Agenda Item 14 Enclosure KPCT/08/137
KIRKLEES PCT Report To:
PCT Board
Title:
Commissioning Strategy for Substance Misuse 2008-2011
FOI Exemption Category
Open
Lead Director:
Carol McKenna Director of Commissioning
Author:
Key Points to Note:
Tony Cooke Assistant Director (Drugs, Alcohol, Community Safety) A new partnership commissioning strategy has been developed to reflect changes to: •
local priorities and the revised partnership structures (Local Area Agreements)
•
clinical and commissioning guidance
•
levels of drug and alcohol misuse
•
The drugs and alcohol needs assessment and the Joint Strategic Needs Assessment
Budget Implications:
None at present.
Risk Assessment:
Stretch targets have increased year on year and these have been met in 2007/08. The current financial year presents different challenges as targets have been re-formulated and linked to budgets from 2009/10 onwards.
Health Benefits
Effective substance misuse services benefit service users directly and support the achievement of wider targets around physical and psychological health.
Staffing Implications
None
Sub Group/Committee:
Joint Commissioning Group Substance Misuse
Recommendation:
Board to consider this report and support ongoing measures to address substance misuse in Kirklees.
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DAAT Commissioning Strategy and Treatment Plan (2008-2011) 1.0
Introduction This paper outlines the Commissioning Strategy for Substance Misuse 200811 as well as briefly updating board members about performance in 2007/08.
2.0
Background The Kirklees Drug and Alcohol Action Team (DAAT) is charged with delivering the national drug strategy at local level. It is a partnership focused body managed by the PCT from within the Commissioning Directorate. The primary focus of the DAAT has been to deliver improvements to both the commissioning and delivery of treatment interventions for people with substance misuse problems. a) Kirklees Treatment Plan The Drug and Alcohol Action Team has met its target to double numbers in tier 3 treatment to 2,000 by 2007/08 whilst also reducing waiting times from 13 to 1 week for most interventions. Since 2005/06 successful programme completion has increased from 34 to 58%. Both locally led and National Treatment Agency service user surveys reveal high rates of satisfaction with service provision and recent outcomes data shows that over 70% of service users show significant crime reduction and health improvement. Despite this there is more to do. A significant number of users continue to use drugs, although at far lower rates than previously. Likewise, we know that although drug treatment drastically reduces offending, many people do continue to offend, but less frequently. The DAAT has achieved some very challenging targets – but there is now a need for a more creative approach that ensures services and partners promote social inclusion and general wellbeing by improving access to counselling, employment, housing and family support. This will require a partnership approach involving a wide range of agencies as outlined in the new strategy. In addition to improving exits out of the system partners must do more to attract the 1,200 people currently outside structured treatment into services. These are primarily adult offenders with heroin and crack problems aged 25 and over. These people will be targeted these through strengthened delivery of offender management schemes, direct appeals in communities and harm reduction and peer education programmes. The DAAT needs assessment, when coupled with national data, shows that heroin use amongst young people has declined significantly, with cocaine and cannabis use stable. Class A drug use remains a significant problem for over 25s and many people remain outside treatment. In addition, alcohol use has increased significantly across all age groups in Kirklees but our services remain underdeveloped. Changing patterns of substance use require changes to the approach. A long term shift away from heroin will lead to downward pressure on acquisitive crime, whilst a long term increase in alcohol use leads to upwards pressure on violent crime and impacts on public health. 3
The overall approach is to deliver evidence-based services and focus on continuous improvement through implementation of national guidance and tight performance management of commissioned services. It is this approach that led to the DAAT scoring strongly in recent Healthcare Commission inspections. During the life of this commissioning strategy the aim is to ensure all drug and alcohol services are subject to the same systems of performance management, whether they are focused on health improvement, criminal justice or young people. b) Commissioning Priorities The results of National Treatment Agency monitoring and Healthcare Commission inspections in 2007 coupled with unit costing and service user survey findings demonstrate that the existing system is fit for purpose. The intention is to deliver improvements through effective joint commissioning and ongoing service review. The underlying theme behind these priorities is to enable service users to break with dependence on problematic use of substances and associated ill health and social exclusion. There are ten core priorities in the new strategy, these are: Develop more pathways into treatment, particularly for offenders As noted, there remain significant numbers of drug users outside treatment and only a small percentage of problem drinkers accessing treatment services. As a result our priority is to better target the most entrenched users into services. • • • • • •
Services will remain open access with waiting times better than national targets The most entrenched offenders will be better targeted via review of offender management (Drug Intervention Programme) and criminal justice services (Drug Rehabilitation Requirements). Older treatment resistant drug users will be targeted through peer education and inreach into needle exchange schemes Younger less problematic non opiate drug and alcohol users will be targeted via brief interventions in community settings Shared care in general practice will be expanded to ensure people who can be managed in primary care with the support of a drug or alcohol worker can be managed within their community Brief interventions for hazardous drinkers will be implemented in general practice, with structured treatment reserved for those that need it
Develop more pathways out of treatment by promoting social inclusion Services have successfully attracted large numbers of drug users by using a harm reduction approach that has resulted in large numbers of people on methadone maintenance. This is the carrot into services, but now it is time to develop more potential pathways out of treatment including offering broader interventions and better access to good housing, employment and training. 4
