31 9.3 16 9.2 359 881 657 332 173
Damian House (Males only) Since this facility began being used as part of the tiered system, admissions have gone from 62 in 2015/16 to more than treble this – 2017 in 2019/20. This unfortunately complements the trends of users in other services.
Current resources The ASHA unit currently serves the entire Western Trust and whilst it is not the intention of the campaign or this paper to in any way criticise the work being undertaken at ASHA, we simply believe a unit closer to home, the second City, is required. At present, the ASHA unit in Omagh has a total cost per person per bed day of £838, or £5866 per patient per week. This is based on an 8-bed unit, over twice the size of the provision we believe the City would need at three beds. Whilst it is not possible to determine the exact number of staff that would be required for a threebed unit, the Telford Staffing model could determine the number of nursing staff required. The overall cost profile particularly in a unit within Altnagelvin Hospital or other established HSC facility has the potential of being significantly lower.
Options Standard business case practice requires several options to be explored in order to determine the best possible outcome. We have received guidance from trusted advisers from within the NI civil service as well as the Health and Social Care sector as to the preparation of this paper in relation to the format of a business case as we have been focussed on the activism of the campaign. At this point it is reasonable to state that we are determined to see a provision in the City akin to a Tier 4 service for those who suffer from addictions. However, what we have been clear on throughout meetings and briefings is that whilst the overwhelming view of the public is for a competent centre specifically for this purpose, we are not experts in capital investment and it will be for those trusted medical professionals to determine, with the aid of this report, what exactly a local service will look like. For this vital project, there are three options that we have scoped: 1. Status Quo 2. Funding 3 beds in Altnagelvin with appropriate therapeutic support 3. A standalone T4A detox unit
In assessing each of these options, we will consider; -
The societal impact Cost (where appropriate) Sustainability Viability
Option One: Status Quo
In maintaining the status quo – i.e. maintaining the pre-T4 services in the City and District whilst only providing Tier A inpatient beds at the ASHA centre in Omagh is not an optimal situation. The people of the City and District, their political representatives and many of those at the coal face providing services have rallied time and again behind the provision of a service in this locality.
Societal Impact It is unlikely given the rising number of admissions, uptake in addiction services and the public demand for a local provision that the status quo would be acceptable to the populace and could continue to have an impact on the number of ‘emergency’ detox requests as well as presentations at Accident and Emergency whose services are already under severe pressure due to the pandemic and an ageing population.
Cost Currently, the only cost we can quantify in relation to the ASHA centre is a c.£590k per annum staffing cost for administration and nursing costs for 3 x Band 3, 7.5 x Band 5, 2 x Band 6 and 1 x Band 7 members of staff. It does not include costs such as medical personnel, catering, cleansing etc or the upkeep of the premises.
Sustainability The ASHA centre has undergone changes following a reconfiguration of the regional service in 2014 by the Health and Social Care Board. Given its historic admission profile and the impact of the pandemic which has created a waiting list for its services, the long-term sustainability of the service is not in question.
Viability The ASHA centre is currently operating, though Tier 3 services in the form of Damian House is offered to males only and a female service would need to be commissioned to ensure accessibility and equality.
Option Two: Altnagelvin Beds
This option would see three Tier 4A beds available in Altnagelvin Area Hospital with additional therapeutic support. We have modelled that 3 beds would be enough to address the admissions to ASHA from the District.
Societal Impact The aim of the campaign is to establish a detox provision in the Derry City and Strabane District area. Whilst the idea of a detox ‘centre’ is a key demand of that campaign, it is possible that a dedicated service that offered the same services as ASHA within the District would benefit the locality and complement the other tiered services available locally.
Cost Whilst this would be an additional recurring cost to the Trust, it is envisioned that this would be funded by the commitment in New Decade and New Approach and would negate the need for capital costs or those associated with a standalone unit such as catering/insurance though an investment in staff would be needed in line with information provided in this paper.
Sustainability The relevant admissions to ASHA from those living in the locality could be absorbed by three beds within the hospital and could also deter ‘emergency detox’ admissions to general wards and Accident and Emergency. It would also complete the provision of T1-T4B services in the City and District which would be in line with the policy adopted by Derry City and Strabane District Council.
Viability As capital costs would not be a factor, this option provides a viable alternative to ASHA beds without threatening the admissions rate of the centre in Omagh given it will still be able to accept admissions from the Western Trust and further afield. It is possible however from a public perspective that this may fall short of expectations.
Option Three: Standalone T4A Detox Unit
This option would satisfy the public demand to see a ‘detox centre/unit’ within the boundary of the Derry City and Strabane District area requiring new premises and significant investment as well as recurring costs from the HSC.
Societal impact This option would satisfy public demand for a unit/centre in the district and would also allow referral from relevant agencies directly to the service removing the need to travel and would complete the provision of addiction services. It should be noted that the campaign has been clear not to specifically make the determination that a separate building would be required for the provision and the NDNA commitment does not specifically refer to a newbuild facility.
Cost Whilst this option would require one-off capital spend and recurring costs, it is possible that this could be limited to completing an extension to already operating services such as the Northlands Centre that has a long-standing presence in the City.
