2007/08 Birmingham Adult Drug Treatment Planning Needs Assessment FINAL REPORT
Jessica Loaring David Best Birmingham Drug Action Team March 2008
BIRMINGHAM DRUG ACTION TEAM ADULT DRUG TREATMENT PLANNING NEEDS ASSESSMENT 2007
Executive Summary .......................................................................................................................................3 Section 1 - Background and Aims ................................................................................................................6 Section 2 - Update from the 2006 Annual Needs Assessment...................................................................7 Section 3 - 2007 Needs Assessment - Methodology .................................................................................11 Section 4 - Findings from Core Local Data Sources (NDTMS and DIP)...................................................13 Treatment Bulls-eye ...................................................................................................................................13 Problem Drug User Estimates for Birmingham...........................................................................................16 Client Profile Comparisons - National and Regional...................................................................................18 Drug Interventions Programme – Mandatory Drug Testing Data................................................................20 Section 5 - Treatment System Data and Mapping Exercises....................................................................23 Client Profile Data – by Local Service/Agency ...........................................................................................25 Agency retention data - new presentations and retention profiles..............................................................28 Dynamic mapping data – treatment referrals, transfers and exits during 2006/7........................................30 Section 6 - Additional Data Sources...........................................................................................................34 Drug Related Deaths – St Georges Hospital Data .....................................................................................34 Birmingham Treatment Effectiveness Initiative Data (BTEI).......................................................................37 Needle Exchange Data ..............................................................................................................................41 Supporting People Data .............................................................................................................................45 Dual Diagnosis Needs Assessment ...........................................................................................................47 University of Birmingham Addictions’ Research.........................................................................................48 Blood Borne Virus Data..............................................................................................................................51 Probation Assessment Data – eOASys......................................................................................................51 Hospital Episode Statistics – Public Health Observatory............................................................................52 Section 7 - Data Summary ...........................................................................................................................54 Section 8 - Expert Group Meetings.............................................................................................................55 Section 9 - Key Informant Interviews..........................................................................................................55 Section 10 – Needs Assessment Recommendations and Conclusions..................................................57
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Executive Summary This is the second annual Treatment Planning Needs Assessment conducted by Birmingham DAT as requested by the NTA and based on the data provided on population estimates and treatment activity. This means that, for the first time, the report can be used both to reflect on the activities in the previous year as well as conducting an assessment of the strengths and weaknesses of the current system. The method used is consistent with that developed in the first year, in which the data on estimated numbers of Problem Drug Users (using 2005 estimates from the Home Office) and treatment engagement data (from the National Drug Treatment Monitoring System) are supplemented with: •
Three meetings of an expert group to ratify the process and to provide feedback on the findings
•
Analysis of additional data sources available across the city
•
Key informant interviews at both city and local community levels
Among the major changes in Birmingham adult treatment services in the intervening year has been the introduction of the Birmingham Treatment Effectiveness Initiative (BTEI) as a method for improving the consistency of staff training and consequently the delivery of ‘evidence-based’ treatment in the city. The data provided in the report would suggest that the implementation of the initiative has been effective generally, and there is robust evidence that this has led to improved client engagement in key aspects of treatment, particularly among clients new to the treatment process. The second year of Glasgow estimates would indicate both a shift in the overall number of PDUs in the city and in the profile of PDUs. While the total number of estimated PDUs has risen, there are two changes with positive implications – first the number of injectors has dropped, and second, the number of 15-24 year olds identified has also gone down. This has positive implications for both public health (through reduced injecting) and may imply fewer young initiates into problem drug use. However, clear trend data will not be discernible until the third year’s data are available. In terms of the effectiveness of the treatment system, there remain difficulties in accessing and retaining particular risk populations including primary stimulant users (often initially identified through the criminal justice system), clients with co-occurring mental health problems and to provide adequate pathways for those completing treatment or returning to the community following prison release. The increase of drug-related deaths among out of treatment populations may also necessitate further peer based training in overdose management and in accessing vulnerable populations that treatment services do not retain, From a systems perspective, there is also indication that the system has overall blockages resulting in a lack of recovery pathways to abstinence and in providing appropriate links to housing and support services to complement specialist treatment. The key recommendations of the study are: Treatment Pathways 1. Identified system level needs highlight the importance of developing housing links to increase the provision of accommodation for homeless and vulnerably housed individuals particularly prison leavers and those who have recently become drug free. Operationalisation: we have the opportunity of measuring this in terms of Page 3 of 60
both the number of successful transitions to independent living and reductions in the number of homeless drug users identified through treatment services. 2. There is a need to examine and map the pathways for young people with substance misuse issues, both in YP specific services and those needing to make the transition to adult substance misuse services. Operationalisation: Assessment of numbers of transferred cases from young people to adult services engaged and successfully retained in treatment. Reductions in numbers of young people identified through criminal justice referral pathways. Audit of pathways for young people 3. The co-ordination of pathways for clients with a dual diagnosis need to be clarified and mapped to ensure appropriate identification of clients needing substance misuse treatment and support. Operationalisation: This would be mapped as a reduction in treatment dropout and clients being triaged only among those assessed as having psychiatric co-occurring disorders, and in increased rates of client overlap with adult mental health services. 4. There is limited information on the longer term outcomes of individuals who leave treatment ‘drug free’ (either community or Tier 4 residential) and who do not return to community treatment, therefore there is a clear need to map these clients and their outcomes and also to evaluate the existing aftercare provision in Birmingham. Operationalisation: consistent with the rationale for the new Tier 4 treatment centre, the measure of effectiveness here would be in rates of transition to independent living and employment, and reductions in ‘cycling’ back to treatment and criminal justice for those who complete recovery journeys. 5. Pathways need to be developed for young male polydrug users, particularly cocaine/crack users including the development of dedicated interventions to meet their needs. Operationalisation: this should be measured against numbers completing brief targeted stimulant interventions and by the rates with which they fail to reappear on DIR and/or NDTMS databases in subsequent years. 6. Effective pathways and information systems need to be developed to fulfil local and national requirements around Hidden Harm and the Safeguarding Children agenda. Operationalisation: improved identification of children and their needs (including parenting needs) assessed through audit and improved range and delivery of services and joint working with LSCC. Drug Treatment System 7. To develop further the mechanisms for recording and analysing needle exchange activity (and wider Tier 2 interventions) to ensure the coverage and availability of injecting equipment is at an optimal level to address the harms caused by injecting drug use in Birmingham. Operationalisation: successful recruitment rates into treatment tracked by needle exchange as referral source and recording of rates of treatment engagement among current users of needle exchange provision. 8. Increased impetus is required to consolidate the gains made in consistency of treatment delivery across the city. Although BTEI has been highly effective, its implementation remains inconsistent, and new manuals need to be added to improve treatment pathways. Operationalisation: to be measured by audits of rates of mapping in case files, rates of completion of assessment and follow-up instruments and successful completion rates for care plans and reviews. Evidence of use of increased suite of treatment manuals for improving evidence-based practice. Page 4 of 60
9. There are continued blockages for moving clients between Tier 3 services and through to Tier 4 services or exiting the treatment system, the appropriate commissioning of a new Tier 4 service in Birmingham will address some of these needs together with improved community detoxification provision for all individuals wishing to achieve abstinence from opiates. Operationalisation: Improved rates across all services of transition to abstinence-oriented treatments, leading to higher treatment completion rates. 10. Improved care planning is a necessity and the use of care plan reviews to map treatment needs. Operationalisation: Improved completion rates of care plans and reviews; increased evidence of completion rates for care-plan domains. 11. Appropriate training is needed in the identification of clients with both substance misuse and severe and enduring mental health issues including training around appropriate care pathways and interventions that can be utilised as part of an individual’s treatment journey. Operationalisation: measured in terms of successful referrals and inter-agency management of dual diagnosis clients. Staff survey on identification and management of co-morbidities. Criminal Justice 12. Safety net mechanisms for clients engaged in DIP/CJ routes need to be strengthened to reduce dropout and non-conversion of contacts to care-planned treatment episodes particularly for cocaine and crack users. Operationalisation: assessment of database overlap of treatment uptake by characteristics in DIP settings and uptake of treatment by prison release populations. Measurement of translation rates of outreach worker contact into successful re-engagement with DIP teams. 13. There is a need to address the transitional care of individuals leaving prison to increase engagement in community services and to reduce drug related deaths due to overdose or drug poisoning. Operationalisation: assessment of number of drug-related deaths and overlap with prison population. Improvement of data sharing to measure the relationship between DRD and prison release. Improved mapping of uptake of treatment provision in prison release cohort. Community Level 14. To develop community delivery of interventions including the involvement of local community groups who have specialist knowledge in relation to substance misuse and associated issues in their neighbourhoods. Operationalisation: Assessment of LDG treatment pathways and subsequent rates of referral to tier 2 and 3 services. 15. To continue to improve the links with Tier 1 services and non-commissioned community drug services to develop provision and pathways for client groups currently underrepresented in structured treatment. Operationalisation: Measurement of rates of referral and treatment engagement from tier 1 services and rates of effective community re-engagement of clients completing treatment.
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Section 1 - Background and Aims The second annual needs assessment process systematically explores and maps the needs and harms of the problem drug using (PDU) population in the Birmingham DAT and Community Safety Partnership area. This process is a strategic activity that will form an integral part of the partnership treatment planning process for 2008/09. The Treatment Plan outlines the methods local partnerships will employ to deliver the Government’s Drug Strategy, including the development of action plans to address the local needs identified during the a systematic annual needs assessment process. The findings of the needs assessment and resulting recommendations allow evidence based and ethical decisions to be made on how the needs of this client group can be most effectively met within the resources available to the DAT and partnership area. The National Treatment Agency guidance (2007) indicated that a needs assessment should identify the following: •
What works among those in open access and structured drug treatment and what the unmet needs are across the treatment system
•
Where the system is failing to engage and retain people
•
Hidden populations and their risk profiles
•
Enablers and blocks to treatment pathways
•
Relationship between treatment engagement and harm profiles.
In other words, it is an attempt to create an annual map of ‘what works’ in local treatment systems and to develop a method for identifying unmet local needs with a view to building these in to the treatment planning process. This is an ongoing process with each annual needs assessment based on a ‘change model’ to look at what has changed from the previous needs assessment and treatment plan and how well identified needs have been met. This year there has been an increased community level involvement in the need assessment process as a result of previously identified needs in this area to widen the focus of client and system level needs. Within the treatment system there have been some fundamental changes in delivery, firstly full implementation of the BTEI initiative has resulted in new methods for care planning and a revised performance management system for Birmingham substance misuse services. In addition the full implementation of the Criminal Justice ‘Tough Choices’ has increased the number of arrestees receiving mandatory drug tests or drug related assessments. Section two contains a summary of the key recommendations outlined in the previous needs assessment and the extent to which they have been addressed successfully.
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Section 2 - Update from the 2006 Annual Needs Assessment As a result of the 2006 needs assessment a set of recommendations were produced to inform the 2007/8 treatment planning for adult drug treatment services. These recommendations were reviewed as a measure of progress to date, below is an overview of this progress categorised by recommendation.
1.
Recommendation
Progress/Actions
To improve pathways into treatment for key CJ
Following a update of software used for the recording
populations identified in custody, and to increase the
of DIR data an action plan was drawn up to tackle:
translation rates from initial contact into structured
1. The engagement of ‘recreational’ drug users in
treatment episodes for those seen through Arrest
treatment through ARW processes and DIP
Referral
2. Guidance distributed to clarify reporting on CLIPS around the ‘opt outs’ in the new software system 3. The treatment status of positive testers and whether they are actually engaged in Treatment services 4. Clients receiving Tier 2 interventions should still receive a care plan with set goals This action plan has resulted in an upward trajectory of contacts with arrestees being converted to care planned treatment episodes. Further roll out of Test on Arrest during 2007, Tough Choices now fully implemented in Birmingham Plans for BTEI single session motivation work currently being piloted by the ARW’s
2.
To examine options for delivering care planned care
Work undertaken with services providing Tier 2
interventions in a wider range of contexts – in
interventions to ensure care planned clients are
particular through Tier 2 provision and through
inputted onto NDTMS.
engagement with Arrest Referral Workers.
Discussions with Tier 2 service and 5th CDT to participate in BTEI project.
3.
To develop appropriate aftercare provision for clients
New Tier 4 service currently being commissioned will
aiming to leave structured treatment and who require
include this aftercare component (tender process
a period of continuing drug related and non drug
completed plus specification and performance
related support, as part of a new ‘end of treatment
schedule).
journeys’ Tier 4 treatment pathway
Investigation into peer support groups such as
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SMART Recovery and further user and carer groups. Improved links with Supporting People to provide increased housing support services for substance misusers. 4.
To reconfigure the assessment procedure and entry
This recommendation is linked to the new Tier 4
points into inpatient detoxification and develop
service; work has been done on improving the access
rehabilitation provision to increase the numbers
points and understanding how clients enter treatment.
flowing through tier 4 services. Within this reconfigured system, we need to develop a method of
Current interim Tier 4 provision working effectively.
data recording that will enable the monitoring of outcomes from these services and the continuing client treatment journey out of structured drug treatment. 5.
To explore potential safety-nets and increased
DAT DVD and Treatment Directory/Outreach
outreach provision to engage drug users in treatment
directory to promote treatment access in Birmingham.
and re-engage clients who have recently dropped out
BTEI Pilot has continued throughout 2006/7
of treatment. Services must focus on re-engaging
DIP outreach work in Washwood Heath (in
clients who have dropped out of treatment and target
conjunction with Phoenix Futures)
those who fail to engage adequately with treatment
Increase in Tier 2 provision ARW work around translation rates and motivation There is a current pilot to facilitate the engagement of ‘High Crime Causing Users’ (HCCU) in drug treatment services through the criminal justice system.
6.
