Download Bradford District Substance Misuse Recovery System Review

Bradford District Substance Misuse
Recovery System Review
Version:
Date:
Draft v.1
22/09/15
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Contents
Executive Summary ………………………………………………………………………………………
4
Section 1 – Introduction ……………………………………………………………………………….
10
Section 2 - Background to Review ………………………………………………………………..
2.1 Review Aims ………………………………………………………………………………………..
2.2 Review Outputs ……………………………………………………………………………………
2.3 Method of Approach ……………………………………………………………………………
2.4 Governance and reporting structures ………………………………………………….
2.5 Out of scope of review ………………………………………………………………………..
2.6 Limitations and risks ……………………………………………………………………………
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Section 3 – Areas for Consideration ……………………………………………………………...
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3.1 Treatment naïve clients ……………………………………………………………………….
3.2 Re-presenting clients …………………………………………………………………………..
3.3 Long term clients …………………………………………………………………………………
3.4 Clients using on top ……………………………………………………………………………..
3.5 Most complex clients …………………………………………………………………………..
3.6 Increasing recovery capital generally ………………………………………………….
3.7 Early unplanned exit …………………………………………………………………………….
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Section 4 – National and Local Strategic Influences ……………………………………….
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Section 5 – The Bradford Substance Misuse System ……………………………………...
5.1 Development of the Substance Misuse System in Bradford ………………….
5.2 Commissioned Alcohol and Drug Services …………………………………………….
5.3 Commissioned Alcohol Services ……………………………………………………………
5.4 Commissioned Drug Services ………………………………………………………………..
5.5 Referral Pathways …………………………………………………………………………………
5.6 Location of Services ………………………………………………………………………………
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Section 6 – Bradford Population / In Treatment Population ………………………….
6.1 Population – Age ………………………………………………………………………………….
6.2 Population – Ethnicity ………………………………………………………………………….
6.3 Adults in Drug Treatment …………………………………………………………………….
6.4 Prevalence of Opiate and Crack Use …………………………………………………….
6.5 Living with Children ……………………………………………………………………………..
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Section 7 – Performance of Current Substance Misuse System ……………………… 34
Section 8 – Bradford Treatment System Financial Overview …………………………. 41
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Section 9 – Themed Areas …………………………………………………………………………….. 42
9.1 Alcohol …………………………………………………………………………………………………
9.2 Drugs: Opiate and Crack Users (OCUs)………………………………………………….
9.3 Drugs: Non OCUs …………………………………………………………………………………
9.4 Dual Diagnosis ……………………………………………………………………………………..
9.5 Transitional Services …………………………………………………………………………….
9.6 Harm Reduction ……………………………………………………………………………………
9.7 Criminal Justice …………………………………………………………………………………….
9.8 Aftercare, Mutual Aid and Facilitated Support Groups ………………………...
9.9 Education / Training and Employment (ETE) …………………………………………
9.10 Service User Involvement ……………………………………………………………………
9.11 Concerned Others ……………………………………………………………………………….
9.12 Drug Related Deaths ……………………………………………………………………………
9.13 Information Technology ………………………………………………………………………
9.14 Prescribing Costs …………………………………………………………………………………
9.15 Testing Costs ……………………………………………………………………………………….
9.16 Governance …………………………………………………………………………………………
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Section 10 – Consultation with Stakeholders ………………………………………………….. 72
10.1 Aims of consultation …………………………………………………………………………….
10.2 Method of consultation ………………………………………………………………………..
10.3 Topics considered …………………………………………………………………………………
10.4 Promotion and distribution ………………………………………………………………….
10.5 Participation ………………………………………………………………………………………..
10.6 Summary of results ……………………………………………………………………………..
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Section 11 – Recommendations for future Substance Misuse System …………..……..……. 78
Appendices ………………………………………………………………………………………………………………. 81
Appendix A Glossary …………………………………………………………………………………………………. 81
Appendix B Review Group Terms of Reference .………………………………………….……………… 84
Appendix C Committed Funding 2015/16 ………………………………………………………………….. 86
Appendix D Local Authorities which together make Bradford’s ‘Local
Outcome Comparators’ (LOC) ……………………………………………………………………….…………… 90
Appendix E Substance Misuse Treatment and Recovery System Consultation
Results and Findings ……………………………………………………….……………………………..………….. 91
Appendix F Data Sources ……………………………………………………………………………..……..……. 114
Appendix G National and Local Drivers and Influences …………………………….…………….… 115
Appendix H Available Data Novel Psychoactive Substances (NPS) ……………………..……. 130
Appendix I Criminal Justice Review …………………………………………………………………………… 134
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Executive Summary
Purpose of this report
•
This report describes the process and outcomes of the review into the Bradford Substance
Misuse Recovery System, undertaken jointly between City of Bradford Metropolitan District
Council (CBMDC) Public Health Department and Bradford City, Districts and Airedale,
Wharfedale and Craven Clinical Commissioning Groups.
Background
•
For the purpose of this report, substance misuse refers to the misuse of illicit, prescribed
and over the counter medications as well as the misuse of alcohol.
•
For the purpose of this report, Recovery from problematic drug or alcohol use is
defined as a process in which the difficulties associated with substance misuse are
eliminated or significantly reduced, and the resulting personal improvement
becomes sustainable. This definition has been taken from the Welsh Governments’
Substance Misuse Framework document.1
1
•
The commissioning of the local drug and alcohol treatment services became the
responsibility of CBMDC in April 2013 as part of the changes brought about by the Health
and Social Care Act 2012.
•
The use of drugs and alcohol has changed dramatically over the past 10 years but the local
system has struggled to keep up with these changes. Improvements have been made and
there have been developments in services to try and meet the changing needs of those
requiring help and support. The problem, however, has been a historical organic approach
to service improvement.
•
Where funding has been made available, additional services have been commissioned to
increase capacity, provide targeted interventions and attempt to improve outcomes. Some
of these changes have brought improvements and success for both services and service
users, but some have not.
•
It is clear that commissioning in isolation and providing organic solutions which have not
always linked in effectively with existing infrastructure will not provide long term gains for
our drug and alcohol using population.
•
The current provision of services ensures all new referrals into treatment obtain support
through single points of access in both Bradford and Keighley. These offer intensive support
to achieve stabilisation before being transferred to a self-chosen and appropriate
community service.
•
There are specialist teams for both alcohol and drug services including substitute prescribing
and substance misuse clinical health interventions. Additionally the Needle Exchange
Scheme is an integral part of the local Harm Reduction Programme
http://www.unllais.co.uk/documents/Recovery%20Framework.pdf
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•
It should be noted that there are some very high quality services working within the district
to provide comprehensive services to our local population. These services are highly
regarded by service users and professionals alike.
Strategic Context
•
The majority of services within the local district were initially commissioned some time ago
and the original commissioning reflected earlier priorities from National Drug and Alcohol
Strategy. These aims included increasing the number of individuals in treatment and
retaining people in treatment as this was seen to provide the best outcomes.
•
The local system, originally based on a pharmacological model of delivery, no longer reflects
the national model as advocated by the National Drug Strategy.
•
More recently the National Drug Strategy 2010 moved the focus of treatment to recovery
from addiction and exit from treatment services.
•
The National Alcohol Strategy 2012 introduced a new approach to alcohol use and
treatment for those that require it. It champions a change in behaviour so that people think
it is not acceptable to drink in ways that could cause harm to themselves or others.
•
Recovery has become the focus of all substance misuse work and this ethos should be
embedded in all service delivery.
•
There are a number of national and local policies and strategies which directly influence the
review approach including some that whilst not directly related to substance misuse, still
impact on the future commissioning of services. The re-write of the 2007 Clinical guidelines
which provides guidance on the treatment of drug misuse in the UK is scheduled to be
published in early 2016 and will also include alcohol misuse and other wider ranging
determinants and related issues. It is key that these guidelines are considered for any future
commissioning.
The Review
•
The reasons for this review were:
o
The district has benefited from significant funding and has not undergone an overall
review for many years. The transfer of commissioning responsibilities to the Local
Authority provides an opportunity for review of the whole system approach to
substance misuse.
o
The evidence from data collected indicates that our current substance misuse
system has a higher proportion of service users in treatment over a long period of
time who continue to use illicit drugs. National policy is increasingly focused on
encouraging recovery from substance misuse. This review has focussed on how to
best address the needs of this group of service users.
o
There is evidence of a rapidly changing landscape of substance misuse. For example,
the increased use of Novel Psychoactive Substances (NPS), Prescription Only
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Medications (POM) and Over the Counter Medications (OTC). The current system
was not developed to meet the needs of these groups of service users.
•
o
Alcohol services need to responsive to changes in drinking behaviours within the
district and have a focus on both prevention of harmful drinking and recovery from
dependency.
o
There was an opportunity to make improvement in prevention, access, treatment
and recovery alongside key partners such as GPs, Community Groups and the
Voluntary Sector.
o
Given these factors in the context of local and national policy, the Public Health
Department along with local Clinical Commissioning Groups (CCG`s) undertook a full
review of the Substance Misuse Recovery System with regards to both Drug &
Alcohol use. The review has looked at substance misuse as a system rather than
specifically on individual components or discrete services.
The following areas of related provision were deemed to be out of scope for this review;
o
The Exiting Prostitution Service
o
Tier 4 In-Patient Detoxification (IPD) and Residential Rehabilitation
o
Young People’s Specialist Substance Misuse Services
•
During the undertaking of this review key areas which are referenced in the PHE Recovery
Diagnostic Toolkits as clinical prompts for commissioners and service providers were utilised.
•
This consequently enabled greater focus on key areas such as optimising treatment and also
taking into account specific groups including;
o
o
o
o
o
those new to treatment
service users who re-present
those who have been in treatment for four years or more,
individuals who choose to use illicit drugs on top of prescribed medication
those who have more complex needs including mental health problems.
•
The Service Review public consultation process was intended to obtain the views of all
stakeholders including service users, providers, health care professionals and the general
public.
•
The review aimed to gain an understanding on how people feel the system is working and
what is important for those supported by the system.
•
Three main themes emerged from the consultation;
o
the desire for a clear consistent approach to the delivery of services
o
it was identified that a key strength to the system are those who deliver the
treatment and recovery services
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o
more information to be made available about the Recovery System
Key Findings from the Review
•
Future commissioning of substance misuse services in the Bradford District should take into
account the following findings:
o
Recovery should be central to the new system
o
Access to services and movement within a treatment system should be simple and effective
with good information flow which follows the service user through to treatment exit
o
Services should be commissioned in a way that they are able to work effectively with users
of all drugs, including alcohol, thereby cutting down on duplication, offering better efficiency
and improved outcomes
o
Frontline workers within the substance misuse sector should be appropriately equipped with
the skills and knowledge to work with users of the whole range of drug of abuse, which must
include:
Alcohol
Novel Psychoactive Substances (NPS)
Prescription Only Medications (POM)
Over the Counter Medications (OTC)
Image and Performance Enhancing Drugs (IPED)
o
The district requires significantly more treatment places for those with alcohol related
problems
o
The re-write of the 2007 Clinical Guidelines on the Treatment of Drug Misuse in the UK is
scheduled to be published in early 2016. It is imperative that these guidelines are taken into
account for any future commission of services.
o
There is a need for further identification and brief advice interventions to be conducted in
the community, primarily regarding alcohol misuse, but also drug misuse. There is a
particular need to further embed these interventions within primary care
o
Those who have been in the system for a long time without making progress should be
identified and given additional support where appropriate or alternative treatment options
sought.
o
Psychosocial interventions must be evidenced based with staff appropriately trained and
resourced in order be able to deliver effectively
o
Provision of dual diagnosis services requires remodelling into a broader all-encompassing
service to ensure people do not fall between the gaps of service delivery. This should include
working together with other health-based services to provide a complex care outreach
model of delivery where required.
o
Increased levels of physical health issues associated with an ageing population of service
users should be addressed either through service provision or via clear pathway working.
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o
There is a need to incorporate the criminal justice element of service delivery into the
general substance misuse service delivery in order to improve pathways and outcomes
o
Ideally one shared IT medical record and care-planning system should be utilised. Where
this is not possible, IT systems should 'talk' to each other to ensure appropriate sharing of
information. Training for effective use of IT systems is essential.
o
Service User representation within the current system is not integrated effectively. Service
User voice should be more influential, particularly regarding strategic decision making.
o
Quality services for Concerned Others (Carers) are crucial in order to increase the positive
outcomes for those in treatment. The influence of well-informed and well-supported
Concerned Others on substance misusers has been proven to make treatment more
effective and recovery more sustained.
o
Transitional services should be developed to ensure service users between the ages of 21-25
are fully engaged and receive a service appropriate to their age, which meets the particular
requirements of this group.
o
Local good practice and innovation should not be lost through any retender exercise but
where possible built into any new specification/s.
o
GP practices and community locations should be utilised for service delivery where possible
in order to help normalise care and move away from ‘ghettoised’ treatment provision.
o
Health services must take an alternative approach to pain management with regards to the
overuse of pain medications. This issue needs to be addressed outside of this system
development.
o
Prevention work related to the adult drug using population and affecting the wider
population must continue to be supported. This includes:
Blood borne virus testing and immunisation
Primary care screening for both alcohol and drug misuse
Provision of Naloxone to all those who may benefit
o
Provision of small grants to be made available to assist established and new ventures to
work alongside the core business of the substance misuse system. These grants should be
time-limited to 2 years in order for such schemes to become self-funding.
o
Further work should be completed identifying unit costs for the various modalities of care
within the current treatment system in order any changes to commissioning can use these
figures as a benchmark.
o
Strategic input and influence to the prison system in support of recovery of individuals prior
to release
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Key Recommendation from the Review
•
Following this review of current service delivery and outcomes, it is recommended that there is a
fundamental change to the commissioning strategy for the district, based on genuine joined up
commissioning across health and social care.
•
This will be made possible by the formation of a new Joint Commissioning Group bringing
together the Clinical Commissioning Groups, Local Authority and other key stakeholders who will
have the responsibility of commissioning a simpler and more effective recovery system for the
population of Bradford District.
•
The key recommendation is that a Joint Commissioning Group should be formed from key
members of the three local CCG’s, Public Health and other key stakeholders, with a remit to:
•
o
Develop a joint commissioning plan for the whole substance misuse system
o
Develop the necessary service specification/s
o
Agree the funding requirements and funding responsibilities for the new system
o
Ensure all necessary pathways are in place and develop any additional pathways
which are required
o
Develop appropriate clinical governance arrangements
o
Develop a robust quality assurance framework
o
Jointly commission a new substance misuse system
The new joint commissioning group will be tasked with procuring a new evidence based
substance misuse system for the district in a way which successfully tackles the issues raised
within the review. The intention is that a new system will be live by October 2017.
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Section 1. Introduction
1.1.
1.2.
In October 2014 a review of drug and alcohol commissioning was published, which had been
jointly conducted by Public Health England (PHE) and the Association of Directors of Public
Health2.
The key themes reported within this review demonstrated that;
• for many areas 2015-16 will see a focus on reassessing current service provision with
the view to recommissioning services
• there were planned realignments of resources between alcohol and drug services –
with alcohol assessed as the greater need
• there was a focus on improving outcomes
• continuing the move to a recovery model
• improved delivery and performance by providers was a clear aim in all
recommissioning, with a focus on improving treatment completions
• there were concerns regarding the volatility of funding during this time of change,
the continuous drive to reassess and retender services, and the need for
commissioners to understand the impact frequent tendering processes have on
providers
• the Association of Chief Police Officers (ACPO) emphasised the value it places on the
importance of effective drug treatment services to the criminal justice agenda and
the need to ensure any reductions in investment or changes to current provision do
not reduce the effectiveness of services, as this could prejudice the crime-reduction
benefits of the current approach
1.3.
Also, the review picked up on what had not gone so well during 2014-15. The respondents
had focused on three main themes:
• impact of transition from NHS to Local Authority
• issues with provider performance and;
• establishing new governance arrangements.
1.4.
In line with the PHE joint review, the Bradford District review was conducted for similar
reasons and has identified similar findings.
1.5.
Described within this report are the methodologies behind the review, the findings of the
consultation and desktop analysis of best practice, local delivery model and performance
data. The report concludes with an options appraisal for future commissioning complete
with the recommended option which in the view of the Local Authority and Local CCG's
offers the best delivery model for our local population.
2
http://www.nta.nhs.uk/uploads/review-of-drug-and-alcohol-commissioning-2014.pdf
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Section 2. Background to Review
•
The Health and Social Care Act 20123 transferred the responsibility for Public Health into the
local Authorities. As such the local authority-based public health became responsible for
commissioning drug and alcohol prevention, treatment and linked recovery support in April
2013. The system for providing substance misuse services in Bradford has not been reviewed
in full since this transfer took place. There is currently an opportunity to review the
substance misuse system and identify areas for improvement.
•
The shift of responsibility of substance misuse commissioning provides a platform for a more
integrated approach to improving public health outcomes. This approach addresses the root
causes and wider determinants of drug dependence and alcohol misuse, and the harm and
impact they have on communities and troubled families (such as mental health,
employment, education, crime and housing). It also delivers the greatest gains for
individuals and the community.
•
This report is to document the findings of the Substance Misuse Recovery System Review
Project Management Group into the substance misuse system commissioned by the City of
Bradford Metropolitan District Council (CBMDC) Public Health team and the local Clinical
Commissioning Groups. The purpose of Substance Misuse Recovery System Review Project
Management Group is to allow members of the City of Bradford Metropolitan District
Council (CBMDC) Public Health team, representatives from other local authority
departments and partner organisations to come together and conduct a review.
•
The outputs of the review will allow the current provision of services to be evaluated against
both local and national polices and evidence based practice.
2.1 Review Aims
The aims of the review are as follows:
2.1.1. Analysis of current evidence base, national and local guidance and best practice for the
provision of Substance Misuse services.
2.1.2. Analysis of current geographic and demographic data used to inform needs assessment.
2.1.3
Analysis of current system performance data sets and the current local service delivery
model.
2.1.4. Support the commissioning of recovery focused substance misuse services that are
accessible to the population of Bradford.
2.1.5. Demonstrate options for delivering a recovery focused substance misuse system that are
accessible to the population of Bradford.
3
http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted
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2.1.6
Consider the effects of implementing such a system on Service Users, current providers and
the local population.
2.2 Review Outputs
2.2.1
The review will produce a full report of findings of the review and will be given to Council’s
Executive Committee and to the CCG Clinical Boards, which will provide a number of options
regarding the future direction for the commissioning of substance misuse services within the
Bradford District.
2.3 Method of Approach
The method of approach was as follows:
2.3.1
Desktop evaluation of current evidence base, data and available local and national guidance.
2.3.2
Consultation with stakeholders. Consultation has taken place with key stakeholders
including service users, current providers, carers, CCG representatives and the wider public.
2.3.3
Please refer to section 10 below for further details of the consultation process. Full analysis
of the consultation has been included in appendix 3.
2.4 Governance and Reporting Structures
2.4.1
The Project Management Group, from an operational perspective, will report directly to the
Public Health Department Management Meeting (DMT) chaired by the Director of Public
Health at CBMDC. Monthly updates on progress will be sent to this meeting.