Sustainability The sustainability of a range of small capital project types which could perhaps adjoin service provision already in place would increase capacity for linked services at a smaller cost.
Viability This option outlines the need for a capital injection and whilst the funding mechanism for commitments made in NDNA is not yet clear as to whether the ambiguous commitment for an addiction service will include capital costs or not, it is unclear what format this service would take.
Recommendations
Addiction services are a complex service often needed when an individual is suffering debilitating mental and physical health. It is not our contention to inform clinicians how to run an addiction service, merely to seek a reconfiguration of currently available services closer to home as per the wishes of the people of this District. Having considered the background statistics, the profile of the other two Trust services and the emerging snapshot of service uptake both in core services and those emergency services, it is clear that a detox provision at T4A level is required in this City and District. It is also clear that the status quo would be unacceptable to the people of the District and contrary to the corporate position of Derry City and Strabane District Council as well as all elected representatives therein. The widespread belief that a lack of this service has contributed to prolonged addiction experiences, admissions to formal health structures and even deaths will only be addressed when the NDNA commitment is clarified, prioritised and funded. It is now incumbent on political leaders to deliver on the campaign call for a dedicated provision in this City and District, either Option one or two. Given the recent publication of both the Mental Health and Substance Misuse Strategy, we believe that the time has come to address this crucial project. We are content that this document demonstrates the will of the people of the District and welcome any discussions on how we can progress this essential project. We have taken the time to engage with officials, the community and service providers in this City throughout the campaign as the case previously when a Detox campaign first mobilised our people. We have provided the basis for a decision to be made, negating any requirement that research is carried out by the NICS because this issue is too important to us all to see further delay, and we are invested to a point where we felt the need to carry out this assessment now. Next steps This paper will be circulated to the Minister of Health, the First and deputy First Minister, the Irish Government and the Secretary of State respectively to include it in their deliberations around funding for commitments made in New Decade New Approach. It will also be distributed to the leaders of political parties on Derry City and Strabane District Council and Independent members, as well as the respective leaders of their parties at Stormont. It will be for those in authority to move this report into commissioning. We intend to make a digital copy available to the people of the City in due course. We know that they, like us, will be closely monitoring the response of all those who receive it.
Appendices The data below indicated the status of the bed complement in the ASHA unit up to December 2020. It demonstrates the numbers of those using the service, often meaning the service has only one bed available. Table 1.
Month
Bed Complement
No of Available Beds
No of Beds Occupied at last day of month
No of Free Beds at month end
Nov-17
8
8
5
3
Dec-17
8
8
2
6
Jan-18
8
8
6
2
Feb-18
8
8
7
1
Mar-18
8
8
6
2
Apr-18
8
8
3
5
May-18
8
8
7
1
Jun-18
8
8
6
2
Jul-18
8
8
5
3
Aug-18
8
8
5
3
Sep-18
8
8
6
2
Oct-18
8
8
7
1
Nov-18
8
8
8
0
Dec-18
8
8
0
8
Jan-19
8
8
6
2
Feb-19
8
8
6
2
Mar-19
8
8
5
3
Apr-19
8
8
7
1
May-19
8
8
5
3
Jun-19
8
8
6
2
Jul-19
8
8
6
2
Aug-19
8
8
7
1
Sep-19
8
8
10
-2
Oct-19
8
8
7
1
Nov-19
8
8
6
2
Dec-19
8
8
1
7
Jan-20
8
8
7
1
Feb-20
8
8
6
2
Mar-20
8
8
Apr-20
8
8
May-20
8
8
Jun-20
8
8
Jul-20
8
8
Aug-20
8
8
2
6
Sep-20
8
8
4
4
Oct-20
8
8
4
4
Nov-20
8
8
4
4
Dec-20
8
8
3
5
Closed
This data demonstrated the home locality of all users of the ASHA unit in the same period. It should be noted as has been stated, that users from this City and District constitute 59% of all admissions in that period. This is higher than from any other locality. Nov 2017-Dec 2018 No. of Admissions
Locality Derry
32
Strabane
4
Limavady
2
Omagh
16
Fermanagh
11
Other NHS Trust
43
Total
108
Jan 2019-Dec 2020 Locality Derry
No. of Admissions 49
Strabane
9
Limavady
3
Omagh
16
Fermanagh
15
Other NHS Trust
58
Total
150
Total Locality
No. of Admissions
Derry
81
Strabane
13
Limavady
5
Omagh
32
Fermanagh
26
Other NHS Trust
101
Total
258
The data below represents the admissions to Grangewood Mental Health Unit in Derry from 201212 until 2020-2021. Whilst we cannot determine how many of these admissions may be related to addiction, it is clear the need for its services are rising and putting bed availability under pressure.