To increase the retention of clients vulnerable to
Supporting people are increasing the housing
dropping out of treatment with particular focus on
provision with support for drug users
BME (principally black and mixed race clients), non-
An extra nurse has been commissioned to build
CJ 18-24year-olds, vulnerably housed clients and
capacity at SAFE.
female sex workers.
Diversity discussions and action plan implemented Work carried out with community BME substance misuse services (providing both commissioned and non-commissioned Tier 2 services) around profile raising and communications to promote services available within the community.
7.
Build Tier 1 and Tier 2 links and awareness to
6 x 3 day training workshops aimed at Tier 1
increase referrals and translation into treatment
providers entitled “Working with problematic drug
episodes. Clear training programmes for Tier 1
users” have been delivered by the DAT.
providers and training for tier 2 workers to enable
Further training on harm reduction, offending
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8.
them both to deliver structured interventions and to
behaviour, sexual health behaviours have been
improve their links to tier 3 services.
delivered.
Improve early identification of young people misusing
Transitional protocol in place for YP services to adult
substances outside criminal justice and structure links
services
between YP and adult services more effectively.
Young People’s needs assessment has been undertaken and initial report completed. In addition a working group has been established to continue the needs assessment agenda within the Young People’s treatment system and improve data quality prior to the next annual needs assessment. Professional directory on DAT website for Tier 1 services to access information about substance misuse services. Targeted work with Tier 1 services and community Tier 2 BME services, profile-raising exercises.
9.
To develop and improve the treatment journeys for
Training to service staff around crack cocaine has
particular under-represented groups in an attempt to
been implemented to improve treatment pathways for
improve engagement, retention, and completion for:
primary stimulant users (based on work by COCA).
a.
Women
There has been an increased focus on diversity
b.
Asylum Seekers
across services and providers, with language and
c.
BME Groups
translator services now available in DIP teams. An
d.
Sex workers
outreach initiative is being run by Phoenix in
e.
Homeless drug users
collaboration with DIP in Washwood Heath.
f.
Crack-cocaine and other stimulant
A monitoring framework has been implemented for a
users
predominantly BME community drug service, currently not commissioned by the DAT to explore the profile of services users access these services. The DAT are currently investigating commissioning a Psychiatric Nursing post aimed at addressing the high level of Dual Diagnosis among clients seen by the Rough Sleepers Team.
10. To develop a mechanism within needle exchange
A current needs assessment is being carried out to
data collection for recording the treatment status of
assess levels of data and needle and syringe
clients using these services, and for linking data
coverage throughout the city.
collection and collation across community
New standard reporting forms are being implemented
pharmacies, Drugline and BSMHT. However, the
with the piloting of questions around treatment
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initial task is the development of a coherent
engagement and prescribing.
information strategy for needle exchange utilisation
Initiation of new mapping methods are currently being
and linkage to structured care planned care.
trialled.
11. To utilise DIR data to create a method for linking
DIP data team currently undertaking a piece of work
initial criminal justice contacts with client treatment
on this, data will be provided through the course of
status to enable clearer profiling of the criminal
the current annual needs assessment.
justice population against their engagement with the
Data matching and cross referencing has been
wider treatment system. To also have clear data for
maximised with NDTMS entries.
profiling the outcomes and onward treatment journeys for criminal justice clients.
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Section 3 - 2007 Needs Assessment - Methodology The overall process for the 2007/8 needs assessment involves the following key stages: • Establishing a local process to inform and drive the needs assessment (i.e. the Expert Group, who will meet three times over the course of the project) • Reviewing existing sources of information available at local, regional and national level and deciding the key questions that are to be asked at a partnership level for the current needs assessment exercise, starting with the treatment bulls eye and the pathways information provided by the NTA • Create a map of existing services and a description of the client profile across tiers and services • Identification of needs and harms among groups currently not in treatment from key informant information, and sources such as DIR and needle exchange monitoring systems • Understanding unmet need. Analysis and interpretation of local data and identified needs and harms, including discussion and challenge by the expert group(s), in order to draw initial conclusions. The emphasis will be on the identification of vulnerable groups who are either not accessed by treatment services, or who are not retained at the point of contact. • Evaluation and prioritisation. Completing a gap analysis and self assessment of the current state of both commissioning and drug treatment delivery systems and evaluating and prioritising the identified needs, harms and gaps, appraising the options for meeting those needs. This will continue the process of assessing the effectiveness of the treatment system and the extent to which it is seen to be ‘fit for purpose’ • Drawing up and implementing the adult drug treatment plan, including allocation of resources, and creating a framework for reviewing progress against the needs identified in the needs assessment process.
Birmingham in context - Census data Birmingham is a diverse and large metropolitan area with a population of 977,087 individuals (2001 Census Profile). Of this number 473,266 are male and 503,821 are female (48% and 52% respectively). The breakdown of ethnicity for residents of Birmingham can be seen below in table 3.1 with comparative rates for England and Wales combined. Ethnicity White Asian/Asian British - Indian - Pakistani - Bangladeshi Black/Black British - Black Caribbean - Black African Mixed ethnicity Chinese & other ethnic group
Birmingham total number 687386 190761 55774 104052 20847 59784 47798 6191 27928 11198
Birmingham % 70.4% 19.5% 5.7% 10.6% 2.1% 6.1% 4.9% 0.6% 2.9% 1.1%
England & Wales % 90.9% 4.6% 2.1% 1.4% 0.6% 2.3% 1.1% 1.0% 1.3% 0.9%
Table 3.1: Ethnicity groups displaying local numbers per category, percent, and national comparison.
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Religion (all census participants) Christian Buddhist Hindu Jewish Muslim Sikh Other No religion Religion not stated
Birmingham % 59.1% 0.3% 2.0% 0.2% 14.3% 2.9% 0.3% 12.4% 8.4%
England and Wales % 71.7% 0.3% 1.1% 0.5% 3.0% 0.6% 0.3% 14.8% 7.7%
Table 3.2: Religion of census participants by proportion for Birmingham and Nationally (England and Wales)
The age split of the Birmingham population is approximately in line with national averages; however Birmingham appears to have a higher proportion of 15-24 year olds and a smaller population of over 45 years olds compared to the national average. Age Group Aged 15 to 24 Aged 25 to 44 Aged 45 to 74 Aged 75 or over
Birmingham Number 132543 276803 270745 68155
Birmingham % 37% 28% 28% 7%
England & Wales % 31% 29.4% 32.1% 7.5%
Table 3.3: Age groups with total local numbers per group, percentage and national comparison
Within the nationally produced Index of Multiple Deprivation (2004), Birmingham has 243 (37.9%) super output areas (SOA’s) which are within England’s top 10% of most deprived areas. When looking at primary care trust areas (PCT), the most deprived area is the Heart of Birmingham PCT where just under three-quarters of the SOA's within the Trust’s boundaries are amongst the most deprived in England. Its neighbouring trust, East Birmingham is the next most deprived with 45.7% of its SOA’s among the most deprived category.
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Section 4 - Findings from Core Local Data Sources (NDTMS and DIP) Data were analysed using a range of methods including the treatment bullseye and treatment system mapping methods. A description of these methods, the data and findings are presented below and consist of the following: •
Treatment bulls eye data for Birmingham
•
Description of PDU estimates (known as the Glasgow estimates)
•
Client profile data – comparisons against the West Midlands region and nationally
•
Client profile data – by service provider/agency
•
Treatment system data
•
o
Static mapping data – treatment episodes in 2006/7
o
Dynamic mapping data – treatment referrals, transfers and exits during 2006/7
DIP and Police/Arrest Referral data
Treatment Bulls-eye The first task of the needs assessment process was to collect data from a number of local sources, based primarily on NDTMS and DIP data. Data were analysed though a ‘treatment bulls-eye’ mapping system in order to plot current and recent treatment engagement in addition to mapping the profiles of problem drug users in and out of Tier 3 and 4 treatment. The term problem drug user is defined as opiate and/or crack cocaine users and therefore this is the population profiled below. Figure 1 below illustrates the data for total numbers of clients in treatment at some point in the last three years (April 2004- March 2007). This diagram illustrates the engagement of clients from last year’s needs assessment data (on the left of the diagram) and new data for this year (on the right). 2006 Needs Assessment (05/06 data)
2007 Need Assessment (06/07 data)
3474
3913
1444
1264
846
911
410
In Tx now (31.03.07)
1113
In Tx in last year Known to Tx but not treated in the last year (i.e. treated in 05/06 but Not known to Tx but in contact with DIP
Figure 4.1. Number of PDU’s reported to NDTMS during 2005/6 and 2007/8 segmented by treatment status.
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The diagram above illustrates the increase in 2006/7 in the number of PDU clients stably retained in structured drug treatment (in the centre of the bullseye). There is also a large increase from 2005/6 to 2006/7 in the number of clients accessing DIP (in the outer rings of the bullseye); this demonstrates the impact of the Drugs Interventions Programme and wider criminal justice initiatives to engage drug users in treatment. These data for 2006/7 and further sources of data are reviewed and form an overall picture of the problem drug using population and their engagement in structured treatment in Birmingham. The data utilised for the bullseye method from NDTMS data are categorised by the following definitions: •
Drug Groups (i.e. opiates) – The number of individuals that have the named drug(s) in any of their recorded substances, an individual with two drugs recorded will be reported in the column for each of drugs. Opiate and/or crack users is where an individual had either an opiate/crack cocaine or both substances recorded
•
Gender - The gender distribution of individuals
•
Ethnicity - The ethnic distribution of individuals
•
Age Group - The age range of individuals. The age is calculated at the midpoint of the financial year.
•
Injecting status – The individual had been recorded as previously, currently or never injecting at the point of triage.
Further PDU client profile data has been analysed (see table 4.1 below) demonstrating changes in engagement patterns of clients over the last three years. Table 4.1 compares the profiles of PDU clients by treatment status during 2005/6 and most recently 2006/7 (for opiate and crack cocaine users only); therefore providing a comparison of data from last year’s needs assessment.
Treatment (Tx) Status
A In Tx on 31.03.07
Total Number of PDU 2005/6 2006/7 3474
3913
1444
1264
846 treated in last year 410 D Known to DIP but not Tx services Total in treatment per year 4918 (A+B) *For DIP Clients the age group is 18-24
911
B
In Tx during past year
C Known to Tx but not
1113 5177
Gender - Female 2005/6
2006/7
894 (26%) 327 (23%) 212 (25%) 61 (15%) 1121
1019 (26%) 284 (22%) 190 (21%) 157 (14%) 1301
15-24year age group* 2005/6 2006/7 786 (23%) 366 (25%) 195 (23%) 145 (35%) 1152
696 (18%) 274 (22%) 186 (20%) 275 (25%) 970
Current Injectors
BME
2005/6
2006/7
2005/6
2006/7
438 (13%) 166 (11%) 127 (15%) -
484 (12%) 150 (12%) 112 (12%) -
890 (25%) 367 (30%) 51 (25%) -
604
634
856 (25%) 394 (28%) 211 (26%) 141 (34%) 1250
Table 4.1. Opiate and/or crack cocaine user characteristics (PDU’s) by drug treatment engagement and retention for 2005/6 and 2006/7.
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1308
The table above demonstrates the following key changes: • There was an increase in the number of PDU (opiate and/or crack cocaine users) accessing treatment during 2006/7 compared with the previous year i.e. there was improved treatment penetration rates and increased numbers in treatment. • The increase in DIP clients in the ‘total number of PDU’ column highlights the impact of the introduction of the CJ routes into treatment. • The gender split for male and female engagement in treatment demonstrates that females are still underrepresented in the DIP population; however the data for females across the treatment system suggests that females are more likely to be retained in treatment than males. • With regards to the age of clients accessing structured treatment there has been a reduction in the number and proportion of 15-24 year olds engaged in treatment compared to older drug users (on both the 31.03.07 and during the previous year). Conversely, there has been an increase in the number and proportion of older PDU accessing structured treatment. • For BME clients there has been a reduction in the number of Asian and Asian British clients engaged and retained in treatment, for example 487 clients were engaged in treatment on 31.03.06 compared to 466 engaged in treatment on 31.03.07; this reduction also extends to those engaged during the financial year (206 clients during 2005/06 and 188 clients during 2006/7). • However the number of Black and Black British clients has increased both on a particular day and in the previous year (see figure 2 below), therefore the picture for BME clients is mixed with comparative rates across the two needs assessment periods showing little differences for BME clients when grouped together.
Chart 4.1. Engagement and retention of clients with ethnicity recorded as Asian, Black and Other during 2005/6 and 2006/7.
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Problem Drug User Estimates for Birmingham When reconciling the bulls eye data against the estimated populations of heroin and crack cocaine users (derived from the Home Office commissioned work on epidemiology, known as the ‘Glasgow estimates’) we can build a basic picture of the potential ‘hidden’ PDU population or those not engaged in Tier 3/4 drug treatment during the last two years. However, it is important to note that the PDU estimates have not yet been confirmed by the NTA, the data also refer to data obtained for the 2005/6 reporting period, and therefore they do not necessarily reflect the same population who could be active during the 2006/7 period. This figure is calculated as follows:
Glasgow estimate of PDU in Birmingham:
13,543
Minus - in treatment ‘now’:
- 3913
Minus - in treatment at some point in the last year:
- 1264
Minus - known to treatment, but not treated in last year
- 911
Total estimate for population ‘unknown to structured Tier 3 treatment’
7455
The estimated ‘unknown to structured Tier 3 treatment’ figure above includes those clients who may be engaged with the Tier 2 services (for example DIP and Addaction) and not receiving structured interventions that would result in them being recorded on NDTMS. Table 4.2 below gives an illustration of the most recent Home Office estimates based on total PDU’s, segmented by age, substance type and injecting status. The table includes the estimated prevalence rate per 1000 of the population in Birmingham and also the difference between the estimates published last year (based on 04/5 data) and those published this year (based on 05/06 data). It should be noted that for all estimates there is a large confidence interval reported and therefore the figures quoted in the ‘Estimated Number’ figure should be interpreted with caution when used to quantify the number of users in each reported category.