2.4.2
Strategically, the Project Management Group will report to the Bradford Health and Care
Commissioners (BHCC) group on a monthly basis. The BHCC will be asked to make a
collaborative decision on the recommendations identified through the options appraisal of
the review. Ratification of the BHCC recommendations will be taken separately through the
Council Executive committee and the 3 CCGs executive boards.
2.5 Out of Scope of Review
The following areas of related provision were deemed to be out of scope for this review.
2.5.1
Prostitution
A district wide Prevention, Intervention and Exit from Prostitution (4Women) service
targeting women involved in both `on` and `off` street prostitution commenced on 1st April
2015. The service is delivered by Bridge alongside their drug treatment and recovery
services. The service commenced following a joint procurement exercise with Adults and
formed part of the Domestic and Sexual Violence Services 3 year contract. The service,
although funded through Public Health, is not a Drug or Alcohol specific service.
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2.5.2
Tier 4 In-Patient Detoxification (IPD) and Residential Rehabilitation
Currently in-patient detoxification services are commissioned and provided by a number of
contracted organisations services on an approved provider basis both within and outside of
the district. This service is delivered on a spot purchase basis and has recently gone out to
tender. It therefore will not form part of this review in terms of commissioned services but
the pathways in and out of IPD can be reviewed and refreshed.
2.5.3
Services for Young People
Young People’s Specialist Substance Misuse Services - These services were reviewed in
2013/4 so will not be subject to this review. Any subsequent review will take account of the
recommendations of this review.
2.6 Limitations and Risks
In addition to the areas deemed to be out of scope for the review referenced in section 2.5,
there have been a number of other limitations and risks regarding the review. Where these
have become apparent either before or during the review, they have been listed below;
2.6.1
Due to the timing of the review and the subsequent report, the data used when analysing
the effectiveness of the current system cuts across several years. Wherever possible the
most up to date information has been used, however, some of the data used maybe over 12
months old. Where data has used within the report, the source of the data is referenced. A
full list of data reports used has been included in Appendix G.
2.6.2
Further issues regarding data and outcome monitoring are the lack of a single system within
the district for substance misuse reporting, the current constraints around the data set used
by National Drug Treatment Monitoring System and the outcomes which services are
currently monitored against. These issues will be addressed as part of the review
recommendations.
2.6.3
A decision was made by the Project Management Group that the performance of
commissioned services would not be included in this review process as the focus of the
review is on the entire Recovery System.
2.6.4
Within the recommendations, it is noted through the clinical review that health services
should take an alternative approach to pain management with regards to the overuse of
pain medications. Whilst the commissioners have the ability to ensure that any new services
commissioned prescribe appropriately to the service using patients, and recommend
alternative methods of pain management where possible, this is a much bigger issue for
primary care. As such this issue needs to be further addressed outside of the substance
misuse system development.
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Section 3. Areas for Consideration
•
During the undertaking of this review, the following areas were considered. These are key
areas and are referenced in the PHE Recovery Diagnostic Toolkit 2014/15 as clinical prompts
for commissioners and service providers alike.
•
Whilst PHE state that drug treatment continues to head in the right direction in England,
there is recognition that the original pool of heroin and crack users is shrinking and there is a
shift within the treatment population profile. There are now fewer young users of opiates
and crack cocaine, and increased numbers of older users, a high proportion of whom have
been in treatment for many years and may have had several treatment episodes.
•
Below are a number of clinical prompts contained within the toolkit which are intended to
guide, inform and support appropriate solutions to issues within local treatment
populations.
3.1 Treatment naïve clients
3.1.1
National evidence shows that treatment naïve clients (i.e. those new to treatment, with no
prior episodes) are more likely to complete treatment successfully. In order to capitalise on
this commissioners will want to ensure their treatment systems maximise rapid, positive
outcomes for these clients
3.1.2
In order to best serve those within Bradford who are new to treatment, the
recommendations of this report will take into consideration:
o
Working differently with new service users in a way which capitalise on the clients’
enthusiasm for change and maximises recovery benefits during the initial phase of
treatment
o
Ensuring that ‘Recovery’ is visible from the moment service users walk through the
door. This allows them to see that treatment can work and that change is possible.
o
Further development of volunteer and recovery mentors to support new service
users.
3.2 Re-presenting clients
3.2.1
National evidence shows that re-presenting clients (i.e. those who have had prior
episodes of treatment especially multiple previous journeys or unplanned exits) are less
likely to complete treatment successfully. The effect is more pronounced if they have
previously unsuccessful journeys.
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3.2.2
This is a particular issue within the district, and current service configuration has not been
able to manage this client group in a way that enables them to make progress effectively.
3.2.3
In order to best serve those within Bradford who fall within this category, the
recommendations of this report will take into consideration:
o
Working differently with those clients who have a history dropping out of treatment,
by targeting treatment resources proportionately to minimise future risk.
o
Ensuring full assessments are carried out at the point of re-entry into treatment as
this will identify their strengths and the key obstacles to their recovery. It will also
allow them to explore what gains or progress was made during previous treatment
episodes and what wasn’t helpful.
o
Where previous treatment has been unsuccessful and there are multiple
representations a thorough review of the recovery care plan will be required and it
will be important to offer to do something different this time.
o
Ensuring that all treatment is fully optimised. To include optimised doses of
appropriate medications; reintroducing, reducing or dropping supervised
consumption as appropriate; active key-working, including case management and
psychosocial interventions.
o
Developing recovery capital for each service user. This includes links to other health
and social care services, improving relationships with family, friends and peers, and
helping with issues such as housing and employment.
o
Ensuring that Aftercare Services are offered and effective. Within the consultation it
was apparent that service users and services both thought that one of the largest
areas for development and need is Aftercare. Whether this is provided by substance
misuse specific services or more generic services should be considered.
3.3 Long term clients
3.3.1
National evidence shows that clients who have been in treatment continuously for four
years or more, or have very long drug use and treatment careers, are most likely to remain
in treatment.
3.3.2
This is more of an issue for drug using client as alcohol clients tend to have a shorter
treatment journey with small numbers remaining in treatment after one year.
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3.3.3
This is a significant issue for drug using clients within the district, with a higher proportion
staying in treatment over four years than seen nationally.
3.3.4
In order to best serve those within Bradford who fall within this category, the
recommendations of this report will take into consideration:
o
Ensuring that clients within this category receive sufficient ‘challenge’ or appropriate
personalised packages of care that enable them to move on and fully benefit from
treatment. They may be settled and stable, and unable or unwilling to make further
recovery efforts.
o
There may be some service users who need long-term maintained support, perhaps
due to ill-health, where staying in treatment may be best for them. Consideration
should be made regarding the form of that long-term support, eg. Primary Care.
3.4 Clients using on top
3.4.1
National evidence shows a sizeable proportion of clients still use their presenting substances
whilst in treatment. This includes a substantial number who use on top of their substitute
medication.
3.4.2
Also, regardless of the time clients spend in treatment; achieving abstinence from illicit
substances significantly increases their chances of successfully moving into recovery.
3.4.3
Clients who use on top and successfully complete are much more likely to re-present than
those not using at treatment exit.
3.4.4
Locally, data from treatment services and the needle exchange show that there are high
proportions of people currently in treatment, still using heroin and crack cocaine. Many of
whom are still injecting drug users.
3.4.5
In order to best serve those within Bradford who fall within this category, the
recommendations of this report will take into consideration:
o
The need to provide pharmacological treatment in the most effective way. This will
include using the most appropriate type of medication prescribed in an optimal way,
appropriate supervision and an understanding of any other factors that might affect
clinical treatment.
o
Ensuring that clients within this category receive sufficient ‘challenge’ regarding
ambivalence towards continued drug use and harmful drinking.
16 | P a g e
o
Appropriate use of random drug testing to confirm treatment compliance and
support the accuracy of self-reported abstinence. It should also be used to mark
progress in treatment.
o
Ensuring staff foster a culture of optimism and belief in recovery for all when
interacting with service users and other staff.
3.5 Most complex clients
3.5.1
National evidence shows that complex clients are less likely to successfully complete their
treatment. Complexity factors include housing risk, poor education or employment status
and poor quality of life scores. Other factors include low levels of social support, and
physical and mental health problems.
3.5.2
Locally, whilst there are services supporting those with complex needs, the system is
currently unable to meet the full range of complex needs displayed within the treatment
population.
3.5.3
Many of those with complex needs will also be those in treatment over four years or those
who struggle to engage effectively, with repeated cycles of recovery and relapse.
3.5.4
In order to best serve those within Bradford who fall within this category, the
recommendations of this report will take into consideration:
o
The need for clinical expertise to meet the needs of this group.
o
Appropriate assessment in order to develop a thorough understanding of clients’
substance use and the severity and complexity of clinical and other problems.
o
Provision of enhanced packages of care to meet their presenting needs.
3.6 Increasing recovery capital generally
3.6.1
National evidence shows that clients with higher levels of recovery capital are more likely to
quickly complete treatment successfully therefore it is important that the treatment system
is maximising the ability of all clients to improve their recovery capital and make best use of
it.
3.6.2
Locally, the treatment system has seen a shift in focus towards recovery, but this has not
been implemented universally. Recovery is now a key aim and aspiration within the system,
but the system is not currently engineered to support this aim equitably.
3.6.3
In order to best serve those within Bradford who fall within this category, the
recommendations of this report will take into consideration:
o
Consideration of a sufficiently integrated system which will benefit any work to build
recovery capital. Drug treatment services play a part in this, but it depends heavily
17 | P a g e
on contributions from other health and social care services, housing and
employment, family, friends and peers.
o
Monitoring & review of care plan reviews and Treatment Outcome Profile tool (TOP)
to identify areas for improvement, e.g. housing, employment, quality of life.
o
A good assessment will provide information about clients’ substance use, and the
severity and complexity of their clinical and other problems. The process will also
highlight the clients’ wishes, their strengths and the key obstacles to their recovery.
o
Recovery care planning which will initially follow the joint or shared goals identified
in the assessment.
o
Importance of attention to all the areas of a client’s recovery capital including social,
physical, human and cultural issues.
3.7 Early unplanned exit
3.7.1
National evidence shows that those who have early unplanned exits will limit the benefits
they receive from treatment. They also increase their risk of relapse and overdose death.
3.7.2
Increased participation and retention in treatment is associated with positive treatment
outcomes.
3.7.3
Locally, early unplanned exits for drug misusers are higher than national figures, with opiate
users significantly more likely to leave treatment early when compared to national averages.
It is important that changes are made to help ensure that service users stay in treatment for
at least 12 weeks, in order to capitalise on the window of opportunity for improvement
provided during the early months of treatment and increase service users’ chances of
success.
3.7.4
Those in treatment for alcohol use are less likely to leave treatment early than the national
picture.
3.7.5
In order to best serve those within Bradford who fall within this category, the
recommendations of this report will take into consideration:
o
Evidence showing that by reaching optimal levels of prescribing quickly, service
users are more likely to engage effectively in treatment.
o
Identification and targeting of those coming into treatment who have previously
exited early, in order that additional support can be offered.
o
Easier engagement for new service users, to include offering additional support such
as flexible opening hours and help with childcare.
18 | P a g e
o
Improved re-engagement of those who drop out of treatment, which should include
better use of an integrated IT system.
Section 4. National & Local Strategic Influences
4.1
The majority of services within the local district were initially commissioned some time ago
and the original commissioning reflected earlier priorities from National Drug and Alcohol
Strategy. These aims included increasing the number of individuals in treatment and
retaining people in treatment as this was seen to provide the best outcomes.
4.2
More recently the National Drug Strategy 2010: Supporting People to Live a Drug-Free Life 4,
moved the focus of treatment to recovery from addiction and exit from treatment services.
This strategy is further supported by the 2015 update Drug Strategy Annual Review 2015 - `A
Balanced Approach`5
4.3
The National Alcohol Strategy 20126 introduced a new approach to alcohol use and
treatment for those that require it. It champions a change in behaviour so that people think
it is not acceptable to drink in ways that could cause harm to themselves or others.
4.4
Recovery is key to the new alcohol and drug strategies. For the purpose of this report
recovery from problematic drug or alcohol use is defined as a process in which the
difficulties associated with substance misuse are eliminated or significantly reduced,
and the resulting personal improvement becomes sustainable.
4.5
Commissioned services are expected to follow the latest available clinical guidance. The
2007 UK Guidelines on Clinical Management7, known as ‘the orange book’ provides guidance
on the treatment of drug misuse in the UK is currently being updated and is scheduled to be
published in early 2016. This will include alcohol misuse, novel psychoactive substances and
other wider ranging related issues. Future commissioning will need to take this guidance
into account.
4.6
There are also there are a number of policies and strategies that whilst are not directly
related to substance misuse, still impact on the future commissioning of services. Where
possible these have also been considered. A brief description of these policies and
strategies are included in Appendix G.
4.7
The National Treatment Agency (NTA) was created as a Special Health Authority in 2001 to
improve the availability, capacity and effectiveness of drug treatment in England.
4.8
On the 1st April 2013 Public Health England (PHE) was established to bring together public
health specialists from more than 70 organisations, including the NTA, into a single public
health service.
4
http://www.homeoffice.gov.uk/drugs/drug-strategy-2010
https://www.gov.uk/.../drug-strategy-annual-review-2014-to-2015
6
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224075/alcohol-strategy.pdf
7
http://www.nta.nhs.uk/uploads/clinical_guidelines_2007.pdf
5
19 | P a g e
4.9
PHE continues to have a lead role in substance misuse and will support commissioners and
providers with guidance, best practice and provision of data through National Drug
Treatment Monitoring System (NDTMS).
4.10
The implications of substance misuse on health and the health system are wide ranging:
4.11
o
Drinking at levels above the recommended guidelines increases the risk of harm to
health
o
Alcohol is one of the three biggest lifestyle risk factors for disease and death in the
UK, after smoking and obesity.
o
Alcohol related illness is a major contributor to planned and unplanned hospital
admissions
o
Drug misuse impacts on the individual’s health in many ways including increased risk
of blood-borne viruses, overdose and increased mental health issues.
The links between substance misuse and offending behaviour are well documented:
o
The Home Office estimates drug related crime costs £13bn per year.
o
Evidence from PHE shows that drug treatment reduces drug related offending
o
Excessive use of alcohol increases likelihood of involvement in crime or disorder as
either a victim or an offender.
Section 5. The Bradford Substance Misuse System
•
This section provides an understanding of how the current substance misuse system has
developed. There is also a brief description of the current commissioned services which
provide a wide range of interventions to support people with substance misuse issues.
•
These services generally deliver high quality interventions which are viewed positively by
both service users and commissioners. This is further evidenced in the consultation report
discussed in Section 10. However, what is apparent within the district is the lack of
connectivity between services and poor use of pathways, which leads to lack of movement
within the system and high rates of unplanned exits.
5.1 Development of a Substance Misuse System in Bradford
5.1.1
There have been drug and alcohol services in the Bradford District for over 25 years, during
which time services have changed, developed and expanded where funding has been
available in order to try and provide services in line with in line with Government policy.
20 | P a g e
5.1.2
Due to previous restrictions on the use of funding, wherein the Pooled Treatment Budget
was only available to fund drug services, the services available to those with alcohol issues
have always been seen as the poor relation and under-resourced.
5.1.3
Due to issues such as restricted funding and changes in strategic direction, the development
of services can be seen as following an organic approach. New services and elements of
treatment have previously been added to the system in a bolt-on fashion, utilising available
funding streams to bolster provision.
5.1.4
Due to the way services have developed, the system is now supported by a number of
provider organisations, commissioned through an array of contracts, which inevitably leads
to inefficiencies such as supporting multiple management structures.
5.1.5
As with other districts, many of the services working with drug users were originally based
on a pharmacological model of delivery. Due to the way these were originally
commissioned, moving the service ethos to one of a recovery focussed model as advocated
by the National Drugs Strategy has not always been straightforward or successful. The
reasons for this are numerous, but include;
o capacity issues within some services when trying to deliver psychosocial
interventions alongside prescribed treatment
o services not able to work effectively with people who have multiple substance
issues, such as opiate and crack use alongside alcohol and possibly over the counter
medications
o staff and service users attitudes to change.
5.1.6
However a number of services have since been commissioned embracing the recovery
model, and now provide recovery focused interventions within the district.
5.1.7
Commissioners have worked with providers to try and ensure that services have been
accessible, being positioned geographically across the district.
5.1.8
Interventions currently offered within the district include:
o Harm reduction including needle exchange and blood borne virus testing and
immunisation
o Access to recovery support services such as to housing, employment, and mental
and physical wellbeing
o Family focused interventions;
o Psychosocial interventions;
o Clinical services including substitute prescribing and physical healthcare;
o Criminal justice interventions.
o After care;
o Peer support;
o Volunteer training;
o Concerned other / Carer support;
o Access to detoxification and residential rehabilitation services;
o Specialist services for women including enhanced care for pregnant women.
o Simulant Services
21 | P a g e
o
o
o
o
o
o
o
o
o
o
o
o
o
5.1.9
BME specific support
Structured recovery programmes
Family support services
Training services
Complementary therapies
Group work
Brief Interventions
Access to Community Mental Health Teams, i.e. access to secondary services
specialising in mental health if appropriate
Debt counselling
Tenancy support
Welfare benefits
Personal development, education, training and employment
Hostel Liaison
Desired outcomes for people entering treatment into substance misuse services include
o
Recovery and freedom from dependence on drugs or alcohol
o
Prevention of drug and alcohol related deaths;
o
Prevention of infection by Blood Borne Viruses;
o
Reduction in crime and re-offending;
o
Sustained employment;
o
The ability to access and sustain suitable accommodation;
o
Improvement in mental and physical well-being;
o
Improved relationships with family members, partners and friends;
5.1.10 In the service descriptions below, there is reference to the various Tiers across which the
services work. Tiers of service indicate where different components of care may and support
may take place.
Tier 1
Non-substance misuse specific services
Tier 2
Open access alcohol treatment services for drugs and alcohol
Tier 3
Structured community-based treatment services those using
drugs and alcohol at a harmful level
Tier 4
Residential alcohol and drug misuse specific services
22 | P a g e
5.1.11 Tier 1- Non alcohol and drug treatment specific services
These early steps are attended to by a wide range of professionals (e.g. primary care medical
services, community pharmacists, and voluntary/community projects) who often provide
advice and support to individuals with various levels of alcohol and drug use/misuse. This
advice and support may be sufficient depending on the level of problem the individual is
experiencing. Sign-posting or referring to more specific agencies is often considered when a
person is experiencing more significant problems caused by their drug or alcohol misuse.
5.1.12 Tier 2 – Open access alcohol and drug support services
These steps can be early or later in the process of developing alcohol or drug problems and
are characterised by provision of open access to drug and alcohol services for a wide range
of individuals including those who self-refer. The aim of the Tier 2 service is to engage the
individual to reduce the drug or alcohol related harm. Tier 2 services do not necessarily
require a high level of commitment to structured programmes or a complex lengthy
assessment. Tier 2 services include needle exchange, voluntary and community projects,
drug and alcohol information and support, and primary care.
5.1.13 Tier 3 – Structured treatment
The stepped care model considers Tier 3 services as providing stepped care for more
pronounced problems that require more intensive and complex assessment and treatment
planning. Tier 3 services are community based and are targeted toward individuals who are
experiencing harmful or dependency problems from their use of drugs and alcohol and who
are interested in making changes to their current use of substances. Individuals choose their
own treatment goal which can range from seeking total abstinence to seeking to moderate
their substance use and reduce the harm caused by their use of alcohol or/and drugs.