Year
Admissio n
Mal e
Femal e
18-64
65 +
Averag e Length of Stay
% of Bed Occupancy
2012/201 3
174
91
83
170
4
14
59%
2013/201 4
522
232
290
516
6
14
62%
2014/201 5
643
324
319
629
14
10
57%
2015/201 6
781
369
412
765
16
9
58%
2016/201 7
626
282
344
615
11
9
66%
2017/201 8
779
349
430
765
14
8
76%
2018/201 9
825
380
445
809
16
13
78%
2019/202 0
800
394
406
782
18
14
82%
2020/202 1
464
205
259
451
13
15
87%
1. Attendances at ED with Diagnosis containing Alcohol (by Diagnosis) Ye ar
20 16
Gende r
Janu ary
Febru ary
Mar ch
Ap ril
M ay
Ju ne
Ju ly
Aug ust
Septem ber
Octo ber
Novem ber
Decem ber
TOT AL
Male
29
28
30
31
34
44
37
50
33
50
29
32
427
Femal e
19
15
12
17
20
16
10
15
12
26
10
15
187
48
43
42
48
54
60
47
65
45
76
39
47
614
Male
22
35
56
42
46
42
39
32
34
37
40
35
460
Femal e
20
11
16
13
17
15
5
22
11
11
11
9
161
42
46
72
55
63
57
44
54
45
48
51
44
621
Male
41
26
32
29
45
34
40
51
48
35
28
34
443
Femal e
11
7
24
17
14
21
15
24
15
18
14
21
201
52
33
56
46
59
55
55
75
63
53
42
55
644
Male
37
40
36
39
26
43
41
40
51
43
33
36
465
Femal e
12
17
24
10
14
15
18
19
26
21
20
28
224
49
57
60
49
40
58
59
59
77
64
53
64
689
Male
58
39
25
28
53
58
53
51
29
37
31
39
501
Femal e
23
20
9
12
16
18
22
29
17
9
11
21
207
Total
20 17
Total
20 18
Total
20 19
Total
20 20
Unkno wn Total
1 81
59
34
40
69
76
75
80
46
47
1 42
60
709
2. Attendances at ED with Diagnosis containing Drug use or Overdose (by Diagnosis)
Ye ar
20 16
May
J u n e
Jul y
Aug ust
Septe mber
Octo ber
Nove mber
Dece mber
TOTAL
13
22
16
25
23
12
16
13
18
219
33
21
13
28
22
25
15
19
26
13
272
41
60
34
35
44
47
48
27
35
39
31
491
22
16
19
25
16
20
27
36
26
16
23
30
276
25
22
18
24
24
29
28
25
12
17
23
24
271
47
38
37
49
40
49
55
61
38
33
46
54
547
Male
33
25
19
20
26
25
17
23
24
27
22
26
287
Femal e
19
17
19
17
38
23
21
27
23
20
22
28
274
52
42
38
37
64
48
38
50
47
47
44
54
561
Male
26
15
25
29
31
31
33
35
24
18
19
21
307
Femal e
21
15
18
22
22
16
17
21
19
14
13
15
213
Gend er
Janu ary
Febr uary
Ma rch
A pr il
Male
17
17
27
Femal e
33
24
50
Male Femal e
Total 20 17
Total 20 18
Total
20 19
Unkn own Total 20 20
1
1
2
47
30
43
51
53
48
50
56
43
32
33
36
522
Male
12
12
14
12
17
27
22
28
12
17
12
19
204
Femal e
14
18
12
13
17
18
12
20
8
14
15
15
176
26
30
26
25
34
45
34
48
20
31
27
34
380
Total
3. Admissions with Diagnosis containing Alcohol (Altnagelvin) YE AR
Y20 16
Y20 17
Y20 18
Y20 19
Y20 20
GEND ER
Janu ary
Febru ary
Mar ch
Ap ril
M ay
Ju ne
Ju ly
Aug ust
Septem ber
Octo ber
Novem ber
Decem ber
TOT AL
Male
114
127
93
96
10 7
14 4
14 7
134
127
133
108
108
1438
Femal e
52
49
47
54
49
83
69
60
65
60
65
66
719
TOTA L
166
176
140
15 0
15 6
22 7
21 6
194
192
193
173
174
2157
Male
101
122
146
13 2
13 8
13 5
14 4
133
104
110
104
121
1490
Femal e
76
38
61
58
78
66
53
76
46
52
41
46
691
TOTA L
177
160
207
19 0
21 6
20 1
19 7
209
150
162
145
167
2181
Male
110
96
102
11 1
13 6
14 4
15 5
150
146
125
119
116
1510
Femal e
40
42
45
50
89
59
68
71
61
50
62
58
695
TOTA L
150
138
147
16 1
22 5
20 3
22 3
221
207
175
181
174
2205
Male
134
116
142
12 5
13 2
11 9
15 2
138
127
139
80
115
1519
Femal e
69
54
60
59
50
65
66
71
63
43
61
45
706
TOTA L
203
170
202
18 4
18 2
18 4
21 8
209
190
182
141
160
2225
Male
113
103
90
74
87
14 1
12 2
121
84
43
15
12
1005
Femal e
47
54
45
26
45
61
59
54
50
12
3
4
460
TOTA L
160
157
135
10 0
13 2
20 2
18 1
175
134
55
18
16
1465