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Birmingham DAT prevalence estimate figures for: Total estimated number of problem opiate and crack cocaine drug users (15-64yrs) Prevalence rate per 1000 population
Estimated Number 13,543
10,573
16,696
Difference (between 04/05 and 05/06 estimates) +1,678
20.7
16.19
25.57
+2.29
12,600
10,039
15,398
+1,064
Prevalence rate per 1000 population
19.3
15.38
23.58
+1.36
Crack cocaine users aged 15-64
8,489
6,212
10,701
+1,161
13
9.51
16.39
1.61
2,206
1,007
3,512
-689
3.4
1.54
5.38
-1.12
Opiate and/or crack cocaine) users aged 15-24
2,861
2,183
3,516
-652
Prevalence rate per 1000 population
17.4
13.27
21.37
-4.55
Opiate and/or crack cocaine) users aged 25-34
6,415
4,920
7,982
+1,201
Prevalence rate per 1000 population
44.1
33.81
54.86
+7.81
Opiate and/or crack cocaine) users aged 35-64
4,267
3211
5,399
+1,129
Prevalence rate per 1000 population
12.4
9.36
15.75
+3.19
Opiate users aged 15-64
Prevalence rate per 1000 population Drug injectors aged 15-64 Prevalence rate per 1000 population
95% CI
Table 4.2. Glasgow prevalence estimates by characteristic including rates per population, confidence intervals and changes by year.
The above table illustrates some interesting changes in the estimated number of PDU’s. Firstly the estimated number of injecting drug users has decreased to 2,206 (from 2,895 in 2004/5), while there is also a drop in the estimated number of 15-24 year old PDU’s (down 652 to 2,861) indicating a drop in ‘new’ problem drug users. When assessing the changes in the West Midlands region (see table 4.3 below) it can be seen that some DAT areas have an increase in their estimated number of PDU and some areas have a decrease. Estimates
Total PDU
Birmingham Coventry
Change Rate per Crack Change IDU Change 15- Change from 1000 Cocaine from from 24yrs from 2004/5 population 2004/5 2004/5 2004/5 13,543 +1,678 20.74 8,489 +1,161 2,206 -689 2,861 -652 2,282 +411 11.29 1,120 +66 891 +327 392 -27
Dudley
2,026
+181
10.25
988
+78
931
-21
731
+56
Sandwell Solihull Staffordshire Walsall Wolverhampton
1,918 950 2,995 1,912 2,258
-523 -112 +20 -10 -662
10.43 7.39 5.56 11.93 14.54
1,353 666 1,522 1,328 1,690
-310 +173 +10 -19 -183
480 202 1,665 702 588
-298 -46 +261 -15 -243
627 294 690 699 841
-245 -44 -206 -57 -241
Table 4.3. Comparisons of prevalence estimates and rates per 1,000 populations by DAT area.
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The Glasgow data are a useful indicator of overall PDU populations but there are wide ‘confidence intervals’ and the data are older than the rest of the information used in the needs analysis and so need to be treated with some caution. They are most useful as indicators of trends and this will be clearest when the third year of data commissioned by the Home Office are available for the 2009 needs assessment. Furthermore, because the definition of ‘problematic’ uses a low threshold, this does not equate to the population who are likely to benefit from engaging with adult treatment services. What they show is that Birmingham has the highest rate of PDU per 1,000 people in the general population with Staffordshire having the lowest (5.56 per 1,000). Whilst there have been varied increases and decreases in estimates for the total number of PDU, the majority of areas quoted below have reduced estimates for the number of IDU and younger PDU (under 25 years). There also appear to be drops in the numbers of identified injectors in neighbouring DAT areas (Solihull, Sandwell and Dudley) suggesting that this may be a more robust trend. This perhaps suggests a regional reduction in the number of younger PDU captured during the methods used to estimate problem drug use.
Client Profile Comparisons - National and Regional Treatment retention and client profile data from NDTMS for Birmingham show some variations from the national percentages. Comparisons can be carried out to look at the variation between local, regional and national characteristics to understand who we are providing services for and how our client group compares to the national profile from the NDTMS returns.
Birmingham Regional (WM) National
New presentations 2449 8675 80106
% Retention CJS 49% 1952 40% 6590 29% 60073
%
Retained <12wks 80% 447 76% 1662 75% 14941
% 18% 19% 19%
Triaged only
%
50 2% 423 5% 5092 6%
Table 4.4. New presentations to structured treatment and retention rates compared locally, regionally and nationally.
The table above illustrates that Birmingham has a higher proportion of new presentations into drug treatment through the criminal justice route (Birmingham 49%, National 29%). The retention of clients for over 12 weeks is slightly higher in Birmingham when compared to the regional and national retention rates, with the dropout rates within the first 12 weeks being broadly the same across the three measurement areas. There are low rates in Birmingham of clients receiving triage only, in other words clients presenting who do not go on to complete a comprehensive assessment and care plan. The profile of clients (based on age, gender ethnicity etc) in Birmingham can be compared to the West Midlands region and nationally to look at the proportion of clients engaged within each area. Client profile comparisons demonstrate that the number of male clients in structured treatment is 3% higher for men in Birmingham than the national percentage (77% Birmingham, 74% nationally). This figure is consistent with the previous year with 76.8% of new presentations to treatment being male compared to 73.7% nationally in 2005/06. Page 18 of 60
Birmingham has a higher proportion of under 25 year-olds and 25 to 34 year-olds compared to the national figures (24% Birmingham, 21% nationally), while the proportion of new presentations over the age of 35 is significantly lower for Birmingham than the national proportion. This is illustrated in table 4.5 below. This could reflect the census information reporting a higher number of young people in general in the Birmingham area and not a difficulty in engaging older drug users in treatment.
Overall age group Under 25 Birmingham 597 West Midlands 2303 National 16663
% 25 - 34 % 35+ % 24% 1170 48% 682 28% 27% 4179 48% 2193 25% 21% 35972 45% 27471 34%
Table 4.5. Overall age group comparisons of new presentations to structured drug treatment during 2006/7.
The ethnicity breakdown of clients in treatment continues to reflect Birmingham’s ethnic diversity with a higher percentage of BME clients and lower percentage of white clients when considered nationally (table 4.6 below) is consistent with last year’s data and consistent with the census information for the general population in Birmingham. Ethnic group Birmingham West Midlands National
Mixed % Asian % Black % White % Other % 186 8% 320 13% 199 8% 1682 69% 30 1% 350 4% 620 7% 327 4% 7221 83% 47 1% 2167 3% 3187 4% 3731 5% 66681 83% 1018 1%
Table 4.6. Ethnicity comparisons for new presentations to structured drug treatment during 2006/7.
The retention of clients categorised by ethnic group illustrates that Birmingham is able to retain clients from different ethnic groups more successfully when compared to the retention rates of the treatment system nationally; this is illustrated in table 4.7 below, although variations may reflect different drug use profiles. Retention by Ethnic group Birmingham West Midlands National
Mixed retained 156 271 1596
% 84% 77% 74%
Asian retained 252 447 2300
% 79% 72% 72%
Black retained 137 224 2613
% 69% 69% 70%
White retained 1349 5520 50403
% 80% 76% 76%
Other retained 29 42 722
% 97% 89% 71%
Table 4.7. Retention of clients in structured treatment during 2006/7 categorised by ethnic group.
New presentations categorised by their reported main drug illustrates the similar proportion of clients reporting with opiates or crack only as their presenting problem when accessing treatment, and this is also the case for cannabis compared with national figures. However the proportion of ‘opiate and crack cocaine’ users is higher in Birmingham than nationally (31% compared to 22%). New client presentations who identify their main drug type as being ‘other
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stimulants’ (e.g. amphetamine) also differ with Birmingham having proportionally less ‘other stimulant’ users entering treatment. These data are presented in table 4.8 below. Overall drug group Birmingham West Midlands National
Opiates only 1178 4528 38118
% 48% 52% 48%
Crack only 133 333 4899
% 5% 4% 6%
Opiates & Crack 770 2403 17613
% 31% 28% 22%
Other stimulant 174 628 9298
%
Cannabis
%
7% 7% 12%
169 670 7524
7% 8% 9%
Table 4.8. New client presentations into structured drug treatment categorised by main drug use recorded during the assessment process.
Drug Interventions Programme – Mandatory Drug Testing Data Mandatory drug testing from the ‘Test on Arrest’ scheme has provided data on 3,243 positive tests across Birmingham between April and November 2007. Offenders were tested for heroin, crack and cocaine when arrested for acquisitive crimes, such as robbery or burglary. Of these individuals, those who tested positive were subject to a required assessment completed by a drugs worker or arrest referral worker and if deemed appropriate, allocated to a programme of support within the Drug Intervention Programme (DIP). The following is a summary of the most significant findings from the analysis performed on these data specifically for the needs assessment. Demographics The test results were categorised into 3 groups: opiates and cocaine, opiates only, or cocaine only with the majority of individuals testing positive for cocaine and opiates (n= 1451, 45%), cocaine only (n=1278, 39%) and opiates only (n=514, 16%). The testing procedures were not able to differentiate between cocaine and crack and therefore a positive cocaine result could be for either drug. These test results are broken down by age and substance type in table 4.9 below.
Age Group 18-24 years 25-34 years 35 and over Total (by result)
n= % n= % n= % n= %
Cocaine
Opiates
Cocaine & Opiates
508 52.5% 450 31.7% 262 37.6% 1220 39.5%
114 11.8% 250 17.6% 118 17% 482 15.6%
346 35.7% 721 50.7% 316 45.4% 1383 44.8%
Total n= (%) 968 (31.4%) 1421 (46.1%) 696 (22.6%) 3085
Table 4.9. ‘Test on Arrest’ drug screens by age and test result
Table 4.9 above illustrates the higher proportion of younger stimulant users testing positive under the test on arrest initiative (31.1% of all positive tests were for cocaine in arrestees under the age of 35). Polydrug use - defined as both cocaine and opiates - is also more prevalent amongst the under 35 year olds (34.6% of total positive tests). Opiate Page 20 of 60
only use has the lowest number of positive tests across all age groups (n=482, 15.6%). Based on locality of the DIP treatment service, initial contacts made at DIP North and DIP South were more likely than the other DIP teams to test positive for cocaine and less likely to have opiate only or both opiates and cocaine positive test results (Ď&#x2021;2 = 23.06, df = 6, p = 0.001). The ethnicity of clients when grouped by test result (chart 4.2 below) illustrates there are significant differences between ethnic group and positive test by substance. When compared by ethnicity, Black arrestees were more likely than other ethnic groups to test positive for cocaine only (51% of all black arrestees tested), Asian clients were more likely to test positive for opiates only than other ethnic groups (Ď&#x2021;2 = 74.6, df = 10, p <0.0005).
*Figures in the bars relate to number of positive tests by substance and ethnicity
Whilst there were no gender differences amongst individuals testing positive for opiates only, males were more likely to test positive for cocaine only and females more likely to test positive for opiates and cocaine (Ď&#x2021;2 = 28.78, df = 2, p <0.001).
Chart 4.3. Gender comparisons between arrestees testing positive cocaine, opiates or both substances Page 21 of 60
Required Assessments Of the 3243 positive tests recorded, 1685 (52%) were deemed not to need a follow up assessment by the worker carrying out the initial assessment (a further 50 were already on a DRR). Of the total arrestees who tested positive and were required to attend an assessment 1,780 (92%) attended and remained for the entire assessment (from a total of 1,937). Workers were more likely to decide that cocaine positive arrestees did not require further intervention (49% cocaine compared to 14% for opiate users and 37% of opiate and cocaine users) therefore no follow up assessment was conducted (Ď&#x2021;2 = 10.81, df = 2, p = 0.005). Care Planned Care Following the required assessment, 758 cases were translated into a care planned programme of substance misuse support (a translation rate of 23% of the total number of positive tests) of this number the gender, ethnicity, and age of clients are proportionately similar to the demographic breakdown of all recorded positive tests. However, arrestees testing positive for cocaine were significantly less likely to be translated into a care planned episode of substance misuse treatment or support than arrestees with positive opiate test results (Ď&#x2021;2 = 10.81, df = 2, p = 0.005). The translation rate for initial contacts to care-planned care taken from DIP monthly reports (January to December 2007) demonstrates a translation rate of 47% per month when averaged over the year and may give a more accurate picture of the number of assessments resulting in a careplan. The average number for each element of the test on arrest and required assessment scheme are illustrated in table 4.10 below. Drug Intervention Records Completed (Jan â&#x20AC;&#x201C; Dec 2007) All Contacts Initial Contacts Required Assessments Further Intervention Needed Careplans Contact to Careplan translation rate (%)
Average monthly number 411 77 334 234 195 47%
Table 4.10. Average monthly activity for drug intervention records and translation rates from initial contact to formal care planning
In summary, there are a large number of arrestees captured through the test on arrest initiative who test positive for cocaine (and/or crack cocaine) or polydrug use (cocaine and opiates), within the DIP population these users tend to be male and show a higher representation of BME clients than the NDTMS treatment population. Whilst this stimulant using population of drug users do attend the required assessment (and remain for the duration of the assessment) they are typically not further engaged in DIP substance misuse treatment or support. This non-engagement could be due to a lack of pathways and dedicated interventions for polydrug or stimulant users; therefore the current treatment available is seen by both users and workers to be inappropriate for this client group.