Interventions are provided by specially trained professionals, are structured and begin with
motivational interviewing to help guide individuals in determining a way forward and
choosing a treatment goal that they will be most likely to succeed with.
Structured treatment programmes are psycho-therapeutically focused and may have
pharmacological aspects to individual care plans.
5.1.14 Tier 4 – Residential services
Tier 4 services are residentially based services for individuals who experience significant
dependency problems with alcohol and drugs and for whom Tier 3 services have not been
sufficient in helping the individual to succeed in the changes they seek regarding their use of
substances or for individuals with a high level of complex presenting need.
23 | P a g e
5.1.15 It should be noted that the Tier model is mainly based on degree of dependency on the
substance, and has limitations when considering a more holistic approach.
5.1.16 Changes were made several years ago to improve the access routes into treatment for both
drug and alcohol users. Development of Fresh Start assessment hubs in Bradford and
Airedale, and an alcohol assessment hub in Bradford have streamlined access pathways.
However, this hasn’t been without problems. Due to the nature of substance misuse
treatment. Starting all new treatment journeys through 3 services instead of spreading them
out across the district has highlighted some of the engagement issues faced within this
sector.
5.1.17 Due to the nature of the provision by multiple providers through multiple contracts, care
coordination across the treatment system is not as clear or as effective as it could be, which
can result in service users not always receiving the range of provision they could benefit
from.
5.1.18 Whilst there has been some significant decommissioning and re-commissioning of contracts
locally, the contracts for much of the current system have not been tested on an open
market.
5.2 Commissioned Alcohol and Drug Services
5.2.1 Addaction
•
Addaction provide the Substance Misuse Clinical Support Services from within the following
host services
o
o
o
o
o
o
o
Airedale Fresh Start
Bradford Fresh Start
Bridge Project
Bradford City Substance Misuse Service
North Bradford Substance Misuse Service
Piccadilly Project
Safe Haven
•
Delivered by specialist clinicians, the services include substitute prescribing and substance
misuse related clinical health interventions.
•
Addaction work closely with the host provider in order to deliver joined up care-planned
support.
5.2.2 Airedale Community Drug and Alcohol Team (ACDAT)
•
Provided by Bradford District Care Foundation Trust (BDCFT) and provides a Dual Diagnosis
Tier 3 substance misuse service from premises in Keighley (BD21) delivering interventions to
drug and alcohol users and those with mental health problems.
5.2.3 Arch
•
Arch is commissioned by PH to provide the following Tier 2 & 3 criminal justice
interventions. :
24 | P a g e
Targeted Assessment and interventions to drug and alcohol users within Police
Custody, Courts, Prison and Community.
Case management of individuals whilst on case load
Referrals to specialist drug and alcohol services
Referrals to agencies providing wrap around support e.g Housing and ETE
Psychosocial Interventions
Structured day programme for DRR
Alcohol Brief Interventions
Outreach - targeting areas where ASB/nuisance identified delivering
interventions to Street Drinkers / NPS users.
5.2.4 Bradford Community Drug & Alcohol Team
•
Delivered by BDCFT, comprising of a dual diagnosis and prescribing service delivered by a
team of specialist health care professionals working in the alcohol and drug field. The Team
provides professional care and treatment for those experiencing complex problems with
alcohol use, drug use and mental health.
5.2.5 Horton Housing
•
Voluntary sector organisation based at Edmund Street Bradford City Centre (BD5), providing
Tier 2 interventions to address illicit substance misuse issues and housing related support.
•
Providing particular support to people from Central and Eastern Europe, those with housing
issues and street drinkers.
•
Horton Housing also provides workers within the Alcohol Assessment Hub and A&E.
5.2.6 Project 6 (P6)
•
•
•
•
Voluntary sector organisation based in Keighley Town Centre (BD 21), P6 are a recovery
focused, harm reduction service who work to help people reduce the risks associated with
substance misuse.
The organisation also hosts the Substance Misuse Assessment Hub for the Keighley and
Airedale area and contributes to the delivery of the Alcohol Pilot. Where clinical services are
provided within Project 6, these will be delivered by Addaction.
P6 also operate a number of specialist recovery services including the Integrated Family
Recovery Services ,Structured Recovery Programmes and Aftercare
P6 also deliver a number of other services including Needle Exchange Service ,Stimulant
Services , Asian Community project , Complimentary Therapies and Criminal Justice Services
25 | P a g e
5.2.7 West Yorkshire Police
•
West Yorkshire Police provide a team to support the engagement and retention of substance
misusing individuals within community services in order to reduce reoffending and
substance misuse. They also provide a link with local Neighbourhood Policing Teams and
manage the Integrated Offender Management (IOM) process across the district where the
most problematic offenders are managed by the partnership.
5.3 Commissioned Alcohol Services
5.3.1 Hospital based Services
•
BDCFT provides Alcohol Clinical Nurse Specialists within Bradford Royal Infirmary and
Airedale General Hospital. These nurses work on the wards to identify patients who have
been admitted where alcohol is a factor. They assess and provide brief advice regarding the
patients’ alcohol use or refer on for more specialist treatment as appropriate.
5.3.2 Lifeline - Piccadilly Project
•
•
Lifeline Piccadilly is a recovery focussed voluntary sector organisation providing support to
those with issues around alcohol use, based in Piccadilly, Bradford (BD1). It provides a drop
in service, structured day programme and psychosocial interventions.
They also provide an alcohol specialist worker who works at BRI A&E department providing
identification and brief advice, referrals to detoxification and residential rehabilitation and
an abstinence and recovery service.
•
In addition Lifeline Piccadilly delivers the Alcohol Treatment Requirement (ATR) in
partnership with Probation and Community Rehabilitation Company (CRC) providing
interventions to offenders with alcohol issues. (all these services are funded via PH).
•
Lifeline Piccadilly also provides the Bradford Alcohol Assessment Hub staffed by alcohol
specialist staff including a Central and Eastern European worker and Identification and Brief
Advice Primary Care service.
5.4 Commissioned Drug Services
5.4.1 Bradford City Substance Misuse Service (BCSMS)
•
Delivered by BDCFT from Fountains Hall, BD1. It is a Tier 3 clinical drugs service for
substance misusers providing comprehensive assessment and care planning with the client
to assist meeting goals. The service provides psychosocial interventions, substitute
prescribing, liaison and referral to other agencies and regular review with a Specialist GP.
The clinical support is provided by Addaction.
5.4.2 Bridge Project
•
Bridge is a voluntary sector organisation which delivers both Tier 2 and 3 interventions
across Bradford. They are a city centre organisation based in Salem Street, BD1. They also
run the Unity Recovery Centre on Manningham Lane, BD1 and more recently opened up
Forks Café, a social enterprise project on North Parade.
26 | P a g e
•
Bridge hosts the Bradford Fresh Start Assessment Hub with clinical services delivered by
Addaction.
•
Bridge also operate specialist services including a Women’s Service, Hostel Support,
Benzodiazepine Withdrawal Service, Volunteers Service, Specialist Needle Exchange, Gym
facilities and a Young person and Family Service.
•
Bridge delivers The Change Programme, which works with users of Stimulants, Over-thecounter medications (OTC), Prescription Only Medications (POM), Novel Psychoactive
Substances (NPS), and Image and Performance Enhancing Drugs (IPEDs).
5.4.3 North Bradford Drug Service
•
Delivered by BDCFT from Eccleshill Clinic, BD10 and Shipley Medical Practice, BD18. The
service is a Tier 3 drugs service offering care-planned psychosocial interventions with clinical
support delivered by Addaction.
5.4.4 Dr Bavington & Partners GP Prescribing Service
•
Based at Kensington Street Health Centre in Girlington, BD8. It is a Tier 3 service offering
substitute prescribing, psychosocial interventions, along with the full range of GP care.
5.4.5 One Stop Maternity Service
•
Based at Bradford Royal Infirmary and is delivered by Bradford Teaching Hospital Foundation
Trust (BTHFT). The service delivers specialist ante-natal services to pregnant women who
have a substance misuse issue.
5.4.6 Keighley Primary Care Substance Misuse Service
•
•
The service provides specialist prescribing to individuals referred from the Fresh Start
Service. The service is delivered from the following four GP surgeries within the Keighley
area and supported by staff from BDCFT;
o
Farfield Practice
o
Holycroft Surgery
o
Kilmeny Surgery
o
Ling House Medical Practice.
Service users from these practices are encouraged to access Project 6 in order to receive
psychosocial interventions.
5.4.7 Support and Secure Substance Misuse Service (Safe Haven)
•
This service is delivered from Shipley Medical Practice and is restricted to service users who
have been immediately removed from a local substance misuse service or GP practice. The
service provides substance misuse care within a safe environment for both the service user
and the staff providing the service. The service is managed and run by BDCFT.
27 | P a g e
5.5 Referral Pathways
5.5.1 Referral process
•
All new referrals into treatment are through the following single points of access:
o
o
o
Airedale Fresh Start based at Project 6 in Keighley
Bradford Fresh Start hosted by Bridge in Bradford
Alcohol Assessment Hub based at Piccadilly Project in Bradford
•
The hubs are staffed by workers from several organisations, coming together to provide a
fully care-planned approach to support the service user.
•
The hubs offer an intensive engagement period in order to capitalise on the service users
desire to change. During this period they will be offered a comprehensive assessment
including health check and any substitute medication required will be provided through the
Addaction team.
•
The staff within the hubs will also work closely with the service users to ensure they are
engaged with partner agencies that are able to provide additional support with areas such as
welfare benefits, housing issues and employment, training and education.
•
Following a period of stabilisation, service users will be transferred to the most appropriate
community service chosen in conjunction with the service user.
5.5.2 Referral into drug treatment
•
80% of clients who were in drug treatment during 2013/14 were in Bradford based services
and 20% in Keighley based services.
•
39% of referrals were completely new to the treatment system. This is lower than the
national average with 43%, but slightly higher than regionally.
•
49% of referrals were self-referrals by service users, demonstrating the easy access into
treatment made possible through the Assessment Hubs.
•
There are a high proportion of service users (27%) which are referred via Arch (the criminal
justice service) which highlights the correlation between drug use and crime.
•
Following the change to drug testing implemented by the Police the numbers of tests has
reduced considerably. Arch have adapted their processes within Police custody to ensure
that substance misusers who have not been drug tested are still identified, assessed and
referred into treatment. This is reflected in the numbers being referred into treatment by
Criminal Justice Services.
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5.6 Location of Services
5.6.1
As discussed, the substance misuse system has developed over a number of years, and the
reason for the current geographical location of existing services is a combination of;
o
Commissioning decisions based on geographical need
o
A willingness of certain provider groups to deliver services, such as GP provision in
Airedale and a historic pattern of delivery remote from primary care in City and
Districts CCG area.
o
Ability to get planning permission to move services to available premises
o
Existing long-standing services and their available estate.
o
Historic establishment of services based on a particular viewpoint that substance
misuse should only be managed by specialist services.
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Section 6. Bradford Population / In Treatment Population
This section looks at Bradford’s current and future population, including the age, gender and
ethnicity of the population and comparing this with the current service population. This will help
when looking at planning services as it identifies possible areas of future need.
6.1 Population - Age
6.1.1
The following chart compares the District’s age profile to the age profile of clients in alcohol
and drug treatment in 2013.
Age profile of Bradford (2013 ONS mid-year estimates) and drug treatment clients)
Source: NDTMS and ONS mid-year population estimates 2013
6.1.2
The age profile of clients in alcohol & drug treatment presents some differences from the
profile of the Bradford population as a whole.
6.1.3
The largest proportion of service users accessing drug treatment are between 30 and 44
years old, whereas for alcohol treatment the highest proportion is between 30 and 54.
6.1.4
This supports the understanding that there is an aging drug using population in Bradford,
which brings about additional issues within that cohort such as multiple long term
conditions.
30 | P a g e
6.2 Population - Ethnicity
6.2.1
Bradford celebrates a broad and ethnically diverse population. The ethnic profile for the city
compared to alcohol & drug clients in treatment is shown in the following table
Bradford Ethnicity Profile compared with Alcohol & Drug Misuse Clients in Treatment
Ethnicity
White British
White Irish
Other White
White & Black
Caribbean
White & Black
African
White & Asian
Other Mixed
Indian
Pakistani
Bangladeshi
Other Asian
Black
Chinese
Other
Not stated
Total
Number in Alcohol
& Drug Treatment
(2013/14)
3,474
32
274
43
% of total
service users
10
0.2%
78.3%
0.7%
6.2%
1.0%
26
16
46
336
27
49
0.6%
0.4%
1.0%
7.6%
0.6%
1.1%
39
0
31
35
4,438
0.9%
0.0%
0.7%
0.8%
100.0%
Bradford
Population
(Census 2011)
334,034
2,573
2,089
4,674
917
5,787
2,856
1,261
106,743
9,874
15,385
9,643
2,127
24,489
0
522,452
% of Bradford
Population
63.9%
0.5%
0.4%
0.9%
0.2%
1.1%
0.5%
0.2%
20.4%
1.9%
2.9%
1.8%
0.4%
4.7%
0.0%
100.0%
Source: NDTMS 2013/14 & Census 2011
6.2.2
Over three quarters (78.3%) of those in treatment are White British; a further 6% of those in
treatment are White Other, which covers a multitude of ethnicities. Evidence from within
services suggests this group is predominantly made up from Eastern European communities.
6.2.3
It is forecast that over the next few decades Bradford’s population will have proportionally
less White British residents and an increased proportion of residents who describe their
ethnicity as ‘Pakistani’. Forecasts also suggest that there will be a slight increase in the
‘Other White’ group, and this is quite possibly due to an increase in the number of Eastern
European residents. Based on the information in the previous table, if this is the case, then
there should be a corresponding increase in those requiring treatment from this group.
6.2.4
These predicted changes in local population should be considered during any future
commissioning.
31 | P a g e
6.3 Adults in Alcohol & Drug Treatment (April 2013- March 2014)
6.3.1
The table below outlines the primary substance profile of adults in alcohol and drug
treatment between April 2013 and March 2014. The largest drug group is primary heroin
users with 52.7% followed by alcohol with 28.9%.
Primary substance of abuse profile of Adults in Alcohol and Drug Treatment between April 2013 and March 2014
Drug
Alcohol
Amphetamines
Cannabis
Cocaine
Crack
Heroin
Other Drugs
Total
Number Percentage
1281
28.9%
55
1.2%
285
6.4%
160
3.6%
90
2.0%
2337
52.7%
230
5.2%
4438
100.0%
Source: National Drug Treatment Monitoring System (NDTMS)
6.3.2
It should be noted that this table represents the in-treatment population and not service
need. Whilst there are more people in treatment for heroin misuse rather than alcohol
misuse, this is likely to be due to more treatment places being available for heroin users,
rather than there being more people using heroin than problematic alcohol users.
6.4 Prevalence of Opiate and Crack Use
6.4.1
Research into the prevalence of opiate and crack use in England is conducted by Glasgow
Prevalence Estimation, University of Manchester and Liverpool John Moores University.
6.4.2
The most recent report for (2011/12) estimates that in Bradford there are 4,441 OCUs, 4,215
of which are opiate users and 3,637 are crack users. 1,332 are estimated to be injecting.
Estimates of the Prevalence of Opiate Use and/ or Crack Cocaine Use (2011/12)
Source:
Bradford
Yorkshire & Humber
England
Number of users
Opiate
OCU
Users
4,441
4,215
36,270
32,312
293,879
256,163
Crack
Users
3,637
19,006
166,640
Injecting
1,332
11,692
87,302
University of Manchester and Liverpool John Moores University
6.4.3
On 31st March 2014 there were 1,997 OCU clients in treatment within the District, and an
additional 626 OCU clients that had been in treatment during the previous year, but were
no longer in treatment. Further to this there were 401 OCU’s that were still known to the
service but had not received any treatment in the previous 12 months. This means that
there were an estimated 1,027 OCU users known to the system who were not engaging in
treatment at that point in time. If the estimates in the chart above are used then the
number of OCU’s not engaging at that point was 2,444.
32 | P a g e
6.4.4
Both the local and Glasgow estimates demonstrate that there are significant numbers of
people with opiate and /or crack misuse problems who are not engaged in the system. Any
future commissioning should ensure that measures are taken to increase the likely
engagement of these individuals in treatment.
6.5 Living with children
6.5.1
As the following table will demonstrate, Bradford has a significantly higher reported number
of service users who live with children than compared to the national average.
6.5.2
This information is collected at the point of assessment when entering services, and is used
to ensure appropriate safeguarding measures are put in place when risks are identified.
6.5.3
Services have strived to become more family orientated, and have worked hard to break
down some of the myths held within this treatment population around parenting and risk of
children being taken into care.
6.5.4
A point to note is that with the enhanced assessment process undertaken by all service
users entering treatment, collecting information regarding children is extremely important.
There is a possibility that the reason the reported proportion of service users living with
children is higher than the national average, is due to the high quality of data collection in
the district. That being said, given the research and evidence base regarding the
negative impact of alcohol and drug misuse upon the family, children and young people
these statistics are of concern.
Proportion in treatment who live with children under the age of 18
(n) = number of clients in treatment who live with children / all in treatment
Latest Period
Opiate clients
Non-opiate clients
Alcohol clients
Alcohol and non-opiate clients
%
43.1%
27.1%
34.9
32.0%
N
1086/2519
128/472
433/1240
93/291
National
average
%
31.2%
25.6%
25.8%
25.1%
Source: National Drug Treatment Monitoring System (NDTMS) 2014/15
33 | P a g e
Section 7. Performance of Current Substance Misuse System
7.1
The way that the district currently measures of success of the substance misuse system
against predetermined outcomes is through the use of data submitted to the PHE National
Drug Treatment Monitoring System (NDTMS) and additional information gained directly
from the service providers using a performance framework. The following information is
taken from NDTMS information for 2014-15.
7.2
The table in 7.5 shows local performance against the main Public Health Outcome
Framework Indicator which shows the proportion of all those in treatment who successfully
exit and remain out of treatment for a further 6 months.
7.3
Locally the performance for opiate using clients is poor when compared to national figures
and Bradford’s Local Outcome Comparator (LOC) group. This group is made up of other
Local Authority areas which have similar demographics and levels of deprivation. The full list
of LOC groups can be seen in Appendix D.
7.4
Performance against this target for opiate users has been poor for some time, and does not
show any signs of improvement. Work has been undertaken across the system and within
individual agencies to try and improve levels of successful exits, with no impact on district
performance.
7.5
Levels of successful completion for non-opiate users continuing to improve.
Proportion of all in treatment, who successfully completed treatment & did not re-present within 6 months (PHOF 2.15
i/ii)
(n) = number successfully completed and did not re-present / all in treatment
Baseline period: Completion period: 01/10/2012 to 30/09/2013, Re-presentations up to: 31/03/2014
Latest Period: Completion period: 01/10/2013 to 30/09/2014, Re-presentations up to: 31/03/2015
Baseline Period
Local opiate clients
National opiate clients
Local non-opiate clients
National non-opiate
clients
%
6.2%
7.8%
38.4%
37.8%
n
165/2641
278/724
Latest Period
%
6.1%
7.6%
40.1%
39.0%
Top Quartile
range for
Comparator LAs
Range to
achieve Top
Quartile
n
157/2581
8.34% - 10.60%
216 to 273
308/769
46.23% - 58.59%
256 to 450
7.6
The following table shows the levels of successful exits as a proportion of all those in
treatment, but does not take into account re-presentation into treatment.