Actions include: • Develop an abstinence based support group for those requiring aftercare support or relapse prevention to promote exit completely from substance misuse • Use the NTA Tier 4 supported housing programme to ensure we have housing available for those requiring an abstinence based intervention • Review access to housing, particularly for service users effectively engaging with treatment regimes • Ensure drug and alcohol users have access to employment and training • Investigate the possibility of working with mental health services to develop a social enterprise scheme for current/former service users Improve the health of service users Over 50% of people with drug and alcohol problems also have significant mental or physical health problems. The DAAT needs assessment shows that many service users continue to offend and use drugs, albeit at drastically reduced levels. Tacking the issues behind substance misuse is vital to further progress, particularly for the most entrenched. • • • •
Ensure that service users have improved access to mental health services through implementation of the Kirklees Dual Diagnosis strategy Ensure the advances made in addressing Hepatitis B are extended to Hepatitis C by implementing the Hep C improvement plan Ensure that access to counselling services is improved Ensure that newly released prisoners receive appropriate harm reduction information to prevent relapse and/or overdose
Improve treatment outcomes for all service users aged 16 plus The DAAT will continue, through contract management, to drive service improvement and meet national and local targets. This includes: • • • • • •
Delivery of the retention improvement plan in Lifeline Delivery of the successful discharge improvement plan Implementation of the Treatment Outcome Profile and evaluation of the findings Ensure all service users have an appropriate care plan and healthcare assessment Continue engagement with NTA and HCC improvement programmes, including delivering the improvements determined necessary Ensure services address ‘barriers to change’ such as continued low level offending and drug use
Continue to develop user and carer led initiatives Service user and carer initiatives continue to be recognised nationally and it remains a priority to ensure both groups are key to service delivery. At all stages the input of service users and carers, through peer education, organised groups and advocacy, will be entrenched in both service planning and delivery. This includes: 5
• • •
Implementation of the findings of the review of involvement. Review the Alliance led advocacy project and ensure are factored into treatment service contracts Ensure newly commissioned carer services are effectiveness and assess the need for services problematic alcohol service users
service user lessons learnt reviewed for for carers of
Ensure services are driven by quality standards, the evidence base and clinical effectiveness Kirklees was the first DAAT in the country to implement Standards for Better Health across commissioned services and we will continue to implement new guidance from NICE and the NTA. Commissioners and clinical leads will ensure that they provide leadership and support for implementation of new guidance. This includes: • • •
Deliver an ongoing assessment of the services commissioned in Kirklees to ensure they remain evidence based and driven by both quality and clinical effectiveness DAAT will drive ongoing implementation of Standards for Better Health Clinical Leads will drive full implementation of new NICE clinical guidance in partnership with Kirklees PCT where appropriate
Consider the changing needs of the drug and alcohol using population, particularly ensuring appropriate support for under 25s It is essential young service users receive support where it is most appropriate. The young people’s needs assessment will assess what needs younger people under 18 have for drug and alcohol services. In addition, we will implement NICE guidance by reviewing the needs of young people aged 16-25 with use of alcohol, cannabis, cocaine and ecstasy (ACCE). Further actions include: • • •
The evidence base will be studied closely and a strategic approach taken across commissioning structures for both adults and young people Consider the best means of expanding prevention and treatment options for users of alcohol, cannabis, cocaine and ecstasy (ACCE) Review the effectiveness of existing services for 16-25 year olds including appropriateness of setting and length/type of intervention
Tackle alcohol misuse both amongst the drug using population and general population by commissioning evidence based interventions West Yorkshire has a particular problem with problem drinking, and within this Kirklees has some of the highest levels of alcohol misuse, with early onset of drinking combined with high rates of binge drinking and alcohol related crime and health problems. • •
Ongoing implementation of Kirklees Alcohol Strategy Implementation of alcohol treatment requirements for offenders in partnership with probation 6
• • •
Investigate provision of a Locally Enhanced Service (primary care based provision) with Kirklees PCT and pilot shared care for alcohol structured interventions Expansion of brief interventions for existing drug service users Dependent on resources, tender a fully integrated alcohol treatment service that delivers access to interventions from Step 1 to 4 of the alcohol treatment system
Ensure that parental problem drug and alcohol use and its impact on children is fully addressed by adults and young peoples services It is estimated that there are between 250,000 and 350,000 children of problem drug users in the UK – about one for every problem drug user. This equates to approximately 3,000 children of drug using parents in Kirklees. Increased support to family members of drug users is vital and possibly the best means of preventing the next generation of substance users. Actions include: • • •
Work with the NTA and children’s commissioners to assess how best to improve support to children of drug and alcohol users Improve links with children’s joint commissioning and safeguarding structures Ensure providers are implementing recent NTA guidance
Ensure that people across Kirklees, from all backgrounds and localities, have equitable access to relevant services staffed by appropriately skilled staff It appears that service location is not a barrier to access for crack and opiate users, and that people from different genders, races and backgrounds receive services that result in broadly the same outcomes. However, despite improvements services remain unrepresentative of the Kirklees population and most users are male, white and 25-40. Additionally, the Kirklees Tracker Survey (2007) shows that news about recent improvements in services has not filtered down into the community. Further actions include: • •
Develop a communication strategy to improve perceived access to, and effectiveness of, services and improve community awareness about what happens in treatment services Improve contract monitoring by including clear action to improve uptake of services by black and ethnic minorities
c) Direction if Travel for Substance Misuse In Kirklees Drug and alcohol services have to ensure they remain relevant and are delivering improvements not only in the treatment population but also more widely by impacting on crime reduction, health inequalities, social exclusion and community cohesion. The table in appendix 1 below outlines a possible general direction of travel for services taking current developments in the field, local priorities and national trends into account.