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Section 5 - Treatment System Data and Mapping Exercises An aspect of the comparative element of the needs assessment is the creation of a number of treatment system maps as a method of charting the provision of treatment available in the city and linking this to the progression of clients through treatment journeys. The NTA have provided the DAT with referral, retention and discharge data for each adult drug treatment service commissioned during the last two years. These data allow us to plot the movement through the system of new presentations during 2006/7 including their entry, length of treatment, transfer, and exit from the treatment system. As with the previous needs assessment process, the treatment maps can be utilised firstly to illustrate a static picture of the treatment system, i.e. who is in treatment on a particular day; and secondly a dynamic picture by demonstrating the flow of clients through the system enabling identification of the existing blockages and pathways within the system and how this compared to last yearâ&#x20AC;&#x2122;s mapping processes. The usefulness of the tiered system outlined below was discussed at length in the Expert Groups. Figure 5.1 below represents the basic shape of the current treatment system based on the Models of Care (2004, 2006) tiered framework.
Figure 5.1. A basic representation of the current adult drug treatment system in Birmingham
This map aims to identify the services that provide interventions within this tiered framework. For example if a generic service acts as a referral source into a tier 2 service or structured tier 3 treatment they would be regarded as a tier 1 service (e.g. housing) a fuller description of the tiered framework can be found in Appendix 1, although it is important to note that Models of Care (NTA, 2002) specifies that the tiers should refer to functions rather than services and so individual providers may well offer services across a range of tiers of treatment.
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Static mapping data – treatment episodes in 2006/7 The second map detailed below (figure 5.2) aims to identify the number of clients in treatment during 2006/7. Firstly to see how many clients presented as new treatment episodes (recorded on the map as ‘new’) and how many were existing clients from the previous year (‘existing’) to understand how many people are in the system at any one time and where they are within this system.
Figure 5.2. Static treatment systems map illustrating the segmentation of clients in treatment as new or existing clients in 2006/7
The map in figure 5.2 above indicates the high proportion of Birmingham treatment clients who are engaged in either Tier 2 criminal justice services or in shared care treatment provision within the city, with the number in shared care treatment exceeding those in community drug treatment provision. Additionally, the chart has identified community drug teams (Azaadi, Slade Road, Terrace and Mary Street) have a higher number of clients remaining in their service for some time, well over the 12 week retention target. Nonetheless Figure 5.2 would suggest a dynamic picture in Tier 3 services with only 1,248 existing clients recorded, in contrast to more than 4,000 new cases accessing treatment. Last year’s needs assessment suggested that around 344 drug users were engaged in the DIP process, with a further 165 in DRR and around 150 in criminal justice treatment with Drug Solutions Birmingham, primarily those users identified as Prolific and other Priority Offenders (PPOs). This year the numbers reported from NDTMS indicate in the region of 1,390 new clients across the DIP services and 680 new clients in DRR, although this does not refer to the numbers in contact on any given day. The implications this has for movement through the system are discussed below in the context of the dynamic treatment mapping process. More information is needed on both previous treatment histories and on discharge reasons before inferences can be reached about the effectiveness of this treatment uptake pattern. Page 24 of 60
Client Profile Data – by Local Service/Agency The data provided by the NTA allows comparison across the commissioned services in Birmingham providing Tier 3 and 4 interventions; although it does not allow statistical analysis it does enable some description of the differences between services. Below is a summary of the data for clients categorised by treatment status. Treatment status for this particular analysis is categorised into clients with a treatment episode beginning in 2006/7 and those with a continuing treatment episode (beginning in a previous year and continuing into 2006/7). Clients in treatment during 06/07 Information on the number of clients accessing structured treatment by service were provided by the NTA in aggregated form, which enable comparisons of the profile of clients engaged at each service and how this reflects local and specialist knowledge. The gender ratio of clients across the services is broadly consistent with the bullseye analysis reported earlier in this report. The majority of services reported a 70/30 male to female ratio (range 70-81% males and 19-30% females). The age breakdown of clients demonstrated some more noticeable differences across structured treatment services. Within the DIP North team there was a higher proportion of 18-24 year old clients than in other services (31% of all clients at DIP North), in contrast DIP East had the highest proportion of 25-34 year old clients (57% of all clients engaged at DIP East) and Mary Street CDT had the highest proportion of 35-64 year olds engaged in structured treatment (44% of all clients). Given the attempt at ‘net widening’ we would expect to see more people in the younger age group coming through the DIP teams, and this is reflected in all of the criminal justice teams. These age breakdowns are presented in chart 5.1 below.
Chart 5.1. Clients in treatment during 2006/7 categorised by service and age group
Further investigation of the data for individuals in treatment during 2006/7 demonstrates the wider diversity of clients in treatment at The Terrace CDT in Handsworth (57% white referrals and 25% Asian) and the Heart of Birmingham DIP team (55% white, 22% Asian). In contrast, South Birmingham DIP and Slade Road CDT have a high proportion of Page 25 of 60
white referrals (85% and 83% respectively). This may reflect the geographic location of these drug services and not necessarily a gap in attracting individuals into treatment from different ethnic groups. Chart 5.2 below graphically illustrates the ethnicity of clients engaged in structured treatment during 2006/7.
Chart 5.2. Clients in treatment during 2006/7 categorised by service and ethnicity
Whilst opiates were the predominant primary substance used by individuals in treatment during 2006/7 there are some differences within services. DIP North, DRR and Mary Street CDT have a higher proportion of cocaine users engaged in their services (12%, 10% and 8% respectively), whilst Azaadi CDT, The Terrace CDT, and DSB had higher proportions of opiate users (92%, 91%, and 91% respectively). DIP HoB, DIP East and DIP South had the highest proportion of crack cocaine users engaged in their services, however across all services the proportion of crack users ranged from 0% in DRR to 11% in DIP HoB. Chart 5.3 below represents the recorded substances of those referred engaged in structured treatment and DIP/DRR services during 2006/7. The ‘Other’ category refers to amphetamines, benzodiazepines and/or the NDTMS unspecified category of ‘other’.
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Chart 5.3. Clients in treatment during 2006/7 categorised by service and substances used
The data from treatment services do not match those from criminal justice where there is a markedly higher rate of primary cocaine users and increased qualitative reporting around higher levels of problematic powder cocaine use. There remains a problem with recruiting and retaining primary stimulant users, particularly those who are earlier in their drug using careers and who do not also use opiates, that is reflected both in the disparity in primary crack use between DIP teams and CDTs in Figure 5.3, but more markedly in the failure to engage cocaine users into any form of structured treatment, at least relative to uptake rates for primary opiate users. This reflects the prescribing focus of the majority of treatment providers in the city and ongoing difficulties with the consistent delivery of psychosocial interventions. Birmingham has a reported low rate of injecting drug use in the city among those engaged in treatment and across the PDU population, this notion is supported by the injecting status of clients engaged in drug treatment with 12% of those engaged during 2006/7 classifying themselves as current injectors and 16% as previous injectors (58% were reported to have never injected and 14% were unknown). Across the services in this analysis there are some variations in the proportion of IDU engaged in treatment, for example 26% of Drugline clients were recorded as current injects compared to 9% of clients at Slade Road CDT. The highest proportion of clients who report previous injecting were from Slade Road CDT (29%) and the lowest at DIP East (11%). However, 72% of clients at DIP North were reported to have never injected compared to 56% at DIP South. These findings are presented in chart 5.4 below.
Chart 5.4. Clients in treatment during 2006/7 categorised by service and injecting status
Specific needs assessment work is underway assessing needle exchange utilisation to improve our understanding of the uptake of needle services and the implications for the adequacy of treatment provision and the â&#x20AC;&#x2DC;coverageâ&#x20AC;&#x2122; of injectors provided by both structured treatment and lower threshold services. Page 27 of 60
Agency retention data - new presentations and retention profiles In an attempt to assess the retention of clients in the treatment system we can use the aggregated data from NDTMS categorised by treatment service. These data have been provided for new presentations only during 2006/7 and provide a picture of treatment retention based on service type, with consideration needed when comparing these numbers across services due to the varying profile of clients seen at each service and the type of service provided (i.e. Drugline versus DIP services). Figure 4 below provides the breakdown of new presentation at each service listed in the NDTMS needs assessment data.
*Data for Drugline does not include Vulnerable Services or Rough Sleepers Service data. Figure 5.3. Number of new presentations (and % of total) at each service providing structured interventions in Birmingham in 2006/7.
Within the new presentations we are able to assess the proportion of clients retained for more than 12 weeks, chart 5.5 below illustrates the high retention of clients at the SAFE project and reflects the small caseload and intensive service provided to this vulnerable group of women. Within the DIP services there is between 63% and 76% retention of new clients and between 74% and 88% in the Community Drug Teams (CDTâ&#x20AC;&#x2122;s). Drugline has a retention rate of 42%, however this does not include data for the Vulnerable Services and Rough Sleepers service elements of Druglineâ&#x20AC;&#x2122;s provision.
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Chart 5.5. Retention rates of new presentations only by service for 2006/7
These rates reflect the diversity of clients within the treatment system with high rates of retention amongst the clients engaging at DSB where the profile of the client would be perhaps more stable and almost certainly be in receipt of a substitution therapy prescription which could be argued was a protective factor for retaining these clients in treatment. In contrast, the clients in DIP services may be more complex cases in terms of offending behaviours and criminal justice activity (prison), not having a substitution prescription and being younger in age. The new clients who were not retained for more than 12 weeks were classified as retained for ‘less than 12 weeks’ i.e. dropped out in the first 3 months of treatment or ‘triaged only’ i.e. they only received an initial assessment. The majority of services had very few triaged only clients (Azaadi – 1%, Phoenix – 6%, and DIP East – 1%), suggesting low rates of attrition relating to the assessment and induction process into treatment. However, Drugline has a 44% triage only rate, this perhaps reflects the profile of their clients and the drop-in and instant access nature of the service, therefore this is not necessarily a poor reflection on their ability retain clients. The retention of clients for less than 12 weeks is illustrated in chart 5.6 below and demonstrates the higher rate of client drop out in DIP services compared to other treatment services in Birmingham.
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Chart 5.6. Proportions of new presentations (by service) that are retained for less than 12 weeks during 2006/7
These data need to be judged with caution, as stated earlier the profile of clients accessing each service differs between services and therefore comparisons cannot necessarily be made between certain services. However these data do allow comparisons between similar services (for example DIP services) and do to some extent enable conclusions to be drawn around the provision of services to particular client groups.
Dynamic mapping data – treatment referrals, transfers and exits during 2006/7 The third type of treatment map that has been generated attempts to illustrate the number of clients referred into each service and those who are discharged from the system. In the NTA guidance on needs assessment, this is defined in terms of movements of users through services to assess treatment pathways, and reflects the effectiveness of the overall treatment system rather than individual providers. The treatment system map is a graphical representation of a treatment pathway for an individual or for groups of individuals. The map aims to plot how clients move through three stages of their treatment journeys: •
System Entry – the referral routes into treatment
•
Movement within the system – clients moving between agencies
•
Exiting the system – clients discharging from structured treatment
Understanding this process is critical within the requirements of the new Drug Strategy (HM Government, 2008) in which there is increased emphasis on the successful completion of treatment as a key component in social reintegration. The treatment system map aims to identify where the blockages are in the system and where clients are at the greatest risk of dropping out and failing in treatment services. This is the process of creating an initial data based Page 30 of 60
process for identifying where safety nets are likely to be needed and what aspects of the system structure are not facilitating either client choice or client movement through the services based on their planned treatment journeys. From a systems perspective, the essence of the tool is to identify flows, but also to assess the adequacy and effectiveness of entrance points to the treatment system, unintended drop out points, planned exit routes and safety nets for those who drop out from within or between interventions. Chart 5.7 below begins by demonstrating the number and proportion of clients referred to structured treatment by four condensed referral types Self Referral, General Practitioner, Criminal Justice, and Other.
Chart 5.7. Referral sources and number of referrals by treatment service (2006/7 data)
When comparing the referral sources of clients referred into structured treatment during 2004/05 and 2005/6 it is clear that there are some differences in referring patterns but these have remained broadly stable across the two time periods. The chart above illustrates that BSMHT Community Drug Teams have a high proportion of self referrals (between 73% and 84%) compared to DIP services, and conversely DIP services have a higher proportion of CJ referrals (between 64% and 81%) and almost a quarter of referrals into DIP services are self referrals. As would be expected DSB has proportionately more referrals from GPâ&#x20AC;&#x2122;s who are referring their patients for the support provided by DSB drug workers as part of the shared care scheme(46% of all DSB referrals). Unfortunately due to the way the data are provided it has not been possible to conduct statistical analyses on this dataset, therefore we are unable at this time to assess the treatment journeys of clients referred from the four referral sources to assess retention and discharge reasons. From the dynamic system map we can attempt to identify flows, assess the adequacy and effectiveness of entrance points to the treatment system, unintended drop out points, planned exit routes and safety nets for those who drop out from within or between interventions. The following diagram illustrates these key points by service (figure 5.4 below). Page 31 of 60
Spot purchased episodes/non-commissioned services
Slade Road Referrals R eferrals – 160 Planned – 9 Unplanned – 73 Referred on - 10
Terrace CDT Referrals – 142 Planned – 11 Unplanned – 76 Referred on - 19
DRR Referrals – Planned – Unplanned – Referred on -
Mary St CDT Referrals – 124 Planned – 14 Unplanned – 62 Referred on - 12
DIP (N) Referrals – 118 Planned – 16 Unplanned – 48 Referred on - 15
Gordana House Episodes – 15 Planned – 0 Unplanned – 6 Referred on - 0
Azaadi CDT Referrals – 121 Planned – 0 Unplanned – 65 Referred on - 12
DIP (S) Referrals – 205 Planned – 10 Unplanned – 71 Referred on - 16
Addaction
Broadway Lodge Episodes – 21 Planned – ? Unplanned – ? Referred on - ?
ADAPT Episodes – 5 Planned – ? Unplanned – ? Referred on - ?
Church Road Episodes – 103 Planned – ? Unplanned – ? Referred on - ?