7.7
The picture is very similar to the PHOF performance above. Successful exits for opiate
clients continue to decline whereas non-opiate and alcohol clients continue to improve.
34 | P a g e
Successful completions as a proportion of all in treatment
(n) = number of successful completions / all in treatment
Baseline period: Completion period: 01/04/2013 to 31/03/2014
Latest Period: Completion period: 01/04/2014 to 31/03/2015
Baseline Period
Opiate clients
Non-opiate clients
Alcohol
Alcohol and non-opiate
clients
7.8
Latest Period
%
n
%
N
6.4%
43.7%
34.8%
31.6%
166/2611
203/465
336/965
90/285
6.0%
46.0%
37.0%
38.5%
150/2519
217/472
459/1240
112/291
Top Quartile
range for
Comparator LAs
*National
average
8.24% - 10.94%
46.15% - 61.27%
*39.21%
44.16% - 50.40%
Range to
achieve Top
Quartile
208 to 275
218 to 289
39.21%
129 to 146
As discussed in Section 3.2, re-presentations into treatment continue to be an issue in
Bradford for opiate clients. Bradford is falling short of the Top Quartile performance range
by some way. Re-presentations for both alcohol and non-opiate clients are reasonably low,
with alcohol re-presentation being within the top quartile range for comparator local
authorities.
Proportion who successfully completed treatment in the first 6 months of the latest 12 month period and re-presented
within 6 months
(n) = number of re-presentations / number of completions
Baseline period: Completion period: 01/04/2013 to 30/09/2013, Re-presentations up to: 31/03/2014
Latest Period: Completion period: 01/04/2014 to 30/09/2014, Re-presentations up to: 31/03/2015
Baseline Period
Opiate clients
Non-opiate clients
Alcohol
Alcohol and non-opiate
clients
%
25.7%
4.7%
13.1%
19.2%
n
28/109
5/106
20/153
10/52
Latest Period
%
27.2%
9.6%
7.0%
12.5%
N
28/103
11/115
16/228
9/72
Top Quartile range for
Comparator LAs
*National average
16.33% - 7.69%
0.00% - 0.00%
*10.94%
5.88%-0.00%
Range to
achieve Top
Quartile
16 to 8
0 to 0
4 to 0
7.9
Effective treatment indicator shows those that have either stayed in treatment for 12 weeks
or more following triage or have completed treatment. This is seen as an indicator of good
engagement practice from the service, and positive in terms of the service user making
progress.
7.10
Whilst Bradford is performing relatively well in terms of effective treatment, there is a risk
that some of the individuals this indicator captures may be ‘stuck’ in treatment, and it is
important for services to identify these individuals and ensure they are provided
with appropriate support to make further progress in their treatment journey.
35 | P a g e
Effective Treatment - Treatment completed / retained for 12 weeks or more
(n) = number of clients in retained or completed / all in treatment
Baseline period: 01/01/2013 to 31/12/2013
Latest Period: 01/01/2014 to 31/12/2014
Opiate clients
Non-opiate clients
Alcohol and non-opiate clients
Baseline Period
%
n
94.0%
2453/2610
90.0%
405/450
88.5%
247/279
Latest Period
%
N
93.2%
2395/2569
87.7%
401/457
87.0%
260/299
National average
%
95.1%
87.0%
86.8%
7.11
Bradford excels in getting people into treatment quickly. Waiting times have continued to
improve, and with the Assessment Hubs in place less than 0.5% of clients wait longer
than 3 weeks (which is the national measure).
7.12
The services aim to get people into treatment within 5 days of presentation or the same day
if a prison release or continuation of care from another area.
Percentage of clients waiting over three weeks to start first intervention
(n) = number of clients waiting more than three weeks / all first interventions
Latest Period
Opiate clients
Non-opiate clients
Alcohol
Alcohol and non-opiate clients
7.13
%
0.0%
0.0%
0.4%
0.0%
National average
Number over 6 weeks
%
2.1%
2.1%
4.8%
3.6%
n
0
0
1
0
n
0/322
0/112
1/233
0/41
As referenced in Section 3.7, early unplanned exits for drug misusers are higher than
national figures, with opiate users significantly more likely to leave treatment early when
compared to national averages. It is important that changes are made to help ensure that
service users stay in treatment for at least 12 weeks, in order to capitalise on the window of
opportunity for improvement provided during the early months of treatment and increase
service users’ chances of success.
Proportion of new presentations who had an unplanned exit or transferred and not continuing a journey
before being retained for 12 weeks
(n) = number of clients in treatment who had an unplanned exit or were transferred and not picked up to continue a treatment journey
before being retained for 12 weeks / new presentations to treatment
Latest period: 01/01/2014 to 31/12/2014
Latest Period
Opiate clients
Non-opiate clients
Alcohol
Alcohol and non-opiate clients
National average
%
n
%
23.5%
18.0%
164/697
53/295
15.2%
16.1%
15%
131/875
17.2%
18.8%
36/192
16.9%
36 | P a g e
7.14 In Section 3.3, length of time in treatment was discussed. Over a third of those in treatment
for opiate issues in Bradford have been in treatment for 6 years or more.
7.15 Whilst some individuals may require longer in treatment, there are a proportion of service
users that require additional challenge, with support, to help them move through the treatment
system and reach a point where they can move out of services, drug and medication free.
Time in treatment for opiate and non-opiate only clients in treatment at the end of the reporting period
(n) = number of clients in treatment for stated time period / all clients in treatment at the end of the reporting period
Latest Period
National average
Opiate clients, under 2 years
%
35.5%
n
698/1965
%
40.1%
Opiate clients, 6 or more years
38.4%
755/1965
31.3%
Non opiate only clients, 2 or
more years
7.6%
13/171
8.0%
Opiate
Non-opiate
Average Years in treatment
5.1
0.7
National average
4.5
0.8
7.16
The following two charts show performance regarding the immunisation of Hepatitis B and
testing for Hepatitis C within the in treatment population. Work has been on-going to
ensure that the recording of both these interventions is improved to reflect the level of work
correctly.
7.17
Everyone entering treatment through the Fresh Start Assessment services is offered
Hepatitis B immunisations and Hepatitis C testing where appropriate.
Clients with no record of completing a course of HBV vaccinations as a proportion of eligible clients in
treatment at the end of the reporting period
(n) = number of clients who have no record of completing a course of HBV vaccinations / all clients in treatment at the end of the reporting
period who were eligible to be offered a course of vaccinations
Latest period: Up to 31/03/2015. New presentations started since 01/04/2014
Latest period
All clients in treatment
New presentations to
treatment
%
68.1%
95.2%
n
1215/1785
717/753
National
Average
73.9%
90.7%
37 | P a g e
Clients with no record of a HCV test as a proportion of all clients in treatment at the end of the reporting
period who were eligible to receive one
(n) = number of clients who have no recorded HCV test on NDTMS / all clients in treatment at the end of the reporting period previously or
currently injecting who were eligible to be offered a test for HCV
Latest period: Up to 31/03/2015. New presentations started since 01/04/2014
Latest period
All clients in treatment
New presentations to
treatment
7.18
%
15.3%
33.3%
n
272/1778
149/447
National
Average
20.0%
29.5%
The proportion of Alcohol clients (117) during 2014/15 who were in contact with the
criminal justice system and completed treatment successfully was 39.3% (46). This shows
a dip in performance in comparison to the previous year at 52.5%
Percentage of Successful completions from the criminal justice system- Alcohol (Rolling 12 months)
7.19
A key entry point into the system has been through drug testing in police custody. There
have been significant reductions in the number of tests over a 7 year period in an effort to
reduce the costs of negative tests. West Yorkshire Police established and adopted new
criteria for drug testing in 2012/13 which has had a dramatic impact on the number of
individuals being assessed following a drug test.
•
67% reduction in overall drug tests from 6434 to 2019
•
53% reduction in number of positive tests from 2077 to 980
•
80% reduction in positive tests for opiates from 473 to 96
This has had a significant impact upon the numbers accessing drug treatment and also
resources. ARCH has adapted to this reduction through proactive engagement both in
custody and the community and has maintained caseload sizes.
38 | P a g e
7.20
The numbers of individuals who commenced treatment following a referral via CJS route
over the last 3 years is as follows:
Period
2012/13
2013/14
2014/15
Referrals from
CJS
155
144
154
Commenced
treatment
95
80
115
%
61
55
75
7.21
There has been an improvement over the last few months of 2014/15 to improve upon the
`drop out `rate from treatment.
7.22
The proportion of Opiate clients in contact with the criminal justice system who completed
treatment successfully in 2014/15 was 4.7% overall there were 534 in treatment with 25
successful completions. In comparison to 13/14 the data shows 595 in treatment with 37
successful completions (6.2%).
Percentage of criminal Justice Clients completing successfully- Opiates (12 month rolling)
7.23
The proportion of non-opiate clients in contact with the criminal justice system which
completed treatment successfully in 2014/15 was 44.6% (92 in treatment with 41 successful
completions) this is an improvement compared to 2013/14 data of 34.7% (121 in treatment
with 42 completions).
Percentage of Criminal Justice clients completing successfully- non- opiates (12 month rolling)
39 | P a g e
7.24
Arch deliver the structured day programme element of the DRR . CRC are responsible for the
offender management of DRR clients. The majority of these clients will be receiving
specialist drug treatment at community based services.
Period
2013/14
2014/15
7.25
Starts
252
203
Completions
101
91
Arch will report any non-attendance or potential breach of the DRR order to the Offender
Manager (CRC). Any decision to breach the individual and return to court is made by the
Probation Service. There has been considerable progress made in increasing the number of
DRR commencements and completions over the last 2 years however, individuals subject to
the order can complete the order continuing to use substances and reoffend.
40 | P a g e
Section 8 Bradford Treatment System Financial Overview
•
The contractual commitment for financial year 2015/16 is £13,294,465.
•
The total investment in drug and alcohol treatment in Bradford & Airedale is made up from a
proportion of the Public Health Grant, CCG funding and Police & Crime Commissioner
funding.
•
Public Health currently contributes £11,955,990 (90%), the 3 local CCG's contribute £819,850
(6%) and the Police & Crime Commissioner (PCC) contributes £518,625 (4%)
•
In terms of total value for those contracts held for 2015/16, 51% is held with the third and
independent sector, 42% is contracted with NHS Trusts, 5% within Local Authority and Police
and 2% held with primary care providers.
•
The table in Appendix C provides a brief overview of current services with respective
provider sector, contract values and funding source. From the table it is possible to identify
that there are a large number of providers across a variety of locations. Due to the way
services have developed, the system is now supported by a number of provider
organisations, commissioned through an array of contracts, which inevitably leads to
inefficiencies such as supporting multiple management structures.
•
Consideration was given to providing a unit cost for episodes of care within the current
system but it was decided that due to the way that finances are apportioned to contracts
and service specifications cross more than one modality of care or type of substance, it is
not a straightforward process to break costs down to a unit cost level.
•
Even if local unit costs were attainable there would be no similar unit cost available either
nationally or regionally that could be used as comparators. It was therefore decided that
whilst it isn’t currently possible to provide a valid unit cost for substance misuse treatment,
the development of a unit cost should be a future consideration.
41 | P a g e
Section 9. Themed Areas
The following themed areas have been identified through the review and the consultation process as
key areas for improvement, with the gaps and risks highlighted along with views from the
consultation. Recommendations for these areas are included within Section 11.
9.1 Alcohol
9.1.1 Background
•
The 2012 National Alcohol Strategy builds on the four pillars of the 2004 Alcohol Strategy and
includes:
o Education and communication
o
Identification and treatment
o
Alcohol-related crime and disorder
o
Supply and industry responsibility
•
The 2012 Strategy set out intentions to provide more powers to stop serving alcohol to people
who are already drunk, more powers for local areas to restrict opening and closing times, control
the density of licensed premises and charge a late night levy to support policing. Intentions also
include more powers for hospitals to tackle alcohol related A&E presentation, and addressing
the sale of cheap alcohol.
•
The new strategy introduced a new approach to alcohol use and treatment for those that
require it. It champions a change in behaviour so that people think it is not acceptable to drink
in ways that could cause harm to themselves or others.
•
High levels of hazardous drinking have been identified previously in the district and there
remains a strong commitment from local partners to ensure that the negative impacts of alcohol
use are addressed.
•
The Alcohol Health Needs Assessment carried out in 2010 for the Bradford District estimated
that there were 92,000 people in Bradford District drinking at hazardous levels that may damage
their health. This places nearly a fifth of the population at risk of adverse health effects.
Approximately 17,000 of those are drinking at harmful levels that will result in physical or
psychological harm. Many people drinking at harmful levels will also be alcohol dependent. This
population of harmful drinkers need to have access to appropriate, high quality services.
•
The development of the local system providing support to this client group is outlined in Section
5.
42 | P a g e
9.1.2. Identified Gaps/Risks
•
•
•
•
•
•
•
Prevalence estimates of alcohol use were last undertaken in 2010 by the National Treatment
Agency (now part of Public Health England. Using this prevalence data of 17000 drinking at
harmful levels and Alcohol Concern recommendations of 15% able to access treatment, the
district requires approximately 2550 treatment places for dependent drinkers. The number of
individuals accessing Tier 3 treatment in 2014-15 was 1531.
The pilot alcohol community detoxification service was discontinued following the evaluation
report in 2014. There is still a strong appetite for this service from both within the service user
population and current services. Should a similar service be considered in the future, there is a
strong viewpoint that it should be scoped up as a joint alcohol and drug service.
National recommendations that there should be seven day per week alcohol clinical nurse
provision. Currently the service falls well below this and would benefit from this being revised to
meet these recommendations as far as is practicably possible.
The alcohol pilot highlighted a number of improvements required for the delivery of IBA within
primary care with emphasis upon embedding Identification and Brief Advice (IBA) more
effectively and screening pro-actively.
There are a number of routes into alcohol services but the pathways into treatment require
clarification. Also pathways between providers including primary care,
There is resistance from some GP practices to take on the initial screening for alcohol misuse
and/or the delivery of brief advice. CCG feedback from the consultation is that IBA needs to be
embedded into primary care.
The Substance Misuse System, with the exception of the CCG funded Alcohol Pilot, has not
specifically addressed the issue of high rates of unplanned admissions for this patient group.
9.1.3 Summary of Evidence and Consultation Feedback
•
•
•
•
•
•
•
•
Feedback from service users, services and other stakeholders recommends a move to
commissioning services that can work effectively with both alcohol and drug users, thereby
cutting down on duplication and offering improved efficiency.
The prevalence estimates indicate that there is a requirement for additional capacity within the
alcohol recovery system particularly when factoring in the issue of those with dual diagnosis
which is currently under-served.
The alcohol pilot highlighted that referral pathways into alcohol treatment should be review as
they are not clear to potential service users
Given that there is an increasing cross over between alcohol and drug use it should be
considered that wherever possible alcohol and drug services could be combined. Skills set for
staff are common to both alcohol and other drugs and would provide efficient use of staff
resources although there may be additional workforce development issues to consider
Nalmafene has been approved for use by NICE. Whilst this drug is not currently being widely
prescribed, a local protocol has been written and agreed. Arrangements need to be put in place
to allow for appropriate prescribing to take place.
Primary care alcohol related interventions have improved access to treatment, help and support,
and is the obvious route into treatment for much of the community, in particular non-dependent
alcohol users.
The Alcohol Pilot has highlighted the need for pro-active screening within primary care, for
example, long term conditions.
Consideration should be given to further develop the model of delivery of alcohol services in
primary care.
43 | P a g e
•
•
•
•
Following the alcohol pilot the findings showed a very low uptake of community detoxification
for alcohol. Some of this was due to under performance by the provider. This is an area of
service that requires development with close links to secondary care.
Consider embedding a wider screening service in Primary Care, using data available within those
services to identify those at risk from alcohol related issues.
Service users identified a need for help towards childcare and travel costs to ensure they could
attend their session. Given the high incidence of children living with alcohol users this would
seems a crucial point to consider.
There is a perceived lack of group work for alcohol users. There are a number of groups in the
district but service users need to be proactively introduced to them.
9.2 Drugs – Opiate and Crack Users (OCU)
9.2.1 Background
•
The National Drug Strategy 2010: Supporting People to Live a Drug-Free Life set out a
fundamentally different approach to tackling drugs use, with commitments to protect
communities more effectively and radical ambitions for recovery-focused treatment. The
government recognised we must go further than merely reducing the harms caused by drug
misuse, by offering every opportunity for people to choose recovery as a way out of
dependency.
•
This new approach is accompanied by an equally radical shift in power both to local areas and
people in the system. The Government set out a distinct national vision and set of expectations
for responding to this challenge, but has made it clear that it will be for local areas to design
their own tailored responses, by commissioning services which meet the needs of their differing
populations and by acting as gateways to full recovery.
•
The Drug Strategy Annual Review 2015 - `A Balanced Approach` keeps recovery at the heart of
the strategy and the annual review reaffirms the commitment to focus on Reducing demand,
Restricting Supply and Building recovery. Over the past four years, there has been a
comprehensive and evidence based approach to tackling the challenges caused by drugs,
including new psychoactive substances (NPS) through the three key themes of the strategy.
•
There is a continued focus on improving recovery outcomes including wider factors such as
employment and housing that are essential in supporting drug users to fully recover and
integrate back into society.
•
The development of the local system providing support to this client group is outlined in Section
5.
9.2.2 Identified Gaps/Risks
•
With the increase in co-use of alcohol by opiate and crack users, workers within drug services
need to be appropriately equipped with the skills and knowledge to manage alcohol issues.
•
Access into treatment is seen as straightforward and pathways are clear, however once in the
treatment system, service users and staff have concerns about complicated pathways,
communication and record sharing.
44 | P a g e
•
Significant numbers of heroin users in prescribed treatment are also accessing needle exchange
services, in order to get equipment to continue to inject. There is no evidence to suggest that
this is just a transitional position at the point of starting treatment, as many of the needle
exchange users have been using both services for a long time.
•
Prescribing within opiate treatment has not been at optimal dosing levels across the district, as
evidenced through service user feedback and by speaking to service staff during a recent round
of training on this area. Concerted efforts have been made to improve on the rate of optimal
dosing and there is some improvement. It is hoped that this improvement will continue with the
new provider delivering community prescribing.
•
Through consultation with the assessment hubs, service user feedback and provider data, we
know there is a hard to engage cohort of long term heroin users. This group continue to go
round and round the treatment system, not fully engaging in treatment, dropping out and then
re-entering. This cohort takes up a disproportionately large amount of service time, and can be
disruptive to other service users. A way to work effectively with this group needs to be found.
•
Both the amount and quality of psychosocial work delivered to OCU’s is difficult to monitor, but
due to capacity issues and time constraints within services, it is reported that coverage of
psychosocial delivery is inconsistent, and generally underutilised.
•
Level and format of dual diagnosis mental health / drug / alcohol support is not appropriate for
the demand within services.
•
Due to the ageing population of OCU’s, more service users are encountering complex health
issues, some of which are hampering their move to become drug free.