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3.0
Risk Assessment There are an estimated 3,200 problem drug users in Kirklees, leaving over 1,200 people outside treatment. Alcohol services are rudimentary and are only addressing a very small percentage of potential need (only 1 in 46 of dependent drinkers in the region access treatment). However, services continue to develop and are increasing both their ambition and their effectiveness as outlined in the Commissioning Strategy. There remain risks both to individuals and to the community presented by substance misuse, but without significantly increased investment in treatment provision it is likely that these will have to be managed from within tier one mainstream provision.
4.0
Conclusion The commissioning and management of adult drug treatment services has been assessed as being fit for purpose and effective by the Healthcare Commission and National Treatment Agency. The new commissioning strategy builds on existing progress and outlines priorities and direction of travel for the next three years covering adult services and criminal justice interventions. The strategy is an ambitious document and if fully implemented will make a significant difference to the health and wellbeing of drug and alcohol users, as well as having a positive impact on the wider community in Kirklees.
5.0
Recommendation The Board CONSIDER this report and SUPPORT ongoing progress in addressing substance misuse in Kirklees.
6.0 Appendix 1: DIRECTION OF TRAVEL FOR SUBSTANCE MISUSE SERVICES IN KIRKLEES Appendix 2: KIRKLEES INTEGRATED TREATMENT SYSTEM
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DIRECTION OF TRAVEL FOR SUBSTANCE MISUSE SERVICES 2003 2007 2011 NTA release of Models Services commissioned Extension of choice of Care (National according to MoC agenda to some services Service Framework) framework with individualised budgets Alcohol treatment PCT fully mainstream Fully integrated alcohol voluntary with limited NRF funded treatment service able to operate access to brief posts but services only effectively at all stages of interventions able to see small % of interventions recognised need Service expansion Programme completion Outcome targets for each targets targets and introduction of individual and possibly by treatment outcome profile keyworker Clear division between Integrated treatment Integrated treatment health and crime systems for drugs system and offender based approaches management for alcohol Hard to reach groups Most are in treatment but All hard to reach groups in outside services need for improved dual treatment and engaging diagnosis services successfully No clinical leadership/ Specialist services with Decentralised primary care nurse prescribers, evidence based based services in place over/under prescription prescribing, clinical leads with specialist support as of certain substances and nurse prescribers all necessary in place Limited partnership Strong links across CJS Pooled budgets across working at both and adult services, young people’s, criminal strategic and inadequate links to CYP justice and adults services operational level commissioning structures Service user surveys Surveys show high Appropriate menu of show services satisfaction but services available meeting unpopular and under inadequate focus on diverse needs utilised abstinence Inadequate carer and Strong services for drugs, Alcohol user/carer services service user not alcohol in place involvement Unmet housing need Supporting People Integrated understanding services developed but between commissioners still unmet need and housing providers Limited controls and Financial and Tier 4 need met by limited access over management controls in regionally commissioned Tier 4 referrals place plus contracts being placements that reduce developed cost and improve outcomes No advice around Employment support Social enterprises for employment/training projects and workforce service users accessing for users development system in increasing funds for place innovative projects Inadequate focus on Increased number of BME Progressive services diversity and equalities service users and support equally accessible to all issues for women and families individuals and communities
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Kirklees Integrated Drug Treatment System
Reduce flow in: Prevention Programmes/Targeted interventions for at risk groups
<18s & Young Adults <U25
Target entrenched users causing most harm to self/others
Problem Users
Improve flow out: new approaches, more outcome focused and better quality
Effective Treatment
INCREASE FLOW
REDUCE FLOW
Family focus
Offender Management Programmes
Social inclusion via housing, ETE, local services
User Led Programmes
Tony Cooke Assistant Director (Drugs, Alcohol, Community Safety) Commissioning and Strategic Development May 2008
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