Mother & Baby
Phoenix Daycare
Zephyr Daycare
Referrals – Planned – 6 Unplanned – 0 Referred on - 6
Referrals – 12 Planned – 6 Unplanned –0 Referred on - 0
Referrals – 8 Planned – 6 Unplanned –5 Referred on - 0
DIP (E) Referrals – 171 Planned – 0 Unplanned – 57 Referred on - 14
Pharmacy Nx
DIP (HOB) Referrals – 245 Planned – 16 Unplanned - 114 Referred on - 20
CARAT/ Prison IR
DRUGLINE Referrals – 115 Planned – 11 Unplanned –85 Referred on - 10
BRO-SIS Referrals – 7 Planned – 0 Unplanned – 0 Referred on - 0
DSB Referrals – 514 Planned – 47 Unplanned – 242 Referred on - 21
SAFE Referrals – 0 Planned – 0 Unplanned – 0 Referred on - 0
Phoenix Outreach
Tier 1
Tier 2
Tier 2 (+ Tier 3)
Tier 3 (+ Tier 2)
Tier 4
Willowdene Fm Episodes – 7 Planned – ? Unplanned – ? Referred on - ?
Number on this map refer to Tier 3 and 4 referrals, activity and interventions only
Figure 5.4. Adult drug treatment system dynamic map illustrating the number of referrals and discharges (planned, unplanned and referred on) in Tier 3 and 4 services
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In summary the above dynamic mapping exercises illustrate the following key pieces of information obtained from NDTMS new treatment journey data: • 2,449 treatment journeys started in 2006/7, of whom around 80% were still in treatment at the 12 week point and 12% were retained for less than 12 weeks. • 1,332 clients were existing clients from the previous year, of whom the majority were in CDT’s (55% of the total existing clients) • The largest referral source into structured treatment was from criminal justice services with 984 referrals, followed by self-referral with 783 referrals. The smallest referral source was from GP’s with 272 referrals. • There is a high retention rate (over 12 weeks) in DSB and the CDT’s (up to 91%) but lower retention in DIP services and at Drugline (as low as 42%) but this is perhaps a reflection of the services provided and the client profiles • There are generally low rates across the system of clients who are triaged only and who do not go on to have a formal care plan • Of those new presentations that had left treatment within the first year, only 12% had a planned discharge. Planned discharge is defined as ‘treatment completed’ or ‘treatment completed drug free’. This suggests a need to ensure appropriate aftercare and wrap-around services are available for people wishing to exit the treatment system and also the need for developing more effective safety nets for those who exit in an unplanned way • 212 clients were transferred within the treatment system (15% of closed cases), suggesting a low rate of specialism within the treatment system and some indication of a ‘silted up’ system where clients do not progress as their needs change over time. • There were 1,085 unplanned discharges across the treatment system in 2006/7 - defined as all the episodes in the latest treatment journey identified as closed. When assessed against the total number of treatment episodes during the year across all reporting services (35 services including spot purchase Tier 4 services and the specialist young people’s service) this equates to 73% of those who left treatment doing so in an unplanned way. This represents the same proportion as in the previous needs assessment for data from 2005/6. • There is limited information on the longer term outcomes of individuals who leave treatment ‘drug free’ (either community or Tier 4 residential) and who do not return to community treatment. This is a critical issue that will have to be addressed in developing the treatment system within Birmingham. Of the 2,449 treatment journeys initiated within the year, although four-fifths were retained for 12 weeks, implying some client benefits, less than half were still in treatment at the end of the year. Of greater concern is the fact that of those who do leave within the year, only 12% had planned discharges, suggesting more short term gain in treatment outcomes than sustained changes towards long-term recovery.
Section 6 - Additional Data Sources Further sources of data were identified that improve the picture of needs and harms for problem drug users in Birmingham. These data together with other sources of data identified through the expert group and key informant processes were important for supplementing the core data sets from NDTMS and DIP as described in the previous section.
Drug Related Deaths – St Georges Hospital Data The number of drug-related deaths in Birmingham has risen from 18 in 2005 to 41 in 2006, as reported by St George’s Medical School based on returns from coroners across England. The definition used for this reporting is broad and so includes a number of deaths where the verdict at inquest was suicide, natural causes or other causes – 26 of the 41 cases had ‘abuse of drugs’ as the verdict at inquest. Heroin was implicated in 26 of the deaths and cocaine in six. Only one of the 41 deaths involved an individual who was in treatment at the time of death, indicating the protective effect of drug treatment against acute drug-related deaths, and necessitating further efforts to engage vulnerable drug users in structured treatment services, although we do not know how many had recent treatment contact or a prison release. The overall rate of deaths, 4.37 per 100,000 population, is around the national average, and markedly lower than equivalent cities such as Newcastle (where there were 10.07 drug-related deaths per 100,000 population) or Liverpool (7.92 deaths per 100,000 population). However, the rise is a cause for concern and the analysis below attempts to examine patterns and trends in the deaths reported. The mean age of fatalities was 36.6 years (range = 18 – 64 years) and the 41 deaths consisted of 31 males (75.6%) and ten females. Five deaths occurred among individuals under the age of 25 years. 37 of the deaths were recorded as of white ethnicity, one as Indian, one as Pakistani, one as not known and one as of ‘other’ ethnic group. Perhaps surprisingly, more than half of the deaths (n=22, 53.7%) occurred among individuals in employment, and none were among individuals classed as homeless (one person was classed as living in a form of sheltered accommodation). However, 18 (43.9%) of the individuals did live alone. Thus, while the age and gender profile are consistent with the evidence base around DRDs, the high rates of employment and low rates of homelessness are less typical. Figure 6.1 below identifies the known address of each of the fatalities and gives us a picture of the distribution of deaths throughout Birmingham. Whilst there is an even distribution across the city for the 41 deaths in Birmingham the main cluster of deaths occurred just outside of the Birmingham area to the east of the city.
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Figure 6.1. Drug related deaths illustrated by residence of the deceased
Using the Drug Strategy definition of a problem drug user, 31 of the individuals who died (75.6%) meet this condition. Of the 41 deaths, 23 (56.1%) were known to be drug users, for 17 this was unknown and only one individual was clearly identified as a non-user. However, only 6 of 41 individuals were known to be injectors (15.4%).At least one of these individuals was known to be a recent prison leaver highlighting the need to address the transitional care of clients leaving prison in Birmingham and returning to drug use. Further linkage between prison information systems and knowledge is needed to assess the true number of DRDs amongst those who had recently been released from prison in those who were defined as a death related to drugs.
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Figure 6.2. Drug related deaths illustrated by place of death
The map above illustrates the place of death, however three incidents did not have enough geographic information to be mapped (described as car / car park / public toilet). Of the 38 deaths mapped here 7 deaths occurred in Solihull. This map does not necessarily report the place where the incident took place or were the victim was found as 8 locations are Hospitals and are probably as a result of attendance at A&E (Good Hope Hospital, 3 deaths, City Hospital, 5 deaths) Further comparison with a previous dataset would be useful to assess increase and location of deaths
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Birmingham Treatment Effectiveness Initiative Data (BTEI) The first full phase of the initiative is now complete, using the method of gathering initial baseline data on staff, managers and clients, introducing the new method of working, based on node-link mapping through an evaluated training programme, and then repeating the initial assessments to measure change. The total number of questionnaires completed across Birmingham and Wolverhampton, shown in Table 6.1, makes this the largest project of its kind carried out in drug services in the United Kingdom and has placed Birmingham at the forefront of treatment innovation in the UK.
Clients
Time 1 1020 questionnaires
Time 2 702 questionnaires
Staff
236
150
Managers
21
19
Training evaluations
198
164
Type of data collected Over 1400 questionnaires completed by Bham clients across the two phases of the project Over 200 confidential but not anonymous questionnaires completed by treatment staff in Birmingham Formal interviews and questionnaires with 18 Birmingham managers on each occasion More than 300 forms completed by frontline Birmingham staff about mapping training and its implementation
Table 6.1: Data collected across the BTEI initiative
Additionally, as part of routine practice, more than 1500 Client Evaluation of Self at Intake (CESI) forms have now been completed as routine activity within treatment services. As reported in the 2007 needs assessment, the key baseline findings were that: •
Compared to the US client group, clients in UK services had higher levels of psychological health problems that had not been addressed satisfactorily in treatment
•
Criminal justice clients in the UK had higher average levels of criminal thinking than their US equivalents, and this did not reduce over the time in treatment (criminal thinking has been shown to be linked to subsequent offending)
•
Clients with higher levels of criminal thinking also reported poorer engagement in treatment, lower motivation for treatment and worse psychological health
•
Although staff in the UK were broadly comparable to their US equivalents, there was considerable variation across teams, with teams showing better staff morale and resources also having clients that engaged better in the treatment process
•
There were strong associations between positive manager satisfaction and lower stress and better client engagement in treatment
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The key findings from the remainder of the first year of the process are reported below: 1. Client factors
Chart 6.1: Significant changes in Client Functioning Time 1 â&#x20AC;&#x201C; Time 2
Where there were significant overall changes in client functioning, they were all in the positive direction, with reductions in reported risk-taking, depression and pressure to be in treatment, and improvements in average levels of client selfefficacy. However, it is more useful to focus on changes where we are able to match clients as shown in Table 6.2. The table below makes comparisons between two specific groups of clients â&#x20AC;&#x201C; those who had been in treatment for between one and three months, and those who had been in treatment for between 3 months and one year, as this was where the greatest changes are seen. Statistically significant changes are shown in bold in the table with the key to statistical significance given at the bottom of the table.
CEST Scale Desire for Help Treatment Readiness Treatment Needs Self Esteem Depression Anxiety Decision Making Self-efficacy Hostility Risk Taking Social Consciousness Treatment Satisfaction Counsellor Rapport Treatment Participation Peer Support Social Support Na a Largest N, +p<.10, *p<.05
Treatment Tenure 1-3 months 3 months - 1 year Cohort 1 Cohort 2 Cohort 1 Cohort 2 39.9 (5.7) 40.1 (5.7) 39.2 (5.9) 39.5 (5.6) 39.1 (5.5) 39.8 (5.7) 39.5 (5.5) 39.5 (5.3) 31.7 (7.2) 30.9 (7.1) 31.9 (6.9) 31.9 (6.9) 29.7 (6.9) 30.8 (8.0) 30.0 (7.0) 31.7 (7.6)* 32.7 (7.4) 30.5 (7.3)* 32.0 (7.0) 30.7 (7.5)+ 32.8 (7.8) 31.1 (8.1)+ 32.7 (7.9) 31.5 (8.3) 34.6 (5.6) 35.5 (6.0) 34.3 (5.5) 35.4 (5.2)* 33.1 (6.5) 34.6 (6.5)* 32.9 (5.9) 34.0 (6.2)* 26.6 (8.5) 24.7 (7.8)+ 25.3 (7.8) 25.4 (8.5) 28.8 (5.7) 27.2 (6.2)* 28.3 (5.7) 27.1 (6.0)* 34.0 (5.0) 35.4 (4.8)* 34.6 (4.8) 35.5 (5.0)* 39.8 (6.0) 41.2 (4.9)* 40.5 (5.9) 40.6 (4.5) 40.1 (6.8) 41.9 (4.8)* 41.5 (6.8) 41.7 (4.7) 38.3 (5.7) 39.7 (5.1)* 39.0 (5.9) 39.6 (4.3) 33.5 (6.6) 33.6 (7.3) 32.4 (7.6) 33.4 (6.2) 35.5 (6.8) 36.6 (7.3) 36.3 (6.8) 36.5 (6.4) 170 107 277 191
Table 6.2: CEST profiles for clients in Birmingham for who received at least 1 month to less than 1 year of treatment Page 38 of 60
As can be seen from the table, the main changes occur among those early in treatment (both for those between 1-3 months in treatment and those between 3-12 months in treatment). It is in these two ‘new to treatment’ groups that the biggest progress has been made. There were no significant changes in motivation for treatment, but in both groups there were significant improvements in social and psychological health, and in new clients (less than 3 months in treatment) there were improvements in all three measures of treatment engagement. For those in the initial 12 weeks of treatment, across Birmingham services, there were overall reductions in depression and anxiety and linked improvements in average client levels of self-efficacy. Clients in this first 12 week period also showed overall improvements in treatment satisfaction, active engagement in the treatment process and improved quality of relationships with workers. Similarly, new clients also reported lower levels of risk taking and hostility and higher average levels of awareness of others’ needs. For clients in treatment for between 3 months and one year, a similar pattern emerged for improvements in psychological and social functioning factors only. No equivalent improvements were seen in clients in treatment for more than one year, suggesting that, when the worker-client relationship is of longer duration, improvements in training do not necessarily affect established clinical relationships. With regard to criminal thinking, Birmingham clients averaged higher scores on 5 of 6 dimensions of the criminal thinking scale than an incarcerated population in the US. Furthermore, there was no indication that levels of criminal thinking reduced over the course of DIP treatment. This is worrying as the criminal thinking measure has been shown to have predictive validity – in other words, people who score high on this scale have significantly enhanced risk of further offending. Audit and research work on criminal justice services would suggest that there is insufficient structured intervention around offending delivered in treatment services, and the CTS measure has not been widely used in routine practice. 2. Staff and managers The positive client findings are reflected in general positive improvements in the reports of both staff and managers in the services that were trained in the BTEI assessment and mapping processes. In part, this reflects a gradual shift across teams to effective engagement in the process – initial scepticism has largely been replaced by an openness to change and the follow-up worker assessment showed the following staff attitudes to aspects of the BTEI training and its implementation:
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Chart 6.2: Staff attitudes to implementation of BTEI
Thus, more than half of the respondents reported that ‘mapping fits well into our team’ and more than two-thirds reported that ‘mapping has been beneficial to key working’. Crucially, given the focus of the initial training, 61% of clinical staff reported that ‘mapping has improved care planning’ and around half that it has made sessions with clients more collaborative. This is consistent with generally positive changes in key aspects of worker functioning as shown in Table 6.3 below: Domain Staff attributes
Organisational climate
Scale Growth Efficacy Influence Autonomy Mission Communication Cohesion Stress Openness to change
Time 1 average 34.0 38.4 33.6 33.0 34.5 32.1 34.2 35.1 32.6
Time 2 average 34.7 40.2 34.9 34.6 37.4 33.3 35.5 34.2 34.5
Table 6.3: Overall changes in staff attitudes from baseline to follow-up
Thus, all of the changes in the above table are in a positive direction and, when comparing the 109 staff who completed forms on both occasions, there are statistically significant improvements in team sense of mission, improved staff efficacy and improved ability to influence colleagues. This is reflected in positive changes in managers’ views with marked reductions in average reported stress levels by staff and clear improvements in both sense of organisational mission and openness to change. What the study has also provided clear evidence of is a hierarchy in which better resourced and satisfied managers and keyworkers result in better levels of client motivation and engagement in treatment endorsing the fundamental principles of the Treatment Effectiveness model. There are also initial indications that service level retention is Page 40 of 60
associated with better client functioning as reported on two dimensions of the CEST – higher levels of treatment satisfaction and lower levels of reported pressure to be in treatment. 3. Future directions One of the key problems with the BTEI process has been inconsistency of implementation based on variable levels of commitment by team leaders and managers across services. As a consequence a major aim for 2008/09 will be around ensuring consistency of implementation and improving the training and support to team leaders and senior practitioners in ensuring adequate implementation. We are also looking to extend the range of manualised interventions available for use in teams particularly around harm reduction and relapse prevention, while attempting to improve the use of the scales and scores as part of the care plan and care plan review processes. We are aiming to extend the use of the criminal thinking approaches as a method of addressing underlying risk of offending among drug users in treatment and to assess the pattern of offending behaviour more consistently.