•
There are different models of delivery across the district which can lead inequitable choice of
service delivery options for service users dependant on postcode.
9.2.3 Summary of Evidence and Consultation Feedback
•
Ensure that services addressed the needs of this increasingly complex, and ageing group, with
specific regard to co-existent physical, mental illness and mobility problems. It is therefore
important that a properly integrated approach with Primary Care is delivered, both clinically &
with a shared record
•
Ensure that Intravenous Drug Use related problems such as Blood Borne Virus Screening and
Hepatitis B vaccination are coordinated effectively with Primary Care
•
All substance misuse services (unless a specialist area) need to be able to manage both drug and
alcohol issues. This will undoubtedly require some workforce development, and redrafting of
care pathways, as the current system is not equipped to deliver drug and alcohol care
consistently across the whole district.
•
Consider segmentation of treatment in order to offer different levels of support dependant on
what stage of recovery an individual might find themselves.
45 | P a g e
9.3 Drugs: Non-OCUs (including Novel Psychoactive Substances (NPS), Image and Performance
Enhancing Drugs (IPEDs), Over the Counter Medications (OTC) and Prescription only Medications (POM)
9.3.1 Background
•
While nationally, the trend of heroin and crack cocaine use continues to decline, the use of
stimulants such as Cocaine and Amphetamine does not appear to be declining and the use of
Cannabis has increased considerably particularly amongst younger people.
•
In addition to these substances, there is an emerging range of drugs of abuse being used. These
include:
o
o
o
o
•
Novel Psychoactive Substances (NPS)
Image and Performance Enhancing Drugs (IPEDs)
Over the Counter Medications (OTC)
Prescription only Medications (POM)
With the exception of some OTC and POM medications, there is little evidence of
pharmacological interventions being useful within the treatment of these substances.
•
Evidence shows that psychosocial interventions, when delivered appropriately and to a high
quality can be very effective in helping people stop using these substances.
•
Where individuals have developed problematic use of OTC and POM, then there is a growing
evidence base that shows engagement with psychosocial interventions, alongside medical
reduction plans (where appropriate) can be very effective.
•
NPS are drugs deliberately manufactured to mimic the effects of traditional recreational drugs,
so they stimulate or depress the central nervous system.
•
They are defined by the United Nations as substances that are not controlled by the
international conventions on narcotic drugs and psychotropic substances. Specifically designed
to evade drug laws, they are often marketed as `legal` alternatives to banned drugs, although
they have the potential to pose risks to public health and safety, and can be fatal.
•
NPS are generally supplied from China and India and are accessed in general via the Internet, so
called `head Shops` or friends/street level dealers.
•
Nationally there has been an increased availability of NPS along with a consistent climb in the
number of people presenting to treatment services and awareness that health services are not
equipped to address the serious harms that NPS drug users are now reporting
•
In 2012 it was reported that approximately 1 million adults used club drugs and novel
psychoactive substances each year and at the same time it was reported that, on average one
new NPS was being made available for sale each week in the European on-line market. Over the
past 2 years this trend has worsened, with the UK seeing a continuing increase in reported use of
club drugs and NPS and having a reported prevalence of NPS use among 15-24 year olds of
approximately 10%.
46 | P a g e
•
There is a lack of clear prevalence information on NPS use and any information is anecdotal
however there are a number of information sources which local authorities are encouraged to
utilise to improve the sharing of intelligence. Sources include:
o
o
o
o
o
o
o
o
•
•
Schools and further education
Substance misuse treatment providers
Mental Health Services
A & E departments
Sexual Health clinics
Community based programmes
Prisons
Police
Suggested changes to current treatment provision for NPS from the Royal College of
Psychiatrists` 2014 report include:
o
Existing drug services need to make the needs of NPS users core business. Many NPS
users do not see traditional drug services as meeting their needs, as they are usually
designed around those dependent on heroin, crack and alcohol.
o
Drug services also need to understand who uses NPS and what these different groups
need to tailor their services accordingly , ensuring they have the right skills and
knowledge to deal with NPS
o
Links need to be made between different frontline health services such as A & E
departments. GP`s, mental health services and sexual health clinics.
o
Commissioners of local substance misuse services will need to ensure that the needs of
NPS users are factored into service development.
An analysis of hospital inpatient admission data over a 5 year period from April 2009 to March
20-14relating to NPS use was carried out with the following results:
o
Admissions have increased year on year from 162 in 2009/10 to 183 in 2013/14.
o
60% of admissions are male
o
Majority of admissions fall between 15-49 year olds
o
Two thirds of admissions are described as British with the second highest group being
`any other white background (11%)
o
Small numbers admitted to wards -less than 5 and 7 to mental health wards
o
Mental/behavioural disorders and accidents/injuries account for 40% of total NPS
related admissions
47 | P a g e
Source: Hospital Episode Statistics, 2014
•
A full breakdown of the analysis is detailed within Appendix H
•
13.2% of clients in treatment in 13/14 reported Prescription only or over the counter medicine
use as part of their latest treatment journey. This is lower than the National average (16%) 10%
of those who cited use of over the counter medication said they did so illicitly. Amongst those
who reported illicit use over 80% said they have used Benzodiazepine, the second highest was
prescribed opioids; this was similar for those who did not cite illicit use. The chart below
highlights the number of individuals by drug; to be classified in a category they must have cited
the relevant substance in drug 1, 2 or 3 at any point during their last treatment journey.
Over the counter and Prescription medicine (illicit and non-illicit use)
Source: National Treatment Agency for Substance Misuse 2013/14
9.3.2 Identified Gaps/Risks
•
Numbers of individuals using non opiate substances is increasing
•
Development of a full range of interventions that can be delivered.
•
Lack of available funding development of these services
•
Lack of prevalence data relating to NPS use
•
Lack of co-ordination in relation to prevention
•
Workforce development issue - there is a lack of knowledge within staff teams
48 | P a g e
9.3.3 Summary of Evidence and Consultation Feedback
•
The growth of NPS use should be viewed as an illustration of the importance of service reactivity
and flexibility.
•
There is an issue that services which have a fixed remit (e.g. only alcohol or only heroin/Crack)
may not reflect patient need. There is a risk that such services may result in patients ‘falling
between two stools’ or may be unable to coherently address new problems such as medication
interactions or new adverse effects. There is a concern that patients cared for in ‘silo services’
may not be able to react appropriately to new side effects or drug interactions which may
impact upon the patient’s wider physical or mental health. Examples anticipated include e.g
Teratogenicity or renal failure with NPS
•
As new guidance is released, services need to be able to adapt in order to work effectively with
these emerging substances
•
Workforce development to respond to changing needs
•
Additional investment in psychosocial interventions / cognitive behaviour therapy
•
Local service delivery for POM is providing high quality care with high rates of successful exits
(over 50% exiting drug free), but the coverage for the district is poor.
•
Further understanding of the size of the problem required. Use of ePACT data and possibly
pharmacy based data to be used to identify local prescribing and retail patterns.
•
There are issues with non-substance misuse related POM being prescribed within substance
misuse services, which needs better management. Discussions need to take place with the CCGs
about moving this prescribing back into primary care.
•
Conversely, some prescribing in primary care does not take into account the substitute
prescribing being provided by the substance misuse services. This could be due to poor
communication between the services and the GP practices, or GP prescribers not realising that
substitute prescribing is taking place.
•
Increased primary-care based provision of support required for those individuals who have
issues with POM/OTC medications should be considered
•
It is important to ensure that pain management, mental health, and drug and alcohol treatment
services all work together to provide coordinated and integrated responses to patients.
•
Have a clear plan to address prevention of Addiction To Medication (ATM), whether that
addiction is initiated by the patient, Primary Care or Secondary Care
•
Street drug agencies can be considered inappropriate settings for ATM patients, who are
generally older, more functional and may not recognise they have a problem. As with all
provision, the setting of the service is extremely important in order to get engagement from
patients.
•
Better communication links between Substance Misuse services and primary care to ensure that
all prescribing is appropriate and safe.
49 | P a g e
9.4 Dual Diagnosis
9.4.1 Background
•
Dual diagnosis is the term to describe people who have severe mental health problems and drug
or alcohol problems. The mental health problems may include schizophrenia, depression, bipolar disorder, manic depression or personality disorder.
•
Treatment of people with dual diagnosis can be difficult because typically their needs are
complex and often long term. They may also be difficult to engage and motivate and have poor
medication compliance.
•
The NICE guidelines `Psychosis with coexisting substance misuse: Assessment and management
in adults and young people NICE 2011`8 provide best practice advice on the assessment and
management of people with psychosis and coexisting substance misuse. Revised guidance is
due out in early 2016.
•
This guidance should be considered during any future commissioning of Dual Diagnosis services
in the district.
•
Locally BDCFT provide a specialist Dual Diagnosis Tier 3 Substance Misuse Service from premises
in both Bradford and Keighley delivered by a team of specialist health care professionals working
in the alcohol and drug field. The team provides professional care and treatment for those
experiencing complex problems with alcohol use, drug use and mental health. The team also
provide outreach clinics within some of the community drug services.
•
There is a referral pathway from Substance Misuse services into the Dual Diagnosis services, and
service users are seen at the specialist service or within the substance misuse service dependent
upon need.
9.4.2 Identified Gaps/Risks
•
Lack of in-reach dual diagnosis services within existing drug and alcohol services
•
Concern that the more complex/higher risk/chaotic patients are being seen in the most
accessible (GPSI), rather than the most appropriate substance misuse services
•
Particular concern about those patients with psychosis who primary drug of abuse is alcohol
•
Additional concern that ‘Dual Diagnosis’ as defined by NICE is an overly restrictive term, and
does not reflect the complex needs of many ageing and unwell substance misusers
•
No clear provision for those individuals who have lower level mental health issues, therefore not
able to access the existing dual diagnosis service. Due to no pathway in place, some of these are
8
https://www.nice.org.uk/guidance/cg120
50 | P a g e
then being picked up by other services inappropriately, such as Ambulance, A&E, and Police
Custody.
•
Some of the PCC money has been diverted from DIP services to co-funding the First Response
service with Adult Mental Health Services in order to provide a response from both community
and police custody to provide interventions to those with lower level mental health issue in
order that they don’t access services inappropriately. The feedback so far is that the service is
effective and welcomed by both A&E and the police, however this funding is only secure until
March 2015
9.4.3 Summary of Evidence and Consultation Feedback
•
There is a need to properly address the needs of patients with severe and enduring mental
illness (SMI) who also have co-existent alcohol or drug use
•
There is concern about patients known to have severe and enduring mental illness who also
have co-existent alcohol or drug use. Those patients who use heroin and are engaging with drug
treatment services should be easy to identify with a shared clinical record.
•
However this is not the case for patients with SMI who abuse alcohol, and there is a real concern
that services for these patients may be uncoordinated, or indeed they may not get appropriate
treatment. There is a recognised risk of self-harm or exploitation in this vulnerable group
•
There is a need to secure on-going support for those with lower level mental health issues that
are at risk of ‘falling through the cracks’.
9.5 Transitional Services (Services for those aged between 21 and 25)
9.5.1 Background
•
Young People’s Specialist Substance Misuse Services work with young people up to the age of
18, and between the ages of 18-21yrs where it can be evidenced that their assessed needs can
only be met within a young people’s service. This means that capacity is an issue within young
people’s services for older young people. Whilst there is good partnership working between
young people’s services and some adult treatment providers, this is dependent on individual
providers.
9.5.2 Identified Gaps/Risks
•
At present there are no specific services to meet the needs of the older young people (i.e. those
aged between 21 and 25).
9.5.3 Summary of Evidence and Consultation Feedback
•
An approach similar to that used by young people’s specialist treatment providers is likely to
result in better treatment outcomes for younger adults – however this would require the
development/establishment of a service/team of specialist practitioners and the development of
referral pathways with adult treatment providers.
51 | P a g e
•
Better treatment outcomes would include:
o
Better retention in services
o
Increase in the number of planned exits
o
Reduction in DNAs
o
Increase in the number of successful/planned discharges exiting treatment interventions
(substance) free
9.6 Harm Reduction
9.6.1 Background
•
Reduction of risk and harm related to substance misuse within the drug and alcohol using
population, and the broader population remains a key driver for service delivery.
•
Reducing the following risks is essential when providing quality services to this client group:
o
reducing potential harm due to overdose including training drug misusers and their
families, concerned others and carers in the risks of overdose, its prevention and how to
respond in an emergency.
o
reduction of risk to blood-borne viruses and other infections including vaccination
against hepatitis B and testing for hepatitis C and HIV infections where indicated
o
reduction on concurrent risk such as tobacco related illness. Drug and alcohol misusers
who smoke tobacco should be offered smoking cessation interventions.
•
Some of the services in the Bradford District started off as Harm Reduction services, offering
advice and harm reduction interventions to those that needed them. As services have
developed and now deliver a range of structured care-planned interventions, harm reduction
remains at the heart of service delivery.
•
Everyone entering treatment in the district engages in a thorough assessment process which
includes a health check. This assessment covers all areas of risk and possible harms, and service
users are offered a range of services such as testing and immunisation to help reduce risks.
•
The district has a community based needle exchange scheme in place which was established in
May 1987 and offers a comprehensive harm reduction response to the issues around injecting
drug use. In the Healthcare Commission audit of harm reduction services in 2008
(commissioned by the National Treatment Agency), the scheme received maximum marks and
was jointly rated as one of the three top services of its kind in the whole of the UK.
•
As the needle exchange has developed, national guidance has been used to ensure the quality of
the service provided.
•
Needle Exchanges have been highly successful in preventing HIV transmission in the UK
(prevalence currently estimated at 1.5% amongst injectors), and this has mainly been due to the
52 | P a g e
swift establishment of these programmes. Hepatitis C infection, however, is much more
widespread (estimated to be around 50% of injectors) although widespread testing, treatment
and the provision of the necessary equipment has only been established in the last few years.
•
The Needle Exchange scheme offers an open-access service to any drug injector because every
person engaged in this activity is at risk of contracting a life-threatening blood-borne virus,
particularly HIV, Hepatitis B and Hepatitis C. It provides a comprehensive range of injecting
equipment and paraphernalia as well as offering advice on safer injecting practices; advice on
avoiding overdose; safe disposal of used injecting equipment and safe storage of controlled
drugs; access to blood-borne virus testing; vaccination and treatment services; help to stop
injecting drugs; sexual health advice and provision of condoms as well as other health and
welfare services.
•
The number of heroin users accessing the needle exchange scheme has been rising significantly
since the autumn of 2013. Compared to two years ago, there are now around 175 more heroin
injectors and this number is increasing. This appears to be against national trends although a
report from Public Health England (Drug Treatment in England 2013-14) notes that there has
been an increase in new starts for treatment amongst heroin users and that “after a period of
declining numbers we may be seeing a new upward trend emerge”. Local evidence suggests
that the bulk of the increase has been the return of older heroin users who have been in and out
of treatment over the last few years. New starts in treatment nationally don’t appear to be
reported by age so it is not known whether these two issues are linked.
•
In recent years, many needle exchange schemes have begun supply foil as part of a
comprehensive range of harm reduction tools. Bradford began issuing foil in December 2014. By
providing foil, the scheme is able to:
o
o
o
o
o
engage better with service users about the possibility of smoking
promote route transition more effectively (both as a permanent alternative to injecting
or as a temporary or periodic alternative in order to ‘give veins a rest’)
engage better with service users around broader issues of harm reduction and changing
risk behaviours
engage with injecting clients who have never accessed NX services before
engage with smoking clients who would not otherwise access NX services (and prevent
them from starting injecting)
•
The scheme uses a bespoke comprehensive harm reduction database, which has a full range of
information on clients from pharmacy and specialist needle exchange services. This means that
data recorded is extremely accurate.
•
Disposal facilities for used equipment are available at every outlet to minimize drug litter and
unsafe disposal across the district.
53 | P a g e
•
3181 injectors accessed the service last year which was an increase of 209 compared to the
previous year. 1721 (54.1%) are primary heroin users; 1347 (42.3%) are Image and Performance
Enhancing Drug (IPEDS) users; 84 (2.7%) are amphetamine users; 29 (0.9%) are primary crack
users. 665,784 Needles were issued during the year which is an average of 55,482 each month,
which is an average increase of 7,753 each month on last year’s results. 45.6% of needles issued
were returned - this is a reduction of 3.5 percentage points compared to 2012/13. 88% of
service users are male, and 61% are aged between 25 and 39.
Age breakdown of needle exchange service users
Source: Bradford Needle Exchange Service Annual report 2013/14
•
69% of individuals accessing the needle exchange service are White British, 12% are Asian British
with a Pakistani heritage. In February 2014 the Needle exchange scheme asked service users, via
its website, if they were a heroin user, and whether they were in treatment at the time. 80% of
respondents were identified as being in treatment. The key challenge identified by the service is
that there are a high proportion of heroin users known to treatment, who are still injecting
heroin.
9.6.2. Identified Gaps/Risks
•
Despite continued efforts within the district, levels of completed Hepatitis B immunisations
whilst above national average, remain lower than desired.
•
Despite Bradford providing a comprehensive range of services for injecting drug users, there
are still a few significant gaps that need addressing.
•
Connection between the Needle Exchange and Treatment services
o
The increasing numbers of heroin injectors accessing the needle exchange is of great
concern but there is no clear interface between the scheme and other treatment
services. The majority of heroin injectors in Bradford are long-term users, most of whom
have been in and out of treatment or are currently in treatment. A scheme survey in
May 2015 found that 57.2% of heroin injectors were currently in treatment although a
similar study in February 2014 showed that 80.6% were in treatment. It is not known
why this number has fallen.
o
If the number of heroin users in the needle exchange are increasing significantly and the
percentage of those in treatment is falling, then there needs to be further investigation
54 | P a g e
as to what lies behind this. Are there treatment factors having an impact on this, for
example, perceived waiting times, optimal prescribing, and treatment options available?
o
•
•
•
Needle exchanges and treatment services are seeing quite an overlap of the same
cohort of clients and many of these are not receiving regular specialist interventions as
they are primarily accessing pharmacy needle exchanges. It is also not known to what
extent prescribers are aware of their patients injecting street heroin on top of their
current prescription.
In order to tackle this issue successfully, then these are the areas that need addressing:
o
Increase specialist needle exchange and harm reduction interventions with heroin users.
o
Engage with clients who are or who have previously been in drug treatment.
o
The provision of opportunistic interventions with the client ensuring immediate and
appropriate referrals including GP, physical health nursing and into structured
treatment.
o
Investigate reasons why clients are continuing to inject while in treatment and
encourage honest discussion, without fear of penalty, of the clients drug use. This will
include the discussion around any barriers to re-engagement to treatment.
o
Increase referrals to physical health nursing, providing basic health check and noncomplex wound care & improve access to blood borne virus testing and immunisation.
o
A comprehensive assessment of need across health and social care.
o
Clear explanation of all treatment options available and how to engage effectively.
Provision of Naloxone
o
Naloxone is a drug which temporarily reverses the effects of opioids such as heroin,
methadone and morphine. For many years, Naloxone has been used within emergency
medical settings to reverse the effects of opioid overdose and prevent death. UK
guidelines on clinical management of drug misuse fully endorse the use of Naloxone in
overdose management and prevention. Naloxone is a medicine that can be
administered by injection by anyone for the purpose of saving a life.
o
A programme that seeks to equip as many heroin injectors as possible with take home
naloxone in order to help prevent overdose deaths needs to be established as soon as
possible in Bradford. Work is currently underway to set this programme in motion.
o
By helping to reduce the number of possible overdose situations, it is hoped to also
reduce unplanned admissions through A&E.
Cost of provision
o
Due to the increasing number of heroin users accessing the needle exchange scheme,
the costs of providing essential equipment and paraphernalia have risen sharply. In the
previous two financial years, the service has needed an additional £25,000 each year just
55 | P a g e
to meet its costs. In a time where all services are seeking to make substantial savings
wherever possible, the needle exchange needs more money to cope with increased
demand. However these additional costs should be viewed as an invest to save
opportunity due to the additional health care costs that would be incurred should the
availability of clean injecting equipment be restricted.
9.6.3
Summary of Evidence and Consultation Feedback
•
The increasing number of heroin injectors using the service represents the biggest challenge as
this not only results in significantly rising expenditure but it needs to be investigated in
conjunction with treatment services to find a way to work together more effectively for the
benefit of the service user.
•
Hepatitis C levels are still high. Among people who inject psychoactive drugs, such as heroin and
mephedrone, around two in five are living with hepatitis C; half of these infections are
undiagnosed. About one in 30 of those who inject image and performance enhancing drugs,
such as anabolic steroids, are living with hepatitis C.
•
Hepatitis B is now rare and vaccine uptake has improved. Hepatitis B infection among people
who inject psychoactive drugs has declined in recent years, probably reflecting the marked
increase in the uptake of the hepatitis B vaccine. However, vaccine uptake levels have been
stable in recent years, even though they could be increased further. Vaccine uptake is much
lower among people who inject image and performance enhancing drugs.
•
HIV levels remain low and the uptake of care is good. Around one in every 100 people who inject
drugs is living with HIV. The level of HIV infection among those injecting image and performance
enhancing drugs is similar to that among those injecting psychoactive drugs, and the uptake of
HIV related care, including anti-retroviral therapy, is high.
•
Bacterial infections remain a major problem. A quarter of people who inject psychoactive drugs
report a recent symptom of an injecting site bacterial infection. One in six of those injecting
image and performance enhancing drugs report having had a symptom of an injecting site
bacterial infection.
•
Injecting risk behaviours have declined but remain a problem. Reported needle and syringe
sharing has halved over the last 10 years, but around one in seven people injecting psychoactive
drugs share needles and syringes and almost one in three had injected with a used needle that
they had attempted to clean.
•
Changing patterns of psychoactive drug injection are a cause for concern. There has been a
recent increase in the injection of amphetamines and amphetamine-type drugs, such as
mephedrone. The injection of these drugs has been associated with higher levels of infection
risk. Although the injection of these drugs is much less common than the injection of opiates,
crack-cocaine, or image and performance enhancing drugs, this increase is a concern.
•
Provision of effective interventions needs to be maintained. The provision of effective
interventions, such as needle and syringe programmes, opioid substitution treatment and other
drug treatment, which act to reduce risk and prevent infections, needs to be maintained. These
interventions need to be responsive to any changes in patterns of drug use. Vaccinations and
diagnostic tests for infections should continue to be routinely offered to people who inject drugs
and treatment made available to those testing positive.
56 | P a g e
•
Britain continues to have a high number of drug-related deaths with opiate overdose remaining
a major cause of death among injecting drug users. In England and Wales 765 deaths were
registered in 2013 in which heroin or morphine were mentioned on the death certificate: an
average of two every day, and a significant increase of 32% compared to those registered in
2012. This increase brings the number of deaths relating to heroin and/or morphine to similar
levels to 2010.
9.7 Criminal Justice
9.7.1
Background
•
Effective partnership working with criminal justice agencies is critical as 25% of individuals
entering the substance misuse treatment system do so via the criminal justice system. A
proportion of these individuals are at risk of causing significant harm to themselves and the
wider community. These relationships include those with Police, Prisons, Probation, Community
Rehabilitation Company and the Community Safety Partnership.
•
The Drug Interventions Programme (DIP)
•
o
DIP is a key part of the national strategy for tackling drug misuse. It engages drugmisusing offenders involved in the Criminal Justice System in formal structured
treatment and other support, thereby reducing drug related harm and reducing
offending behaviour. In 2003 DIP set out to use the criminal justice system as a means to
enable offenders address their drug misuse, at the same time as ensuring they were
closely managed and connected to other services in order to reduce drug related
offending. The programme has proved a clear success. Over 4,500 drug misusing
offenders enter treatment through DIP each month and eight out of every ten persons
are being retained in treatment for 12 weeks or more.
o
Since DIP began, recorded acquisitive crime – to which drug related crime makes a
significant contribution - has fallen by around 32%.
o
The Bradford DIP has been successful in encouraging offenders out of crime and into
treatment.
o
Treatment and recovery are key parts of the government’s strategy to tackle drug
addiction and the crime it causes.
o
Treatment helps drug users to recover from addiction, preventing crime and cutting
health costs.
o
Drug treatment also improves the lives of users, their families and communities.
The Police and Crime Commissioner commissioned a review of DIP across West Yorkshire and in
March 2014 published his recommendations which included a wider remit of criminal justice
interventions to other substances and to formally move away from the name DIP which denoted
an isolated project. This would allow a wider focus on entry points to identify and engage with
offenders to include increased early intervention and pre-custody work in the community.
57 | P a g e
•
A continued investment in criminal justice interventions in drugs and alcohol services with the
aim of reducing reoffending of drug and alcohol misusing offenders was also recommended.
•
The full recommendations are included within Appendix I.
•
Drug Rehabilitation Requirement (DRR)
o
These are part of a community sentence. They are a key way for offenders to address
problem drug use and how it affects them and others. A DRR lasts between six months
and three years, and gets offenders to:
o
•
Identify what they must do to stop offending and using drugs
Understand the link between drug use and offending, and how drugs affect
health
Identify realistic ways of changing their lives for the better
Develop their awareness of the victims of crime.
The DRR is a court order delivered via the National Probation Service and Community
Rehabilitation Company`s across the country. A significant element of the order is the
structured day programme which is commissioned nationally via local health
commissioning arrangements under the authority of Directors of Public Health within
Local Authorities. This is not mandated but is a historic arrangement.
Offender Rehabilitation Act
o
The act has brought in new powers to test offenders released from prison for specified
Class A and Class B drugs. The new testing condition will help to engage and support
offenders who have a propensity to misuse illegal drugs, where that misuse is likely to
be related to past or future offending.
o
A new drug appointment licence condition that can require prisoners to attend
appointments upon release in the community has also been introduced . Its use will be
informed by clinical advice within custody and provides a new incentive for offenders to
engage with community based treatment services and support continuity of their
recovery journey.
•
Criminal Justice Services are co-located within a hub located at Shipley Town Hall and consist of
Police, Community Rehabilitation Company (formerly Probation) and Arch who are a VCS
organisation.
•
Arch provides targeted interventions to substance misusing offenders both within the
Community, Police Custody and Prison settings.
•
PH contribute funding from the PCC to Adults Mental Health towards a First Response service
targeting individuals in the community and police custody identified in crisis with mental health
problems . An aim of the service is to reduce the number of individuals inappropriately attending
A & E departments or being detained unnecessarily in police custody.
•
Arch is commissioned to deliver the structured day programme element of a DRR.
58 | P a g e
•
The CRC provide the offender management element of the DRR programme and work in
partnership with ARCH. They are responsible for the compliance of individuals subject to a DRR
order.
•
Any individual who has a need for specialised drug or alcohol treatment will be referred to the
drug or alcohol assessment hubs for treatment and Arch will work alongside these services.
9.7.2 Identified Gaps/Risks
•
ASB / Nuisance by street drinkers /drug users particularly within the City Centre has been
identified as a key issue through the CSP and is attracting significant adverse press coverage.
Arch is providing outreach workers to address the problems and work with a variety of agencies
in an effort to reduce this behaviour. The Rawson Market area is also an area identified with
high levels of ASB. The situation is exacerbated due to drug and alcohol services and a pharmacy
being located in that area and a perception from local retailers that the service users are
responsible for street drinking and ASB in that area. Services are working together to reduce this
behaviour.
•
Reduction in drug tests and reduced opportunities to engage with Opiate users. Alternative
interventions should be developed to engage with this group who may be accessing needle
exchange.
•
Engagement opportunity lost due to lack of sanctions following a mandatory drug test and
assessment.
•
The treatment commencements following CJS referral identifies significant numbers who drop
out of the system. This is due to inappropriate referrals to treatment as well as communication
issues between services. Robust engagement and retention polices should be more effective.
•
The overall outcomes from DRR are poor with low numbers completing the order drug free and
not offending. The decision to breach any individual is held by the CRC and ultimately the
National Probation Service. Treatment providers report breaches due to non-attendance at
appointments but this does not always translate into a formal breach of the order. The
effectiveness of a DRR order is questionable.
9.7.3 Summary of Evidence and Consultation Feedback
•
Consideration of the integration of CJ services within the recovery system to ensure continuity of
care and retention in treatment which could also include the integration of DRR and ATR
structured day programmes
•
Consideration of the development of a health needs assessment team within Police custody
identifying substance misuse, mental health and physical health needs
•
Explore the possibility and implications on a change to future commissioning of DRR and ATR
structured day programmes.
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9.8 Aftercare, Mutual Aid and Facilitated Support Groups (Post Treatment Support – PTS)
9.8.1 Background
•
Aftercare is the general process in which individuals undertake the transition from treatment
based approach to recovery focused involvement within the system.
•
Mutual aid groups are nonprofessional and include members who share the same problem and
voluntarily support one another. Meetings can be "open" where anyone can attend or "closed"
where attendance is limited to people who want to stop drinking or using drugs
•
Facilitated Support Groups are among the best and most popular approaches to empowering
and connecting people. Participants can open up, realise they are not alone, set new goals, learn
new skills, and take charge of their lives. For many people, a support group is the best arena for
these kinds of changes. (Organisations can ‘facilitate’ support groups by providing suitable
accommodation and refreshments which they usually do at no charge to the support group.)
9.8.2
Identified Gaps/Risks
•
Identified lack of aftercare services
•
The transition into PTS is self-directed and service users have stated that they don’t consider
there is enough provision in this part of the recovery system.
•
Some individuals may not find PTS beneficial to their recovery
•
Outcomes from PTS are difficult to assess and record in meaningful way
•
PTS are only provided by a small number of services
•
Mutual Aid is external to main service provision and as such there is no mechanism for
monitoring quality or performance.
•
Facilitated support groups are ‘controlled’ by individuals rather than commissioned services
•
There are numerous Mutual Aid groups available within the district and opportunities to attend
groups provided by provider, for example, Structured Day Programme and Peer Mentoring.
Service users have fed back that they would like more groups and aftercare.
•
Further work needs to take place to review whether there is a lack of provision of Aftercare or
whether it is a system issue in that there is not a “joined up” approach to these services, which
could be blocking service users from accessing them.
9.8.3
Summary of Evidence and Consultation Feedback
•
A need to increase availability of aftercare services
•
Aftercare services to be integrated in order to provide a district wide resource
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•
Ensure aftercare services act as a conduit into normalised support services
•
All PTS should be fully integrated within the recovery system
•
•
The opportunity to attend PTS that is structured, time limited and produce appropriate
measurable outcomes should be available to service users
PTS should reflect and respond to local need
•
PTS should be flexible enough to incorporate both national and local influences
9.9 Education / Training & Employment (ETE)
9.9.1 Background
•
The focus of the National Drug Strategy 2010 is building recovery in communities. Drug and
alcohol dependence is a key cause of inter-generational poverty and worklessness. For example,
in England, an estimated 80% of heroin or crack cocaine users are on benefits, often for many
years and their drug use presents a significant barrier to employment. It is estimated that
around 160,000 people dependent on alcohol are on benefits, which also presents a significant
barrier to employment.
•
The aim is to increase the number of drug and alcohol dependent benefit claimants who
successfully engage with treatment and rehabilitation services and ultimately find employment,
which is a key contributor to a sustained recovery. People in recovery must be equipped with
the skills to enable them to compete for the jobs that are available.
•
Employment programmes need to be closely integrated with treatment and focus on building up
skills and self-esteem. Training, volunteering and work trials are key stepping stones to
employment. Adult apprenticeships, self-employment and social enterprise are other important
routes into work.
•
The National Treatment Agency for Substance Misuse (NTA) and Jobcentre Plus published ‘The
Joint- Working Protocol between Jobcentre Plus and Treatment Providers’9 (December 2010) to
promote more effective approaches to the education, training and employment (ETE) needs of
people in drug treatment.
•
The recent report ‘Medications in Recovery: Re-Orientating Drug Dependence Treatment’10
(NTA, July 2012) emphasises the important role that education, training and employment has in
supporting the recovery of people in treatment.
•
There are a number of mainstream ETE services available within the district accessed through
the Job Centre and work programmes but it is acknowledged that substance misuse is a
9
http://www.nta.nhs.uk/uploads/joint-workingprotocolwithjcp.pdf
10
http://www.nta.nhs.uk/uploads/medications-in-recovery-main-report3.pdf
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particular barrier to employment. The 3 main VCS providers for Drugs and Alcohol (Piccadilly,
Project 6 and Bridge) all run bespoke life skill courses leading peer to peer engagement and
support. The Department of Work and pensions (DWP) run surgeries with these providers
covering all aspects of ETE through the DWP Community Work Coaches .
•
Bridge recovery have specific volunteering opportunities for recovery volunteers within Bridge
and Unity who can work towards a level 2 and social care of through their social enterprise a
qualification in Hospitality and catering. Clients engaging in these activities are often at a
vulnerable stage in their recovery where main stream provision would not offer the additional
support needed to avoid relapse or disengagement. Clients are encouraged to access these
provisions but also mainstream provision dependant on need.
•
Project 6 have a dedicated work club, support includes digital jobsearch, CV writing,
transferrable skills, realistic job goals.
•
In an effort to improve outcomes for substance misusers in recovery, PH commission a district
wide bespoke ETE service for current or ex-service users of drug and alcohol services. The service
is currently delivered by CRI who are a VCS organisation and are based within premises situated
a mile from Bradford City Centre.
9.9.2 Identified Gaps/Risks
•
DWP believe that the ETE provision they provide is appropriate as is the provision from Recovery
centres. However more work could be done within the local jobcentres to aid claimants and
work coaches’ pre/ in recovery to identify appropriate support for substance misuse issues and
ETE. There is a currently a DWP Grant funding bid in place to procure a skilled recovery adviser
to be located throughout Bradford Jobcentres for specialist support.
9.9.3. Summary of Evidence and Consultation Feedback
•
Consideration of integrating ETE into mainstream recovery.
•
Ensuring skilled recovery advisers are located throughout Bradford jobcentres providing
specialist support (currently subject a DWP Grant funding bid)
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9.10 Service User Involvement
9.10.1 Background
•
As part of commissioning process for services within Bradford, Service User involvement is seen
as an essential part of effective service delivery.
•
The Bradford Service Users Representative Forum provides the following opportunities:
o
For service users from different agencies to share experiences
o
For service Users to influence and improve how alcohol and drug treatment and
recovery services are provided
o
To improve services through partnership working with service users, agencies and
commissioners
9.10.2 Identified Gaps/Risks
•
Not all services provide a service user (SU) representative
•
SU representatives are not influential either locally or at a strategic level
•
Previous formal structures of strategic involvement have diminished or disappeared completely
•
Communication flow between commissioners, services, service users and SU representatives is
poor
•
Difficulty in SU representative representing the ’voice’ of service users in larger services
•
Service user ‘good ideas’ take too long to be implemented, if ever
9.10.3. Summary of Evidence and Consultation Feedback
•
Service user involvement is key to current and future treatment delivery and should:
o
Be fully integrated within the recovery system
o
Be representative of the individuals they speak for
o
Be involved positively within service design, delivery and review
o
Be diverse and structured in order to maintain its relevance and involvement
o
Be flexible in order to respond positively to change
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9.11 Concerned Others
9.11.1 Background
•
Bradford has a district wide service which provides support for anyone who is affected by
someone else’s alcohol or drug use. (Referral to appropriate services are made for those under
18 years)
•
Through a person centred approach, support can range from Brief Interventions, non-structured
or structured support. This will be dependent on the identified needs and choices made by the
Concerned Other with measured outcomes being an integral part of all structured support plans.
•
Involvement in service development, delivery and improvement is undertaken through a ‘task
and finish’ approach which is due to the individual difficulties faced and additional
responsibilities undertaken by most Concerned Others which adversely affects their availability
and ability to commit.
9.11.2. Identified Gaps/Risks
•
•
Concerned others;
o
Are a hidden and often hard to reach group.
o
Do not recognise themselves as providing additional support and care
o
Are largely unaware of the available support
o
Only usually seek information or support at a point of crisis
o
From minority groups & communities seldom currently access support
o
Referrals from external related services including criminal justice, social care and
children’s services are few
Issues with the current service;
o
Support is not available ‘out of hours’ including weekends and bank holidays
o
Providing support for a substance misuser often results in significant harms, including
mental and physical health problems.
o
SystmOne (families and carers) is currently only utilised at a single service
o
Reduced funding limits the availability for telephone contact time and appointments
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9.11.3. Summary of Evidence and Consultation Feedback
•
•
The Concerned Other Support Service should be:
o
Centrally based and managed as a single service
o
Available to provide appropriate information and support
o
A ‘person centred approach’ with a wide range of choices and options
o
Developmental, to reflect the variety of support required and changes in need due to
new addictions
o
Accessible at a variety of suitable venues and locations across the Bradford and Airedale
district
o
Fully integrated within the Recovery System
Advantages of having a quality concerned others support service are:
o
Treatment is more likely to be effective and recovery sustained where concerned others
are closely involved
o
It is acknowledged that supporters of substance misusers contribute to financial savings
o
The service can provide robust data relating to outcomes
9.12 Drug Related Deaths
9.12.1 Background
•
In September 2014, the Office for National Statistics (ONS) reported a 21% increase in drug
misuse deaths registered in England in 2013. Public Health England, DrugScope and the Local
Government Association held a national summit in January 2015 to explore the reasons for the
reported rise. The document, Trends in drug misuse deaths in England, 1999-201311 published
by PHE contains the outcomes from this work.
•
Much of what is identified nationally is replicated locally.
•
Bradford has a Drug Related Death Reporting policy in place in order that any death in service is
reported through Public Health and then passed onto a local consultant who collates the
information.
•
It has been identified that the process for feeding back the information collected locally to
agencies including tier 2 (GPs, mental health services) needs to be improved.
•
By sharing information regarding local and national drug related deaths, it may be possible to
reduce the number of deaths related to substance misuse.
11
http://www.nta.nhs.uk/uploads/trendsindrugmisusedeaths1999-2013.pdf
65 | P a g e
9.12.2 Identified Gaps/Risks
•
There is a lack of dedicated time to manage the collation and dissemination of local information.
•
Grave concerns around poly-pharmacy as a risk factor, both prescribed drugs and the increasing
market in illicit prescription drugs, internet suppliers, and novel psychoactive substances. There
is a need for close liaison between different care agencies in looking after this very specific client
group.
9.12.3 Summary of Evidence and Consultation Feedback
•
There is a very marked and progressive increase in the average age of people dying which has
changed from approximately 26 years of age in 1995, to 43 years of age in 2013.