Needle Exchange Data The annual needle exchange needs assessment is currently being carried out by the DAT. This needs assessment, whilst informing the larger treatment planning needs assessment, will focus on the adequacy of provision and impact of needle exchange services in Birmingham. A snapshot of needle exchange activity in pharmacy and specialist drug service needle exchanges across Birmingham has been collated analysis. Below is a summary of the analysis to assess the number of needles, syringes, and injecting equipment supplied to drug users over a 3-month period. This provides further description of the profile of injecting and other users who use low threshold services and potentially provides a picture of those only accessing these services and therefore characterised by the NTA as currently not engaged in structured drug treatment (i.e. a hidden population). Needle exchange services in Birmingham are predominantly split into two models of service delivery, pharmacy and non-pharmacy based services. The non-pharmacy based services are set within specialist substance misuse services (such as Tier 2 providers or Tier 3 community drug teams) with pharmacy based services delivered from community pharmacies recruited onto a DAT commissioned scheme. The pharmacy based schemes typically provide needle exchange services through a standardised ‘pack’ scheme where needles, syringes and injecting equipment are distributed in standardised packs consisting of syringes (usually 10 fixed head syringes per pack) and injection preparation equipment (pre-injection swabs, acidifiers, cups/cookers, and filters). The packs can also contain condoms and harm reduction literature. In the specialist services this equipment and information is distributed through a ‘pick and mix’ system where injecting drug users can obtain injecting equipment based on need and not in a standardised pack. Across the sample of needle exchange users (both pharmacy and non-pharmacy) the majority of users were in the 2534 year age group (53%), 38% were between the ages of 35 and 64 years and 9% were under the age of 24. There were only six recorded transactions for people under the age of 18. The gender spilt shows an over representation of males (85%) compared to female needle exchange users (15%), this is particularly in contrast to the gender Page 41 of 60
representation of individuals engaged in structured treatment services (taken from NDTMS data). The majority of users were of white ethnicity (93%) and again demonstrates the difference in user profiles compared to the wider NDTMS population; this is illustrated in figure 6.3 below.
All Needle Exchange Users Asian/Asian Other 3% Mixed 3%
Black/Black Other 1%
NDTMS (New Presentations) Black/Black Other 1%
Other 1% Mixed 8%
White 93%
Asian/Asian Other 13%
White 69%
Figure 6.3. Ethnicity comparisons of needle exchange users and the population of substance misusers engaged in structured treatment (Tiers 3 and 4).
Needle Exchange Transactions During the period used for analysis (July â&#x20AC;&#x201C; September 2007) there were 6,940 individual transactions within pharmacy based needle exchange services with a high level distribution of smaller 1ml and 2ml syringes compared to the larger syringes available. The total number of 1ml syringes distributed was 87,530 (68% of the total number of syringes distributed through community pharmacies) and 38,260 syringes of the 2ml size (30%). A smaller number of 5ml syringes were distributed (n= 3,730), however there were no recorded 10ml syringes distributed during the 3-month period. As expected due to the smaller number of non-pharmacy based needle exchanges the number of transactions in non-pharmacy services was significantly smaller than in pharmacy based services (n= 3,426 for all needle types), however this analysis does not at this time include data for Drugline and therefore is potentially missing a large number of transactions in this area. The number of returns is significantly smaller than the number of syringes/packs distributed. Across the sample 2,545 â&#x20AC;&#x2DC;sharps containersâ&#x20AC;&#x2122; were returned to needle exchange services, however it is not possible to quantify how many individual syringes this represents or what size syringes were returned as the sharps containers are sealed to prevent contamination (see table 6.4 below). Geographically, pharmacies with the largest Page 42 of 60
number of transactions are located in the centre of the city (Boots Chemist, High Street; 13% of all transactions recorded), Moseley (7%), Kings Norton (5%) and Castle Vale (3%).
Pharmacy Transactions Total syringes distributed Average number of syringes distributed per transaction Returns (across both types of provider) Extrapolated distribution (over 12 months) Extrapolated returns (over 12 months)
Non-Pharmacy
6,940
304
129,520
3,426
19
11
2,545 containers (potentially 25,450 syringes) 518,080 13,704 10,180 containers (potentially 101,800 syringes)
Table 6.4. Needle exchange activity during the period July – September 2007
The injecting PDU estimate for Birmingham is 2,895 injectors (CI: 2,343 – 3,664), the approximate total number of syringes distributed over the 3 month period and extrapolated over 12 months is 531,784 syringes. This equates to in the region of 184 syringes per person per year (or between 227 and 145 syringes based on associated confidence intervals) and 1 syringe every two days (0.5 per day). This also means that based on the average injector having 2 injections per day, current coverage in Birmingham provides new sterile equipment for approximately 25% of all injections (or between 20% and 31% based on associated confidence intervals). This is compared to research discussed previously by Hickman et al (2004) who reported that sterile equipment was provided for approximately 27% of all injections by IDU in Brighton and Liverpool and 20% in London. Comparisons between Pharmacy and Non-Pharmacy populations Non-pharmacy needle exchange users were more likely to be older (in the 25-64 year age groups) than the users accessing pharmacy based needle exchanges (χ2 =16.33, df = 2, p <0.0005), there was a higher proportion of 18-24 year olds accessing pharmacy based needle exchange services than in non-pharmacy services. Female injecting drug users were more likely to access non-pharmacy based services than community pharmacies for their needle exchange equipment (χ2 =10.68, df = 1, p = 0.001), there were no significant differences in the ethnicity of those accessing either pharmacy or non-pharmacy services. Limitations in this current data need to be noted; firstly the accuracy of the data is questionable although on review the activity by pharmacy looks to be consistent with current knowledge. However, at a service level the recording of client details umber of syringes distributed are problematic. There is also no method at present of knowing whether users are accessing both the pharmacy and non-pharmacy based services as those using these services are not mutually exclusive independent groups. Current data reporting mechanisms are being improved and implemented at this time, Page 43 of 60
there is a need to develop further the mechanisms for recording and analysing needle exchange activity (and wider Tier 2 interventions) to ensure the coverage and availability of injecting equipment is at an optimal level to address the harms caused by injecting drug use in Birmingham. This improved data collection will enable a more consistent and standardised measure of activity within needle exchange services and should provide better quality data for the next annual needs assessment.
Injecting Status in Birmingham There is no known published research on the number of syringes and injecting equipment used by IDU in Birmingham. Were this information available we would be able to map the coverage of syringes for each known or estimated IDU. What this would mean is that we would be able to provide information on the level of syringe and needle exchange activity for problem drug users (PDU) in Birmingham and map this against the estimated total number of PDUâ&#x20AC;&#x2122;s and the numbers of reported PDUâ&#x20AC;&#x2122;s who are engaged in structured drug treatment. Data from the NDTMS for the 2005/6 and the 2006/07 financial years provide an illustration of the reported injecting status of problem drug users in treatment in the Birmingham DAT area (those defined as primarily opiate and/or crack cocaine users). Injecting Status Current Previous Never Not known
In 05/06 604 992 2777 545
% 12 20 56 11
In 06/07 634 1156 3053 334
% 12 22 59 6
Table 6.5. Injecting status of clients in Birmingham engaged in Tier 3 or 4 structured drug treatment and entered onto NDTMS in 2005/6 and 2006/7
These data suggest that in 2005/6 there were 604 current injectors engaged in structured drug treatment and 634 in the 2006/7 financial year, this represents an increase from the previous year of 5%.
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Chart 6.3. Reported injecting status among problem drug users in Birmingham engaged in treatment during the financial years 2005/06 and 2006/07.
According to the Glasgow prevalence estimates of problem drug users in England (Home Office 2006) there are 137,141 injectors nationally (CI: 133,118 – 149,144) and 14, 734 injectors in the West Midlands (CI: 13589 – 17,007) of which 2,895 injectors (CI: 2,343 – 3,664) were estimated to be based in Birmingham. Therefore, when comparing this estimate of IDU in Birmingham against the total number of current IDU engaged in drug treatment in 2006/7 (634 reported clients, 28% of the estimated IDU) this could suggest that there was in the region of 2,261 (78%) IDU not in contact with structured treatment services during 2006/7 (or between 1,709 – 3,030 IDU, based on the published confidence intervals). NDTMS data from 2004/5 suggested that 17.3% clients engaged in treatment were heroin injectors.
Supporting People Data A source of data that can provide information about individuals with substance misuse issues who require accommodation are data from the Birmingham City Council Supporting People funding programme. Housing support services are funded though Supporting People for vulnerable individuals, including those with substance misuse support needs. Therefore this is a Tier 1 service provider and a potential source of ‘hidden’ PDU’s, and these could include individuals who are not currently accessing mainstream structured substance misuse treatment services. The data set obtained originates from details recorded about each client on the ‘Client Record Form’ completed for each new client entering a support service in 2006/07. Of particular interest here is the categorisation of support needs, recorded as a single primary need with up to three secondary support needs. From this analysis, 791 episodes of supporting people funded support were identified for those with a primary or secondary drug and/alcohol (DA) support need. Of these episodes 19% were female and 81% were male, this gender Page 45 of 60
split is significantly different from the wider population of people receiving support (45% and 55% respectively, χ2 =182.57, df = 1, p<0.0005). The majority of the DA population were of white ethnicity (n = 655, 85.3%), followed by black or black other clients (n = 43, 5.6%), clients with DA support needs were less likely to be from a BME group than clients with ‘other’ support needs (χ2 =300.82, df = 4, p<0.0005), this is illustrated in chart 6.4 below.
Chart 6.4: Gender comparisons across those with drug and alcohol support needs and those with ‘other’ support needs
The age of clients across the two groups also demonstrated some significant differences. Within each support group DA clients were more likely to be between the ages of 25 and 65 years (81% DA group, 64% ‘other’ group ) and those with ‘other’ support needs had a higher proportion of clients in the 18-24year age group (χ2 =93.78, df = 4, p<0.0005). This is represented in chart 6.5 below.
Chart 6.5. Age group comparisons of those with drug and alcohol support needs and those with ‘other’ support needs Page 46 of 60
The link between drug use and offending is supported by data for this population, clients with DA support needs were more likely to be subject to a probation order (χ2 =98.77, df = 1, p <0.001) and be engaged with a DIP provider (χ2 =498.0, df = 1, p <0.001). There was also a relationship between support needs and homelessness with the DA group more likely to be defined as homeless (χ2 =9.56, df = 1, p =0.001) than the group with other support needs. Other characteristics of the DA support needs group revealed that 43% (340) were job seekers, 42% (333) were long term sick or disabled, only 1% (9) in FT work and 0.3% (2) in PT work. The majority of DA clients were receiving support from an SP funded supported housing provider (n = 385, 49%) with 30% (239) accessing direct hostels. When assessing who provides these services 73% of clients with DA needs were accessing voluntary sector providers but only 2.5% of clients were in SP funded Birmingham City Council housing services . Whilst this dataset can provide limited information in relation to clients with both substance misuse and housing support needs, questions around the accuracy and validity of this data would need further scrutiny. The database was not designed to monitor numbers of PDU’s engaged in Supporting People services as the definition of substance misuse support need is not interchangeable with the Models of Care definition for a problem drug user. However, it is critical that we are aware of possible information sources around hidden populations and their characteristics and locations.
Dual Diagnosis Needs Assessment The dual diagnosis needs assessment was completed in July 2007 and built on an earlier dual diagnosis needs assessment commissioned by Birmingham DAT. From a drug treatment perspective, there was indication of low levels of successful referrals from mental health services into specialist drug services, while the needs assessment identified poor awareness of services or pathways among primary care and specialist drug service providers for routes into mental health services indicating a need for training in identifying co-morbid clients. Also, while mental health services do not refer to specialist addiction services, clients in substance misuse services are referred with greater regularity to mental health but this referral does not generally result in treatment engagement. The clients identified as having both substance misuse and mental health needs were typically more ethnically diverse than substance misuse only clients, had an older age profile and were more susceptible to treatment drop-out. Finally, clients who are engaged in both services are often poorly coordinated with little evidence through standard monitoring of coherent or planned coordination of service provision for co-morbid clients. Below is a summary of the key data findings: •
275 or 15% of Shared care substance misuse clients are categorised as ‘dual diagnosis’ on NDTMS
•
NDTMS national data demonstrates that clients referred from psychiatry have poorer 12-week retention; higher rates of planned discharge, higher rates of primary crack use and are more ethnically diverse.