•
Marked increase in numbers of people in treatment dying of physical illness directly related,
indirectly related, or indeed unrelated to drug using lifestyle.
•
There is an increasing awareness of drug misuse and stressful chaotic lifestyle as a risk factor for
completed suicide quite apart from treatment of mental illness.
•
There needs to be robust governance of co-prescribing possibly including minimising the number
of different prescribing agencies. Tracking of people in receipt of poly-pharmacy is
recommended in order that all practitioners are aware of the risks. Pharmacy Leads should be
closely involved in this.
•
Ensure the following learning is implemented:
o
Increased supervision of methadone doses, reduce the practice of ‘split dosing’
o
Continued reduction in number of big ‘take home’ supplies of methadone
o
Continued reduction in doses of benzodiazepines prescribed in the district
o
Increase awareness of co-dependency on alcohol and associated risks
o
Roll out training in first aid, and take-home naloxone for users and carers
o
Continue to increase awareness of loss of tolerance as a risk factor for overdose, extra
care around people released from prison, completing detoxes, or detained under a
section of the Mental Health Act
o
Improved liaison between hospitals and community prescribing agencies, improved
participation in Care Programme Approach
o
Increased awareness of tricyclic antidepressants and other sedative medications as risk
factors for overdose
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9.13 Information Technology
9.13.1 Background
•
The Bradford and District service providers are a mixture of statutory and voluntary sector
organisations who are all responsible for providing their own IT and electronic case management
systems. There are a number of different systems which providers utilise and in some cases
more than one system is necessary.
o
SystmOne - is a secure centralised system with modules for healthcare setting from
primary care to hospitals, social care and mental health. It provides clinicians and health
professionals with a single Electronic Health Record (EHR). Patient data can be shared
securely across services. The system is used by all GP`s across the district and the
majority of treatment providers and is linked to the National Drug Treatment Monitoring
System (NDTMS)
o
Prison Healthcare
- use SystmOne however their modules are closed due to
information sharing issues relating to criminal justice. There is a view that GPs are
reluctant to access to this information, as it will record criminal activity onto the patient
record. This has been a significant barrier to effective record sharing for those leaving
prison for a number of years despite recommendations that the information should be
shared via this system. The lack of information sharing from prisons into community
services puts service users at risk of delayed treatment and duplicate prescribing.
o
RIO - is a Mental Health Electronic Patient Record System designed for Mental Health
Organisations that need a single source of clinical and demographic information. This
system is used by Bradford District Care Foundation Trust (BDCFT) due to mental health
provision, however they also utilise Systmone for drug treatment provision as outlined
above.
o
WEB BOMIC - is a patient case management system used by the main VCS provider in
Keighley (P6) and has been designed to meet the needs of a wide range of services
involved with the treatment and care of people with addictive disorders, including drugs
and alcohol. It provides full client record and, comprehensive client communication
functions linked to NDTMS.
o
Access - is a data base used by the main VCS Alcohol provider (Lifeline Piccadilly) Basic
information is stored on this system alongside paper patient records. The assessment
hub utilise Systmone for clients accessing that service
o
Theseus - is a complete case management system used by the main criminal justice
provider (ARCH) and includes data collection and submission for PHE requirements.
(NDTMS). It is a fully integrated system that tracks the whole client journey; from initial
contact, through treatment, into recovery and beyond and simplifies information
exchange between agencies delivering the services
o
Micase - is a system designed for the case management of individuals engaging with
criminal justice services. Drug test and assessment information is recorded and operates
alongside individual providers own systems. It is used across the 5 districts of West
Yorkshire with each district separately contracting with Micase (Casmaco) with an
agreement that this single system will be utilised by all districts and West Yorkshire
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Police who supply drug testing data at the point of test. Funding responsibility lies with
Public Health through the Police and Crime Commissioner element of the funding.
9.13.2 Identified Gaps/Risks
•
IT system is not integrated with multiple systems.
•
Potential for duplication of data entry with some providers using .more than one system.
•
The issue of IT in particular SystmOne and the lack of intelligent use of the data available has
been highlighted throughout the consultation.
•
There is a national on-going issue regarding the sharing of patient information between prisons
and community. This continues to be a significant risk to service user safety at the point of
release.
•
Micase system would need to be kept separate due to the West Yorkshire wide reliance and
agreement on a single system. The annual cost is £7800. The provision of this system could be
reviewed if there is a West Yorkshire wide agreement to stop using Micase.
•
Clinical IT systems are only in widespread use in Drug treatment services, not Alcohol or other
services
•
Information sharing has been highlighted as an issue within the consultation in particular around
safeguarding and unplanned admissions.
•
When these IT systems are used they are primarily record keeping, with limited use for e.g. risk
stratification/outcomes evaluation/patient flow through the pathway/informing SMRS planning
•
Providers cannot or do not access clinical data from within Primary Care which would facilitate
effective screening.
9.13.3 Summary of Evidence and Consultation Feedback
•
There is a need to ensure that there is an agreed data set which is compatible with IT systems,
statutory reporting requirements and local reporting requirements that is not over burdensome
or duplication for providers but provides commissioners with the information they require to
support effective decision making.
•
In order for effective and safe working with this complex and risky client group, where possible
there needs to be one IT system that all practitioners have access to, and know how to use
properly, or as a minimum, IT systems that “talk to each other” effectively.
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9.14 Prescribing / Dispensing Costs
9.14.1 Background
•
Prior to moving across to Public Health and the Local Authority, prescribing and dispensing costs
were met from within the PCT budget, and did not form part of the funding for substance misuse
services.
•
Since April 2013, the funding and responsibility for prescribing and dispensing has moved to the
Local Authority.
•
Via the recent tender exercise for Specialist Clinical Support Services, work was undertaken to
ensure that the prescribing taking place within substance misuse services is relevant and
appropriate to the specialist treatment area.
•
Through this work it was identified that a proportion of the prescribing undertaken by these
services should be sat within primary care, and in terms of patient pathways it is important to
encourage this client group to access their GPs for non-substance misuse specific medical care.
This helps to normalise health care and is part of the recovery ethos.
•
Work is underway in the district to ensure this shift if treatment pattern takes place and is
managed correctly.
•
Regular audits will be taking place to ensure that the substance misuse related prescribing is
following national guidance, including that of optimal dosing where appropriate. The audits will
also ensure that only medications on an agreed substance misuse formulary will be prescribed
within specialist services in the treatment system.
9.14.2. Summary of Evidence and Consultation Feedback
•
Feedback from the consultation showed that some service users were unhappy with the level of
supervision or the frequency of collection of medication from pharmacies. All commissioned
services within the district are expected to follow national guidance for the prescribing of
substitute medication.
•
This guidance is in place to reduce risk of overdose, reduced the risk to others in the household
such as accidental ingestion by children, reduce the risk of diversion of medication and also to
help ensure that the service user follows the agreed prescribing regime.
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9.15 Testing Costs
9.15.1 Background
•
Testing forms a key part of the treatment package delivered from specialist services.
•
There are several key reasons that testing takes place when prescribing opiate substitute
medications;
•
To demonstrate that someone coming new into treatment is actually using an opiate drug. If
this is not proven, and prescribing takes place to someone without a tolerance to opiates, this
may well lead to overdose, which could be fatal.
•
Once in treatment, testing should be used to ensure that service users are taking their
medication, though if the medication is being supervised, this should not be necessary.
•
Testing also helps to demonstrate if a service user is continuing to use illicit drugs on top of their
medication, or if the service user is changing their drug using pattern. As using on top is one of
the major barriers to recovery, it is really important that this is challenged by the service staff,
and work is conducted to help the service user reduce and stop any illicit drug use.
•
Testing can also be used to show that a service user is progressing well with their recovery
journey. Negative test results can really help motivate someone in treatment and boost their
desire to remain drug free.
9.15.2 Identified Gaps/Risks
•
There is not currently an agreed district wide testing policy in place. This needs to be rectified in
order that a consistent approach is taken regardless of which service is attended.
•
The policy would need to cover which type of testing is used, be that onsite testing or laboratory
testing.
•
The policy would also need to provide evidence based guidance on when testing should be used.
9.16 Governance
9.16.1 Background
•
Current governance arrangements for the commissioning of substance misuse are mainly
managed within Public Health (PH) as that is where the majority of the commissioning sits.
Commissioning and procurement decisions are recommended from the Substance Misuse
Commissioning Team, via the PH Commissioning Group and into the Public Health Departmental
Management Team for sign off. Further sign off within the Local Authority may be required
dependent on the value of the procurement.
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•
Further to this, there is additional commissioning through the three local Clinical Commissioning
Groups (CCGs). The CCGs follow their own commissioning and governance framework but work
closely with the Local Authority to ensure that services meet the joint needs of the district.
•
Clinical Governance for the district is currently overseen by a district wide clinical commissioning
group, chaired by PH and attended by key clinicians and service managers from within the
treatment system. This group is responsible for making decisions regarding clinical matters on
behalf of the district.
9.16.2 Identified Gaps/Risks
•
In order to attain a more effective, economical and joined up approach to commissioning, the
future commissioning of substance misuse services needs to be the joint responsibility of both
the Local Authority and the 3 local CCGs. Recommendations from this review will address this
issue.
•
Clinical governance arrangements need to be explored further in the short term to ensure that
they are fit for purpose. Any proposed changes to the local system also need to include a
revised clinical governance framework.
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Section 10 Consultation with Stakeholders
•
A full report detailing the results of the consultation can be found in Appendix E
10.1 Aim of the Consultation
10.1.1 The aim of the consultation was to obtain the views of all stakeholders including service
users, providers, health care professionals and the general public, in order to gain an
understanding of how people feel the system is working currently, and what is important for
those supported by the system. These views will be considered along with the rest of the
review in order to shape the future of the system.
10.2 Method of the Consultation
10.2.1 These views were collated using two methods.
o
a questionnaire, which respondents could complete either online, or on a paper
version
o
focus groups.
10.3 Topics considered
10.3.1 In the questionnaire, there were five questions which sought stakeholders’ views on the
system:
1. Do you feel you know enough about the substance misuse recovery system which is
provided locally?
2. Please tell us how we can improve your knowledge of the substance misuse recovery
system.
3. What do you think works well about the local alcohol & drug treatment and recovery
system?
4. What do you think doesn’t work well about the local alcohol & drug treatment and
recovery system?
5. What would you change about the system if you could?
10.3.2 Questions 2 to 5 were open-ended, allowing respondents to contribute as they saw fit. A
number of themes emerged from these responses, and these are discussed in the Results
section of this report. Since the questions were open-ended and each respondent could
express themselves freely, some respondents made comments which fitted into more than
one theme.
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10.3.3 Additionally, the questionnaire was used to collect a range of background information
questions about each respondent.
10.3.4 The focus groups were asked to consider three of the questions as they appeared the
questionnaire - namely “what works well with the current system?” “What doesn’t work
well about the current system?” and “what would you change about the system if you
could?” Attendees were split into groups who were asked the above questions and then had
to identify which points were of the greatest importance to them.
10.4 Promotion and distribution
10.4.1 The consultation was advertised through a variety of means. These included the
local media, with a news article in the Telegraph and Argus, and social media, with
links to the online survey placed on HealthyBrad4d Facebook and twitter page. Emails
which included the link were sent to various stakeholders including: service providers; the
police; Probation; Prisons; GPs; Housing Related Support services commissioned by BMDC;
and the voluntary and community sector. The consultation was also advertised on the
Bradford Assembly webpage and via a news bulletin on the Bradford Healthwatch website,
where the general public would be able to access the link. Hard copies of the questionnaire
were made available in all Substance Misuse services for staff and service users to provide
their views.
10.5 Participation
10.5.1 161 responses were received to the online questionnaire, and there were 436 paper
responses.
10.5.2 There were 5 focus groups in total, and over 100 people attended.
10.5.3 Two of the focus groups were run for service users and concerned others.
10.5.4 The first meeting was carried out at a Service User Representation Forum (SURF)
open meeting which was held in Bradford. 40 service users and supporters attended
the
session. The session was advertised on the Recovery Guide Newsletter which is available for
all service users.
10.5.5 The second service user group was carried out in Keighley 18 Service Users attended
the
session. This was also advertised via the Recovery Guide Newsletter, the session was also
organised to run directly after a cook and eat session that service users attend in order for
them to come to the meeting on the same day. It is important to note that the majority of
this group attend ‘Progress’, which is an abstinence service. It can reasonably be
concluded that the service is working well for this group, and this may be reflected in
their responses.
10.5.6 Two of the focus groups were for providers; all providers were sent an email to make
them aware of the focus groups.
10.5.7 The first provider focus group was held in Bradford and was attended by 22 people
from 8 different providers; the second was carried out in Keighley which was attended by
14 people from 7 different providers.
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10.5.8 A further focus group was to those who attend the Service User Involvement Group
(SUIG). This group included service users who also use housing associations. In addition to
service users, it also included workers from housing associations who may have limited
knowledge of the actual service. The focus group was advertised via providers of
housing related support services to all their service users and sent to people who had
attended meetings in the past. This event was carried out at Carlisle Business Centre, in
Manningham, Bradford. As this group included a number of people are not in regular
contact with the substance misuse system, the groups were also asked to consider the
question: “Please tell us how we can improve your knowledge of the substance misuse
recovery system.” It is important to note that 4 attendees were from a service which has
recently been decommissioned, and this may be reflected in the responses of those
attendees.
10.6 Summary of Results
10.6.1 Question 1: Do you feel you know enough about the substance misuse recovery
system which is provided locally?
o
The majority of respondents felt that they know enough about the system.
10.6.2 Question 2: please tell us how we can improve your knowledge of the substance
misuse recovery system.
o
There seems to be a general view that services could be promoted better through a
variety of new and existing methods, and that careful consideration needs to be
given to where information about services is made available. On close examination
of the comments, there was a clear demand for information which is clear,
accessible to all and jargon free.
10.6.3 Question 3: what do you think works well about the alcohol & drug treatment and
recovery system?
o
Many people who contributed to the consultation feel that the people who work
within the system are a considerable strength.
o
People also like the variety of services available including the groups and the one to
one support they receive from their key workers. There is an overall appreciation
that the system is not merely about issuing medication, and that individuals’ broader
needs are taken into consideration. There was particular focus on the available
groups meaning that individuals felt a sense of community and less isolation, being
around people who are in a similar situation. Respondents also praised the ease of
getting treatment and the ability to get a prescription. The overall existence of the
service was paramount to many users. Online responses tended to focus on how
the services work well together in partnership and the societal benefits with
reduction in crime.
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10.6.4 Question 4: What do you think doesn’t work well about the local alcohol and drug
treatment and recovery system?
o
From the outset it was considered that questions 4 and 5 may provide the most
useful information in terms of informing how the system might be developed in the
future.
o
It is important to note that even when invited to describe the system in negative
terms, many respondents made positive comments. This was particularly notable
amongst service users, commenting on the service they receive.
o
The most notable negative theme emerging from the questionnaires was that there
is a perceived lack of client focus. This was expressed in different ways: service
users felt that their views were not listened to, whereas focussed more on the
singularity of the service, being heavily reliant on medication.
o
On a similar topic, service users feel that prescriptions are too strict. A number of
service users, responding to the paper questionnaire stated that they are unable to
attend each day for medication and described the negative impact this had on their
lives. Others wanted prescriptions that were longer than a week for the same
reasons. The online responses focussed on the length of time people are on
medication without support for getting clean, leading to concerns around the
system running as a maintenance program rather than a recovery program. Similar
comments were picked up among the focus groups.
o
Service users were unhappy of the penalties that are put on them if they are late for
an appointment, resulting in a long wait for a rescheduled appointment. Some
respondents expressed extra frustration whilst late attendance is not tolerated from
a service user, it is not uncommon for key workers to be late for appointments.
o
Despite a focus in question 3 on service users feeling that they are in a safe
environment, there was a number of responses to question 4 which indicated that
people were unhappy about mixing with people during different stages of recovery.
The point was made that it can be difficult to ‘stay clean’ whilst being around people
who are still using substances, and a number of responses highlighted that people
use substances outside the entrance to important premises.
Online respondents said that there is a lack of communication about other services
and what they all do, and – reinforcing the themes which emerged in question 2 there was a call for services to be better promoted.
o
o
In the focus groups, some of those who attended identified a lack of aftercare;
people felt that once people were clean there was not much support to help them
to stay clean, which led them to relapse. 4 of the 5 focus groups also identified the
lack of cross organisational working. Notably, the focus group which did not identify
this was the group which had little knowledge or experience of the substance misuse
system. Service users identified a need for help towards childcare and travel costs
to ensure that they can attend their sessions.
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10.6.5 Question 5: What would you change about the system if you could?
o
The main thing people would change, given the chance, would be to increase the
focus on individual clients. This echoes the views expressed in response to question
4. Service users expressed this in terms of a desire for a service which ‘listens’ more;
which offers a range of medication instead of just methadone; has shorter waiting
times to enter the service; and a more flexible appointments system.
o
As previously discussed in question 4 there was a little controversy over what was
stated in question 3. Service users said that the people involved need to be more
understanding around lateness and listen to clients around their desire to get clean,
whereas in question 3 the people involved were viewed as the most important part
of the service. Despite the current groups being perceived positively, service users
felt there needed to be more. A small number of service users made the
observation that they felt that they were stuck in their service with no desire for the
current service to move them elsewhere, even if that would benefit their recovery.
There was a notable amount of discussion in the responses around a possible
reluctance of workers to move people through the system – some wondered
whether workers’ best interests were served by dealing with greater numbers of
service users; others suggested workers simply may not be aware of the other
services that were available. If this latter point is true, this calls for better
communication, better partnership working and more transparency throughout.
o
The online responses focussed still more on the promotion of the service to enable
better ‘joined up’ working. As with the paper responses the largest element
respondents would change was to make the service more focussed around the
needs of the individual client. Respondents also noted a need for better promotion
of services, so that other organisations and the general public are aware of what is
available for those who are misusing substances. This will enable more people to
get the appropriate support they require. A lack of funding was also noted as
something that they would change. It was recognised that there is potential for a
really good service it just depends on whether there is enough funding to enable this
to happen.
o
Online respondents referred to a need for more alcohol services, and this was
apparent in the provider focus groups which called for prescribing for alcohol
addiction. Another issue raised via the online respondents was to provide a service
which addresses the wider issues as to what leads people to misuse substances and
continue to use them, as medicating alone cannot eradicate the addiction. Likewise,
respondents noted the importance of ensuring that there is a good aftercare system
to prevent people from using after they have completed treatment.
o
There were a number of lesser-expressed ideas which may still hold some
significance about the way the system operates. These included training for staff,
and education for all to aim to reduce the number of people taking drugs in the
future.
o
The provider focus groups (and in particular focus group 5) looked at what the
future of the system will potentially look like. This will be looked at in more detail if
the result of the review highlights that there needs to be a change in the way the
system currently functions.
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o
Other responses from the focus groups suggested a greater demand for detox and
recovery housing, highlighting that current access to such facilities is timeconsuming and complex. Additionally, the groups echoed some of the themes
which emerged from the questionnaire responses. These included aftercare,
medication and a need for additional groups.
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Section 11 Recommendations for future Substance Misuse System
11.1
Following this review of current service delivery and outcomes, it is recommended that
there is a fundamental change to the commissioning strategy for the district, based on
genuine joined up commissioning across health and social care.