•
When examining local NDTMS data only 9 referrals in 2005/6 and 32 in 2006/07 are identified as being from psychiatry indicating a very low successful referral rate into substance misuse services
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•
In the Birmingham City-Wide Audit 8.5% (239) of the 2,806 clients had contact with a psychiatric team in the last year, 15.9% (445) were at current risk of self-harm and 15% (421) scored high for psychological risk on the CISS Scale indicating greater problem severity.
•
When comparing Audit clients who had had a psychiatric contact with those that had not it was found that these clients had a higher frequency of alcohol use, were less likely to be in opiate substitution treatment (but those that were had higher doses of methadone).
•
BSMHT trust data revealed differences in age, ethnicity, substance use, and retention for clients concurrently engaged in both a mental health and substance misuse team. These clients were older, more likely to be black or Asian and be cannabis or crack/cocaine users. They also had poorer 12-week retention rate and were proportionately more likely to drop out in the first 12 weeks of treatment.
•
Initial BTEI data analyses illustrate that CDT clients have elevated depression and anxiety scores compared with other services in Birmingham and also to clients surveyed in the US treatment effectiveness studies.
University of Birmingham Addictions’ Research 1. “Differences in heroin use patterns and drug careers between Muslim drug users and white British community drug treatment service users” (Faisal Baig, David Best and Tina Oza) This project examined the differing drug trajectories of Asian and white male clients accessing community drug treatment. Asian clients were on average, three years older than White clients at age of entry into treatment; this age difference was also found in age of first use of illicit drugs. Asian client’s drug careers began with tobacco, cannabis and then alcohol; this was different to White respondents, who took alcohol prior to cannabis use. White clients also reported higher IV usage than Asian counterparts. The study also found that white clients that used drugs with nonwhite drug users smoked heroin, whereas those clients that injected, were found to use drugs with white drug users. However, the key differences are outlined below Substance use histories All the participants had a lifetime history of heroin use. Crack cocaine had been used by 86.8% of the sample, followed by cocaine powder (65.7%) and amphetamine (42.1%). All participants followed the classic pattern of drug use described by Kandel (1975) during their drug career. However, there were two key differences between Asians and Whites. First, most Asians had used the gateway drug of cannabis before they used Alcohol; the opposite was true for White participants (Table 1). Second, mean age of first use for all drugs was much higher for Asians compared to Whites. On average, Asians were 3.4 years older than their White counterparts when they used any drug for the first time As shown above, white drug users in treatment start using each drug at an earlier age, although the gap between initiation and treatment seeking is not different for the two groups – possibly suggesting that stigma is not a greater deterrent to treatment entry for male Asian drug users. This interpretation is supported by the finding that Asian users in treatment were more likely to have social supports – to live with partners, to be in contact with their families and to have jobs at the time of treatment seeking. Page 48 of 60
2. â&#x20AC;&#x153;Criminal thinking and self-control among drug users in court mandated treatmentâ&#x20AC;? (Greg Packer, David Best, Ed Day, Kelly Wood) The aim of this study was to assess clients attending a treatment service for drug-using offenders to examine the relationship between drug use and offending and to explore associations between these factors and criminal thinking and self-control. The overall aim was to assess whether low self-control acts as a single linking mechanism that can predict both offending and drug use, and or whether the factors underlying these behaviours are due to criminal thinking, a cognitive style which can be influenced by aspects of drug treatment. Fifty drug using offenders attending the Birmingham Drug Intervention Programme under the terms of a Drug Rehabilitation Requirement (DRR) were recruited for this study The sample constituted just under one-third (30.3%) of the 165 clients receiving treatment from the Birmingham DRR team at the time of the project. Forty three participants were male (86%), and 39 (78%) described their ethnicity as white. The sample had a mean age of 30.7 (range 19-49, Ď&#x192; 7.5). Most of the Birmingham DRR population have continued to use drugs whilst in treatment: 70% report using heroin in the previous 30 days, 54% crack cocaine, and 90% admit to having spent money on illegal drugs. Additionally, around one third of the sample reported offending in the last 90 days. The absence of any significant relationship between substitute prescribing and heroin use or offending measures would suggest that the methadone treatment received by the majority of the sample does not generate a completely protective effect against heroin use and criminal behaviour in this population, although there was no measure of change completed in either of these dimensions since the start of the treatment programme. However, there was marked variability across the sample in the patterns of offending and ongoing substance use. There were strong correlations between measures of past and present drug use (both heroin and crack cocaine) and past and present offending, supporting the evidence base linking drug use and crime. Further justification for the DRR process comes from the low self-control scores provided by the research sample in comparison with the norm data (Grasmick, Tittle, Bursik Jr & Arneklev, 1993). It is also worthy to note that, within the Birmingham DRR population, lower self-control was strongly associated with earlier age of onset and higher current intensity of drug use as well as with greater intensity of current offending. There was a positive association between the measured criminal thinking styles and intensity of current offending. This suggests that reported criminal thinking may not be directly related to current or historical offending patterns, but may reflect a more generic belief system associated with the drug-crime nexus. Both low-self control and high criminal thinking have been previously demonstrated to be associated with higher intensity of drug use and offending and this study has confirmed those findings. Additionally a strong association has also been demonstrated between high criminal thinking and low self-control. Taken together these findings suggest that the range of predisposing factors for concurrent drug use and offending is more complex than could be understood through a simple reliance on either a self-control or criminal thinking model and that both self-control and criminal Page 49 of 60
thinking may have a significant role to play in predisposing individuals to become drug abusing offenders as seen in this population. 3. “Assessing the extent of drug dependence in young drug users accessing criminal justice services” (Anna Greaves and David Best)
Although clear relationships have been identified between dependent drug use and crime, the relationship is less evident in young offenders, particularly those whose substance use is associated with lower levels of physical dependence. This study investigated a sample of young drug-using offenders (aged 18-24 mean age of 22 years 4 months) accessing drug treatment through the criminal justice system in Birmingham. The majority of the sample were white males (22/36, 61%). The average length of time that each client had been in DIP treatment was 19 weeks 4 days. Overall the sample consisted of 64% (23/36) males, 36% (13/36) females and 94% (34/36) white with 6% (2/36) Asian, representing the only other ethnicity sampled. The majority, 78%, were unemployed with the remainder being in employment (14%) or education (8%). There were high levels of heroin dependence identified, with frequency of heroin use linked to both current levels of acquisitive crime and willingness to engage in drug treatment. The relationship between crack cocaine use and offending was less clear and the participants were more ambivalent about their desire to stop using the drug. Whilst most clients complimented their treatment programme, substitute prescribing was less positively endorsed. The study offers tentative vindication of diverting young dependent opiate users from the criminal justice system into specialised drug treatment, but presents a less positive prognosis for primary stimulant users. 4. “Assessing non-injecting heroin use in Birmingham: a comparison of characteristics and reasons for non-injection in equal samples of never-injected and formerly-injecting heroin users in contact with adult drug treatment” (Alison Smith, David Best and Ed Day) This project explored the reasons why individuals who prefer to use heroin by routes other than injection have abstained from intravenous use despite entrenched heroin use. Forty non-injecting heroin users (20 former injectors and 20 who had never injected) were recruited at two Community Drug Team sites in Birmingham. Following completion of a cross sectional survey by these participants, the most endorsed reasons for non-injection were worries about appearance. Additional reasons emerging included identity issues and stigmatised status of injecting. Comparing the groups, ‘never injectors’ were younger (p<0.05), more likely to have an educational qualification (p=0.05), had higher measured heroin dependence (p=0.05) and lower prior exposure to injecting (p<0.001) than former injectors. There was no difference between the groups in estimated prevalence of injection amongst peers. This study points to continuity between injecting and non-injecting cultures, challenges the concept of injection as a natural progression from non-injecting heroin use, and highlights personal addiction career factors in injection transitions.
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Blood Borne Virus Data A recent joint publication between the Health Protection Agency (HPA) and the NTA has enabled us to begin building a picture of the estimated prevalence of Hepatitis C (HCV) in Birmingham. Using data from the Unlinked Anonymous survey of injecting drug users it is estimated that Birmingham has a prevalence rate of at least 50% in IDUâ&#x20AC;&#x2122;s who have injected drugs in the last year. This is the highest banding given (low, medium and high) and it is suggested that half of all IDUs in Birmingham who have been injecting for 5 years will have been exposed to HCV and will therefore continue to have the disease (sustained PCR positivity). As a region the West Midlands is categorised as having a 4050% prevalence rate overall with a national picture suggesting a prevalence rate of 43% for all IDUs and 45% for those who have injected in the last year. A recent piece of analysis performed by the West Midlands Public Health observatory has identified the number of drug users in treatment receiving a number of interventions relating to Hepatitis B and C. The data includes clients engaged in structured treatment from April to November 2007 (taken from NDTMS data returns). We are currently unable to assess the length of injecting length among previous and current injectors engaged in structured treatment services; however we do know that there were 724 individuals who were current injectors and 1,168 previous injectors. As a crude measure of HCV prevalence in the treatment population this could mean up to 946 clients have sustained HCV positivity. Of the individuals engaged in structured treatment between April and November 2007, a quarter had been offered and received immunization for Hepatitis B (n =1,428: 25%), 14% (781) refused vaccination and a further 14% (783) were already immunized. A small number of clients already (n =20) had an acquired immunity to HBV from previous exposure to the virus and 46% were either not offered the immunization (n = 669; 12%) or data were missing/not known (n =1,923; 34%) There was a similar picture for missing data for client information on Hepatitis C status, 64% (n = 3,570) of cases had missing data in the HCV fields on NDTMS. However, it is known that 20% of individuals were offered an antibody test for Hep C (n =1,125), 16% (n =909) were not offered the test and 4% were known at the time to be HCV positive (n=223). Birmingham has well-developed blood-borne virus team based in BSMHT who provide significant proactive interventions in this area. Probation Assessment Data â&#x20AC;&#x201C; eOASys Limited information has been obtained from the probation service on the level of drug use within offenders assessed by Birmingham probation officers. From the dataset held on OASys there were 3,885 new assessments completed between 1st October 2006 and 30th September 2007. These assessments took place as part of pre-sentencing reports or post-sentencing interventions as imposed by the courts. Of the 3,885 assessments 49% (n=1895) have misused drugs at some point in their lives. Table X below provides a summary of drug use amongst this population of offenders with percentages shown for the total population of offenders assessed as opposed to those assessed as using drugs.
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Drug
Previous
Current
Within those who currently use:
Use
Use
Daily
Weekly
Monthly
Occasionally
Cannabis
22%
15%
42%
30%
2%
26%
Heroin
12%
6%
67%
21%
1%
11%
Crack Cocaine
12%
5%
40%
26%
6%
28%
Cocaine Powder
5%
1%
13%
39%
7%
41%
Table 6.6. Drug use by type amongst offenders assessed by the probation service between October 2006 and September 2007.
Table 6.6 above illustrates that cannabis is the drug used most often by offenders assessed by probation during this time period (15%, n = 583) with 245 individuals reporting daily use. Heroin was currently being used by 6% (n = 233) with 156 offenders reporting daily heroin use. Crack cocaine was currently being used by 5% of people assessed (n = 194) with the majority reporting daily use (n = 78) with Cocaine powder used by 1% (n = 39) of whom the majority were occasional users (n = 16). Details were not provided on the other drugs used within this population, however from key informant interviews conducted with members of the probation service it was felt that other drug use accounted for less that 3% of the total population who had ever used drugs (mainly ecstasy and amphetamines). The current presentation of this data did not allow for profiling of these drug users to assess their demographic profiles against drug use and outcomes within the context of their probation order. This was discussed during the key informant interviews and highlighted as a potential area for data development for future needs assessment exercises.
Hospital Episode Statistics â&#x20AC;&#x201C; Public Health Observatory Limited data was obtained from the West Midlands Public Health Observatory on the number of hospital admissions in Birmingham where substance misuse was implicated as a primary diagnosis (under ICD10 code F10-F19, Psychiatric Admissions: Substance Misuse). This data covered both 2004/5 and 2005/6 and pointed to a reduction in the number of admissions over this time, a total of 129 admissions were recorded in 2004/5 and 94 admissions in 2005/6. This data has been broken down by age, gender and ethnicity below. The proportion of female hospital episodes reduced between 2004 and 2006 (36% down to 30% of all substance related admissions) with a slight increase in the proportion of males despite overall numbers of admissions decreasing over the two year period.
Gender Male Female
2004/5 n (%) 83 (64%) 46 (36%)
2005/6 n (%) 66 (70%) 28 (30%)
Table 6.7. Number and percentage of hospital episodes by gender
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The age of patients admitted to hospital demonstrates more variability across the two year time period. There is an 13% (n=31) reduction in the number of 18-29 year olds being admitted to hospital and an increase in the number of older patients being admitted, see table 6.8 below.
Age Group 18-29 years
2004/5 n (%) 70 (58%)
2005/6 n (%) 39 (45%)
30-39 years
33 (28%)
28 (33%)
40-59 years
17 (14%)
19 (22%)
Table 6.8. Number and percentage of hospital episodes by age group
The ethnicity breakdown also suggests a decrease in the number of patientâ&#x20AC;&#x2122;s identifying themselves as white (78% in 2004/5 compared to 65% in 2005/6). Despite the decrease in overall numbers from 2004/5 to 2005/6 there was an increase in the number of Asian patients admitted to hospital (see table 22 below), however the data is provided in aggregated form and does not allow the gender or age of these clients to be identified. Any category where there is less than 5 patients recorded has been collapsed for confidentiality purposes, i.e. Mixed Race and Black/Black British patients, therefore no further analysis could be conducted.
Ethnicity White Asian/Asian British Black/Black British Mixed Other
2004/5 n (%) 88 (78%) 6 (5%) 8 (7%) <5* 11 (10%)
2005/6 n (%) 53 (65%) 13 (16%) <5* 7 (9%) 8 (10%)
Table 6.9. Number and percentage of hospital episodes by ethnicity This data allows us to begin building a picture of the patterns and profile of patients admitted to hospital who have a primary diagnosis related to substance misuse. Future data collation exercises for hospital episode statistics could prove more illustrative if we were able to assess the data on a case basis to analyse any statistical significance based on demographic or diagnosis profile.
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Section 7 - Data Summary There are a number of data sources that due to time constraints were not accessed at this time. Therefore over the next year and in preparation for the 2008/9 needs assessment it is hoped that access to sexual health data for substance users, asylum seeker and ‘non-recourse to public funding’ information, pregnancy and child protection data in relation to ‘Hidden Harm’, will be accessed to provide further evidence of the needs and harms amongst substance misusers engaged and not engaged in structured treatment services. Of the data sources we have there are some identified weaknesses that can be categorised into 3 main areas Overview of available data in Birmingham Having summarised our main data findings this subsection section provides an overview on the progress made in key areas of information access: 1. Epidemiology The main strength is having two years of epidemiological data (04/05 and 05/06 prevalence estimates) albeit they are more dated than most of the other data sources. What this means is that we can look at some trends around patterns of use. However the Home Office data are limited by the inability to measure prevalence by ethnicity and by shifts in definition that mean we cannot infer “true change” 2. Treatment data Until TOP data are available this means we have only limited capture on service use and pathways and there exists in being limited access for the overlap between treatment and criminal justice data sets, particularly in relation to prison data. We would hope that in subsequent years there would also be stronger information on treatment outcomes. We would also hope to gain more detailed data that would enable us to look at treatment need by PCT or Political Ward area, as at present this is not adequately available. 3. Harm reduction This is an area where the epidemiology data are weak and where we have neither good maps of incidence or prevalence of BBV. While it is hoped that improvements underway will address this there is currently no mechanism for reconciling needle exchange use with treatment engagement or the number of individuals accessing these low threshold services. 4. Other data sources We are still too reliant on opportunistic sources of data such that there is no city wide service audit available this year and strategic audit planning will be required to address the number of gaps identified. Issues remain to be addressed around the reconciliation of data sources from providers, including information on Young People and links with housing, employment and education services.
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Section 8 - Expert Group Meetings As part of the needs assessment process, an expert group was convened to ensure the widest possible consultation of local stakeholders. We aimed to provide a balance of stakeholders including individuals who: • Have a professional role in the provision of services to the PDU population, for example service providers from health, social care, and criminal justice and individuals with data management, analysis and research expertise. • Have an interest and experiential expertise in these issues, for example service users, carers and community groups. • Can make changes happen in relation to the needs and harms identified for PDU’s, for example managers, commissioners and planners. The expert group was important in appraising from their specialist viewpoint the accuracy and validity of the data collected and in translating these data into identifiable needs that are compatible with the local treatment system. The expert group will also be a source of additional local data with which to supplement the core data sets from NDTMS and DIP. In other words, they will contribute at three stages: 1. In identifying and accessing relevant data sources – including their own activity data 2. In making sense of the overall data picture, reconciled against their own qualitative knowledge and their awareness of limitations in particular data sources 3. In the ‘translation’ process for turning the epidemiological map of unmet needs into actions that can be addressed through the treatment planning process The needs assessment process this year widens the stakeholder involvement by consulting with the wider community. The aims are to discuss adult drug treatment issues with community groups and services that have an agenda involving substance misuse that will inform the needs assessment and treatment planning process. Community groups will be identified and asked to participate in the needs assessment process through key informant interviews or via community based focus groups.
Section 9 - Key Informant Interviews In order to determine and balance the views of local stakeholders qualitative research methods will be used during interviews with key local informants, this includes those involved in the Expert Group and additional individuals identified as having expert local knowledge (e.g. community groups and Tier 1 service providers). Key informant Interviews were conducted to gain an in-depth knowledge of the treatment system profile in Birmingham and what gaps and needs may exist within the current system. Additional interviewees were identified on the basis of addressing particular issues that arise in the course of the quantitative data process and the group processes. Views and experiences of local users and ex-users were also sought through service user groups. These collective methods
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provided information and expert knowledge on the people accessing (and not accessing) local treatment systems, the existing treatment provision, the needs and gaps within the system, and the emergent needs assessment findings. In total 35 interviews with key stakeholders were completed, these consisted of a wide variety of individuals from commissioners and councillors to community groups and previous substance users. The interview schedule consisted of 15 open-ended questions exploring 1) the treatment bullseye, prevalence of drug users, and the profiles of PDU’s; 2) the static treatment map, service configuration, and entry and exit from the treatment system; 3) the dynamic map, flow of clients through the system, blockages and inadequate pathways, and the 2007/08 target for numbers in treatment. The following findings have been summarised using key information from the interview processes. •
It was identified that there is a need for wider liaison with community groups in DAT processes particularly non specialist drug services, Asian and Black Caribbean community elders, and groups or organisations in known gang areas (prevention and treatment). This involvement with the community would enable further facilitation of localised problem drug users gaining access to structured treatment. Essential the community would act as a referral mechanism with some emphasis on community level interventions.
•
There is little data available for local delivery groups, PCT’s and Community Safety Partnerships to adequately assess the penetration of treatment within their local areas. There is too much emphasis on PanBirmingham data and this is not always the most useful for key stakeholders attempting to assess local PDU prevalence and activity.
•
PDU Estimates – It was felt that there still some question as to the treatability and motivation to engage of those identified through the Glasgow estimates as PDU’s (i.e. there are issues for the 7000+ estimated PDU’s not engaged in T3/4 treatment during 2006/7)
•
Women and BME substance misusers are still not adequately catered for in structured treatment services and this creates an over representation of white male substance misusers in treatment.
•
There are issues with the engagement and retention of stimulant users particularly cocaine and crack-cocaine users and those identified through the criminal justice system.
•
It was felt that prison leavers are an overlooked and very vulnerable population of substance misusers – the transition from prison to community drug services is poor for those needing or wanting to access treatment in the community and there is a substantial and proven link to Drug Related Deaths amongst this population.
•
A number of those interviewed identified that there is a lack of options for treatment leavers including appropriate housing and skills/employment pathways and support
•
Referral pathways – there is continued blockages into and between Tier 3 and Tier 4 services. Clients cannot move easily from community drug teams into shared care services and there is currently a lack of affordable and accessible options for Tier 4 services.
•
There was a general feeling that Nx provision and coverage is good but little is known about activity and transition of pharmacy users into structured treatment. Particularly important in adequately assessing the number of IDU in Birmingham, testing the Glasgow IDU estimates, and modelling the number of syringes used per day against the average number of injections. Page 56 of 60
Section 10 – Needs Assessment Recommendations and Conclusions The overall aim of the needs assessment process is to make the most of what we know locally and to ensure that, year on year, the treatment planning process is more clearly evidence based and that treatment planning becomes increasingly data driven and evidence-based. The commitment of the TFG and its constituent members is essential to ensure that the bridge between the data generated and the resulting plan are ‘ecologically valid’ and take into account the needs of service users, carers, treatment providers and the local communities served by the Birmingham DAT. Needs Assessment Recommendations Treatment Pathways 1. Identified system level needs highlight the importance of developing housing links to increase the provision of accommodation for homeless and vulnerably housed individuals particularly prison leavers and those who have recently become drug free. Operationalisation: we have the opportunity of measuring this in terms of both the number of successful transitions to independent living and reductions in the number of homeless drug users identified through treatment services. 2. There is a need to examine and map the pathways for young people with substance misuse issues, both in YP specific services and those needing to make the transition to adult substance misuse services. Operationalisation: Assessment of numbers of transferred cases from young people to adult services engaged and successfully retained in treatment. Reductions in numbers of young people identified through criminal justice referral pathways. Audit of pathways for young people 3. The co-ordination of pathways for clients with a dual diagnosis need to be clarified and mapped to ensure appropriate identification of clients needing substance misuse treatment and support. Operationalisation: This would be mapped as a reduction in treatment dropout and clients being triaged only among those assessed as having psychiatric co-occurring disorders, and in increased rates of client overlap with adult mental health services. 4. There is limited information on the longer term outcomes of individuals who leave treatment ‘drug free’ (either community or Tier 4 residential) and who do not return to community treatment, therefore there is a clear need to map these clients and their outcomes and also to evaluate the existing aftercare provision in Birmingham. Operationalisation: consistent with the rationale for the new Tier 4 treatment centre, the measure of effectiveness here would be in rates of transition to independent living and employment, and reductions in ‘cycling’ back to treatment and criminal justice for those who complete recovery journeys. 5. Pathways need to be developed for young male polydrug users, particularly cocaine/crack users including the development of dedicated interventions to meet their needs. Operationalisation: this should be measured against numbers completing brief targeted stimulant interventions and by the rates with which they fail to reappear on DIR and/or NDTMS databases in subsequent years. 6. Effective pathways and information systems need to be developed to fulfil local and national requirements around Hidden Harm and the Safeguarding Children agenda. Operationalisation: improved identification of children and their needs (including parenting needs) assessed through audit and improved range and delivery of services and joint working with LSCC. Page 57 of 60
Drug Treatment System 7. To develop further the mechanisms for recording and analysing needle exchange activity (and wider Tier 2 interventions) to ensure the coverage and availability of injecting equipment is at an optimal level to address the harms caused by injecting drug use in Birmingham. Operationalisation: successful recruitment rates into treatment tracked by needle exchange as referral source and recording of rates of treatment engagement among current users of needle exchange provision. 8. Increased impetus is required to consolidate the gains made in consistency of treatment delivery across the city. Although BTEI has been highly effective, its implementation remains inconsistent, and new manuals need to be added to improve treatment pathways. Operationalisation: to be measured by audits of rates of mapping in case files, rates of completion of assessment and follow-up instruments and successful completion rates for care plans and reviews. Evidence of use of increased suite of treatment manuals for improving evidence-based practice. 9. There are continued blockages for moving clients between Tier 3 services and through to Tier 4 services or exiting the treatment system, the appropriate commissioning of a new Tier 4 service in Birmingham will address some of these needs together with improved community detoxification provision for all individuals wishing to achieve abstinence from opiates. Operationalisation: Improved rates across all services of transition to abstinence-oriented treatments, leading to higher treatment completion rates. 10. Improved care planning is a necessity and the use of care plan reviews to map treatment needs. Operationalisation: Improved completion rates of care plans and reviews; increased evidence of completion rates for care-plan domains. 11. Appropriate training is needed in the identification of clients with both substance misuse and severe and enduring mental health issues including training around appropriate care pathways and interventions that can be utilised as part of an individualâ&#x20AC;&#x2122;s treatment journey. Operationalisation: measured in terms of successful referrals and inter-agency management of dual diagnosis clients. Staff survey on identification and management of co-morbidities. Criminal Justice 12. Safety net mechanisms for clients engaged in DIP/CJ routes need to be strengthened to reduce dropout and non-conversion of contacts to care-planned treatment episodes particularly for cocaine and crack users. Operationalisation: assessment of database overlap of treatment uptake by characteristics in DIP settings and uptake of treatment by prison release populations. Measurement of translation rates of outreach worker contact into successful re-engagement with DIP teams. 13. There is a need to address the transitional care of individuals leaving prison to increase engagement in community services and to reduce drug related deaths due to overdose or drug poisoning. Operationalisation: assessment of number of drug-related deaths and overlap with prison population. Improvement of data sharing to measure the relationship between DRD and prison release. Improved mapping of uptake of treatment provision in prison release cohort. Page 58 of 60
Community Level 14. To develop community delivery of interventions including the involvement of local community groups who have specialist knowledge in relation to substance misuse and associated issues in their neighbourhoods. Operationalisation: Assessment of LDG treatment pathways and subsequent rates of referral to tier 2 and 3 services. 15. To continue to improve the links with Tier 1 services and non-commissioned community drug services to develop provision and pathways for client groups currently underrepresented in structured treatment. Operationalisation: Measurement of rates of referral and treatment engagement from tier 1 services and rates of effective community re-engagement of clients completing treatment. Conclusions Significant commitment has been made in the last year to improving the treatment system by both committing to the NTAâ&#x20AC;&#x2122;s treatment effectiveness agenda through BTEI and to clearing system blockages through the development of a new system for Tier 4 provision for both drinkers and drug users in Birmingham. In both cases, the emphasis is on improving the quality of delivery in the city and in ensuring that clients receive a consistent and evidence-based service that offers real choices and that promotes an individualised â&#x20AC;&#x2DC;recovery journeyâ&#x20AC;&#x2122;. This work will need to continue to address a changing drug-using population, and the commitment to a local community approach to meeting needs will be a critical part of this endeavour.
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Section 11 - Acknowledgements The following needs assessment would not have been possible without the input of a number of professionals and local stakeholders. The Birmingham Drug Action Team and the authors would like to thank all those who contributed their time and expertise in helping to develop this needs assessment. We would also particularly like to acknowledge the contribution of the expert group members in providing data and key informant information and the service user group who provided a unique perspective of the drug treatment system.
The Authors Jessica Loaring Dr. David Best Birmingham Drug Action Team Part of the Community Safety Partnership Gee Business Centre Technology Block Holborn Hill Aston B7 5PA
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