11.2
A Joint Commissioning Group should be formed from key members of the three local CCG’s
and Public Health, with a remit to:
11.3
11.4
o
Develop a joint commissioning plan for the whole substance misuse system
o
Develop the necessary service specification/s
o
Agree the funding requirements and funding responsibilities for the new system
o
Ensure all necessary pathways are in place and develop any additional pathways
which are required
o
Develop appropriate clinical governance arrangements
o
Develop a robust quality assurance framework
o
Jointly commission a new substance misuse system
The new system should encompass all alcohol and drug delivery with the following
exceptions as these are out of scope:
o
Young Peoples’ provision
o
In-patient detoxification
o
Residential Rehabilitation
The new system should be developed by the Joint Commissioning Group outlined above,
taking into account the following recommendations:
o
Recovery should be central to the new system
o
Access to services and movement within a treatment system should be simple and
effective with good information flow which follows the service user through to
treatment exit
o
Services should be commissioned in a way that they are able to work effectively with
users of all drugs, including alcohol, thereby cutting down on duplication, offering
better efficiency and improved outcomes
o
Frontline workers within the substance misuse sector should be appropriately
equipped with the skills and knowledge to work with users of the whole range of
drug of abuse, which must include:
Alcohol
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Novel Psychoactive Substances (NPS)
Prescription Only Medications (POM)
Over the Counter Medications (OTC)
Image and Performance Enhancing Drugs (IPED)
o
The district requires significantly more treatment places for those with alcohol
related problems
o
There is a need for further identification and brief advice interventions to be
conducted in the community, primarily regarding alcohol misuse, but also drug
misuse. There is a particular need to further embed these interventions within
primary care
o
Those who have been in the system for a long time without making progress should
be identified and given additional support where appropriate or alternative
treatment options sought.
o
Psychosocial interventions must be evidenced based with staff appropriately trained
and resourced in order be able to deliver effectively
o
The re-write of the 2007 Clinical Guidelines on the Treatment of Drug Misuse in the
UK is scheduled to be published in early 2016. It is imperative that these guidelines
are taken into account for any future commission of services.
o
Provision of dual diagnosis services requires remodelling into a broader allencompassing service to ensure people do not fall between the gaps of service
delivery. This should include working together with other health-based services to
provide a complex care outreach model of delivery where required.
o
Increased levels of physical health issues associated with an ageing population of
service users should be addressed either through service provision or via clear
pathway working.
o
There is a need to incorporate the criminal justice element of service delivery into
the general substance misuse service delivery in order to improve pathways and
outcomes
o
Ideally one shared IT medical record and care-planning system should be utilised.
Where this is not possible, IT systems should 'talk' to each other to ensure
appropriate sharing of information. Training for effective use of IT systems is
essential.
o
Service User representation within the current system is not integrated effectively.
Service User voice should be more influential, particularly regarding strategic
decision making.
o
Quality services for Concerned Others (Carers) are crucial in order to increase the
positive outcomes for those in treatment. The influence of well-informed and wellsupported Concerned Others on substance misusers has been proven to make
treatment more effective and recovery more sustained.
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o
Transitional services should be developed to ensure service users between the ages
of 21-25 are fully engaged and receive a service appropriate to their age, which
meets the particular requirements of this group.
o
Local good practice and innovation should not be lost through any retender exercise
but where possible built into any new specification/s.
o
GP practices and community locations should be utilised for service delivery where
possible in order to help normalise care and move away from ‘ghettoised’ treatment
provision.
o
Health services must take an alternative approach to pain management with regards
to the overuse of pain medications. This issue needs to be addressed outside of this
system development.
o
Prevention work related to the adult drug using population and affecting the wider
population must continue to be supported. This includes:
11.5
Blood borne virus testing and immunisation
Primary care screening for both alcohol and drug misuse
Provision of Naloxone to all those who may benefit
o
Provision of small grants to be made available to assist Education, Training and
Employment ventures which have already been developed alongside the core
business of the substance misuse system. These grants should be time-limited to 2
years in order for such schemes to become self-funding.
o
Further work should be completed identifying unit costs for the various modalities of
care within the current treatment system in order any changes to commissioning
can use these figures as a benchmark.
The new joint commissioning group will be tasked with procuring a new evidence based
substance misuse system for the district in a way which successfully tackles the issues
raised within the review. The intention is that a new system will be live by October 2017.
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Appendices
Appendix A Glossary
A&E
ACDAT
ACIST
ACMD
ACPO
ADEPIS
ASB
ATM
ATR
AUDIT
AWC
BBV
BC&D
BCDAT
BCSMS
BDCFT
BD One Stop
Benzo
BHCC
BME
BPS
CAMHS
CAST
CBMDC
CCG
CEE
CFU
CIC
CJIT
CJS
CRC
CSP
Concerned Other / Carer
DH
DIP
DMT
DOMES
DRD
DRR
Accident & Emergency Department
Airedale Community Drug & Alcohol Team
Alcohol Community Intensive Support Team
Advisory Council on the Misuse of Drugs
Association of Chief Police Officers
Alcohol & Drug Education & Prevention
Information Service
Anti-Social Behaviour
Addiction to Medicine
Alcohol Treatment Requirement
Alcohol Use Disorders Identification Test
Airedale, Wharfedale & Craven
Blood Borne Virus
Bradford City & Districts
Bradford Community Drug & Alcohol Team
Bradford City Substance Misuse Service
Bradford District Care Foundation Trust
Bradford SM Maternity Service
Benzodiazepines are a group of medicines that
can be used to help with severe sleeping
difficulties, anxiety and sometimes epilepsy
Bradford Health and Care Commissioners
Black and Minority Ethnic
British Psychological Society
Child and Adolescent Mental Health Services
Community Alcohol Support Team
City of Bradford Metropolitan District Council
Clinical Commissioning Group
Central and Eastern European
Community Funding Unit
Community Interest Company
Criminal Justice Integrated Team
Criminal Justice Services
Community Rehabilitation Company
Community Safety Partnership
Anyone affected by someone else’s substance
misuse.
Department of Health
Drug Interventions Programme
Department Management Team
Diagnostic & Outcomes Monitoring Executive
Summary
Drug Related Death
Drug Rehabilitation Requirement
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DT
DTO
Dual Diagnosis
DVT
DWP
EPACT
ETE
GP
GPSI
HBV
HCV
HIAP
HIV
HMRC
IBA
IFRS
IOM
IPD
IPED
IVDU
JHWS
JSNA
LAP
LAU
LGBT
Micase
MIT
MoJ
Nalmafene
Naloxone
NCA
NDTMS
NHSE
NICE
NEET
NOMS
NPS
NTA
OCU
ONS
OST
OTC
PAT
PCC
PHE
PMG
Diagnostic Toolkit
Detention and Training Order
Individuals with Substance Misuse and Mental
Health issues
Deep Vein Thrombosis
Department of Work and Pensions
Primary care data system
Education , Training & Employment
General Practitioner
General Practitioner with Special Interest
Hepatitis B Virus
Hepatitis C Virus
Health Inequalities Action Plan
Human Immunodeficiency Virus
Her Majesty’s Revenue & Customs
Identification & Brief Advice
Integrated Family Recovery Services ( now
Families at Project 6)
Integrated Offender Management
In Patient Detoxification
Image and Performance Enhancing Drugs
Intravenous Drug User
Joint Health and Wellbeing Strategy
Joint Strategic Needs Assessment
Local Alcohol Profile
Leeds Addiction Unit
Lesbian , Gay, Bi-sexual & Trans gender
Criminal Justice Case Management System
Migration Impact Team
Ministry of Justice
Medication for use in alcohol dependence
Medication used to reverse the effects of opioids
especially in overdose
National Crime Agency
National Drug Treatment Monitoring System
National Health Service England
National Institute for Health and Care Excellence
Not in education , Employment or Training
National Offender Management Service
Novel Psychoactive Substances -also referred to
as `legal high`s
National Treatment Agency
Opiate and Crack Users
Office for National Statistics
Optimising Substitute Treatment
Over the Counter Medication
Paddington Alcohol Test
Police and Crime Commissioner
Public Health England
Project Management Group
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POM
PSI
PTS
Recovery
SMS
SMART
SU
SUIG
SURF
Systmone
TB
TOP
Transitional Services
UBD
VCSE
Prescription Only Medication
Psychosocial Interventions - are a number of
therapeutic approaches such as Motivational
interventions , Contingency management &
Behavioural therapy
Post Treatment Support
Recovery from problematic drug or alcohol use is
defined as a process in which the difficulties
associated with substance misuse are eliminated
or significantly reduced, and the resulting
personal improvement becomes sustainable.
Substance Misuse System
Specific , Measurable, Achievable, Realistic and
Time Limited - recovery gaols
Service User
Service User Involvement Group
Service User Representation Forum
Clinical treatment patient record system
Tuberculosis
Treatment Outcome Profile
Services designed for individuals between child
and adult
Understand Bradford District
Voluntary ,Community & Social Enterprise
Organisations
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Appendix B Review Group Terms of Reference
Terms of Reference
Substance Misuse Recovery System Review - Project Management Group
Background
The Health and Social Care Act 2012 transferred the responsibility for Public Health in the local
authority. As such the local authority-based public health became responsible for commissioning
drug and alcohol prevention, treatment and linked recovery support in April 2013. The system for
providing substance misuse services in Bradford has not been reviewed in full since this transfer took
place. There is currently an opportunity to review the substance misuse system and identify areas
for improvement.
Aim
The aim of the Project Management Group is to conduct a review of current substance misuse
system.
Principle Purpose
The purpose of Substance Misuse Recovery System Review Project Management Group is to allow
members of the City of Bradford Metropolitan District Council (CBMDC) Public Health team in
conjunction with local Clinical Commissioning Groups (CCG`s), along with representatives from other
local authority departments and partner organisations, to come together and conduct a review of
the current substance misuse system that are provided to adults over the age of 18 years.
For the purposes of this review, substances are defined as alcohol, opiates, crack cocaine, other illicit
drugs, prescribed / over the counter medications and novel psychoactive substances.
The outputs of the review will allow the current provision of services to be evaluated against both
local and nation polices and evidence based practice.
Role
The Project Management Group will have delegated authority to assess and evaluate the current
provision of substance misuse services within the Bradford Local Authority district.
The aims of the group are detailed below:
o
Analysis of current evidence base, national and local guidance and best practice for the
provision of Substance Misuse services
o
Analysis of current geographic and demographic needs analysis data
o
Analysis of current performance data and local service delivery model
o
Analysis of current prescribing, dispensing, supervision and drug testing arrangements and
costs.
o
Providing a comprehensive options paper regarding the future direction of Substance
Misuse services within the Bradford District for consideration by the Councils Executive
Committee.
Membership
The Project Management Group shall consist of:
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•
•
•
•
•
•
•
•
•
•
•
•
•
Co- Chair Head of PH Commissioning & Consultant PH
Project Lead Responsible Officer
Adults services
PH Commissioners
Project Manager
Public Health England Lead
CCG Leads
Commercial Team
Strategic Support
Public Health Performance Team
Public Health Analyst Team
Service Users and Concerned Others Consultation Support
Administration Support
The Project Management Group will be able to co opt further members, as required, from other
partner organisations.
Meetings
Meeting will be held fortnightly or more frequently when required to meet required deadlines.
Quorum
Meetings will be quorate when 3 or more members of the Project Management Board are present.
Two of these must be member of the CBMDC PH team. In the event that this is not achieved meeting
may still go ahead but decisions will need to be ratified at the subsequent meeting.
Governance and Reporting Structures
The Project Management Group , from an operational perspective , will report directly to the Public
Health Department Management Meeting (DMT) chaired by Dr Anita Parkin Director of Public Health
at CBMDC. Monthly updates on progress will be sent to this meeting.
Strategically, the Project Management Group will report to the Bradford Health and Care
Commissioners (BHCC) group who will be asked to make a collaborative decision on the
recommendations identified through the options appraisal of the review. Ratification of the BHCC
recommendations will be taken separately through the Council Executive committee and the 3 CCGs
executive boards.
Conflicts of Interest
Each member is responsible for ensuring that the PMG is aware of any conflict of interest is declared
prior to the meeting. The Co-chairs will determine whether any declared conflict of interest results in
exclusion from part or all of the meeting. Each group member is responsible for maintaining the
confidentiality of restricted information.
Review
These terms of reference will be reviewed following the report to the Executive Committee or
sooner if required.
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Appendix C Committed Funding 2015/16
NHS Providers
Provider
AIREDALE NHS TRUST
Name of Contract
Specialist Midwife
BRADFORD TEACHING
HOSPITAL
FOUNDATION TRUST
BRADFORD DISTRICT
CARE TRUST
BRADFORD DISTRICT
CARE TRUST
One Stop Maternity
Support
BRADFORD DISTRICT
CARE TRUST
BRADFORD DISTRICT
CARE TRUST
BRADFORD DISTRICT
CARE TRUST
BRADFORD DISTRICT
CARE TRUST
Airedale Drugs
Services
GPSi service
BRADFORD DISTRICT
CARE TRUST
BRADFORD DISTRICT
CARE TRUST
BRADFORD DISTRICT
CARE TRUST
NHS BSA
NHS BSA
Total NHS Providers
Primary Care
Provider
BEVAN CIC
FARFIELD MEDICAL
PRACTICE
HOLYCROFT MEDICAL
PRACTICE
KENSINGTON STREET
(Dr BAVINGTON &
PARTNERS)
KILMENY MEDICAL
PRACTICE
LING HOUSE MEDICAL
PRACTICE
Total Primary Care
North Bradford Drugs
Service
Physical Health
Nursing Team
Fountains Hall
Bradford Mental
Health Substance
Misuse
Airedale Mental Health
Substance Misuse
Alcohol Care
Alcohol Care Team
Pilot
Prescribing
Dispensing
Name of Contract
Extended hours
Primary Care Service
Substance Misuse
Substance Misuse
Substance Misuse
Substance Misuse
Substance Misuse
Purpose
Prescribing and
recovery interventions
Prescribing and
recovery interventions
Contract Value (£ p.a)
10,186
78,000
Prescribing and
recovery interventions
Health care
interventions -harm
reduction
Prescribing and
recovery interventions
Prescribing and
recovery interventions
Prescribing and
recovery interventions
Drug & Alcohol Mental
Health Team
406,392
Drug & Alcohol Mental
Health Team
Alcohol interventions
676,052
122,665
Alcohol interventions
163,527
Drug Prescribing Costs
Drug Prescribing Costs
595,979
850,796
5,226,113
Purpose
Primary care for
women engaged in
prostitution
Prescribing and
recovery interventions
Prescribing and
recovery interventions
Prescribing and
recovery interventions
Contract Value (£ p.a)
29,888
Prescribing and
recovery interventions
Prescribing and
recovery interventions
12,217
85,003
119,325
204,750
776,276
1,137,162
12,217
18,217
126,604
36,630
235,773
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Third and Independent Sector
Provider
Name of Contract
ADDACTION
Substance Misuse
Clinical Support Service
ARCH
Criminal Justice
Recovery Interventions
BRIDGE
BRIDGE
Unity
South & West
BRIDGE
Fresh Start/Needle
Exchange
BRIDGE
BRIDGE
Change Programme
Womens Clinic
BRIDGE
Hostel Service
BRIDGE
BRIDGE
BRIDGE
BRIDGE
BRIDGE
Gym
Volunteer Programme
ETE/Cafe
Recovery Activities
CFU SMS Contribution
from Adults
Benzo Withdrawal
Service
Concerned Others
4 Women Service
BRIDGE
BRIDGE
BRIDGE
COMMUNITY
PHARMACY WEST
YORKSHIRE
Supervised Medicines
CRI
Education, Training &
Employment Service
Substance Support
Team
Alcohol Treatment
Requirement
Tier 2 & 3 Core service
HORTON HOUSING
LIFELINE PICCADILLY
LIFELINE PICCADILLY
LIFELINE PICCADILLY
LIFELINE PICCADILLY
PROJECT 6
A&E Interventions
Structured Day care
Complimentary
Therapies
Purpose
Prescribing and
recovery interventions
Drug & Alcohol
Interventions to
Substance Misusing
Offenders throughout
Criminal Justice System
Recovery Interventions
Prescribing and
recovery interventions
Prescribing and
recovery interventions
& Harm Reduction
Recovery Interventions
Prescribing and
recovery interventions
Prescribing and
recovery interventions
Recovery Interventions
Recovery Interventions
Recovery Interventions
Recovery Interventions
Core Costs
Contract Value (£ p.a)
737,276
35,250
51,500
58,800
63,500
117,120
Recovery Interventions
94,750
Support Service
Prevention,
intervention & exit
from prostitution
service
Supervision of
prescribed medicines
to opiate users in
treatment by
Pharmacies
Recovery service for
substance misusers
Floating support for
substance misuse
Court order for Alcohol
Misusing Offenders
Alcohol treatment &
recovery interventions
Alcohol interventions
Recovery programme
Recovery Intervention
25,664
261,628
1,425,944
264,800
421,600
395,700
218,800
137,200
45,400
560,000
117,000
130,744
47,964
241,446
34,541
120,000
37,285
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PROJECT 6
Tier 2 & 3 Core
PROJECT 6
Needle Exchange
PROJECT 6
PROJECT 6
PROJECT 6
Progress@P6
Stimulant Service
Asian Community
Project
BME Engagement
PROJECT 6
PROJECT 6
PROJECT 6
PROJECT 6
PROJECT 6
VARIOUS
Families at Project 6
CFU SMS Contribution
from Adults
Concerned Others
VCS Project -Alcohol
Primary Care Service
In-patient Detox
Treatment and
recovery interventions
Harm Reduction specialist needle
exchange
Recovery interventions
Recovery Interventions
Engagement and
support service
Engagement and
support service
Recovery Interventions
Core Costs
Support -carer service
Treatment and
recovery interventions
Drugs and Alcohol
detox programme
Total Third and
Independent Sector
Total Local Authority
and Police
7,622
60,480
50,692
38,017
57,938
36,954
31,766
3,265
9,668
70,343
120,000
6,318,797
Local Authority and Police
Provider
Name of Contract
Local Authority - Adults Floating Support for
Substance Misusers in
recovery
Local Authority -Adults
First Response Service
Mental Health
West Yorkshire Police
288,081
Criminal Justice
Recovery
Interventions -Police
team
Purpose
Floating support for
substance misusers in
recovery.
Mental Health
Interventions in Police
Custody, A &E and
Community
Providing support to
Drug & Alcohol Teams
to ensure retention in
treatment and reduce
re offending
Contract Value (£ p.a)
£115,000
120,000
145,905
380,905
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Total CCG Funding
Provider
Project 6
Lifeline Piccadilly
Horton Housing
BDCFT
(funding is transferred to PH
team as this element forms part
of PH contract with the Trust)
Infrastructure costs
Services
Primary Care Alcohol Workers
Assessment Worker
A&E Worker
Alcohol Rapid Assessment
Service
Alcohol Primary Care Services
CEE service
A&E Alcohol workers
Physical health Nurse
£60,000
£148,527
£15,000
£43,280
Total shared CCG costs
Project 6
(separate agreement with
AWC)
Total CCG Funding
Value
£70,000
£35,000
£35,000
£135,000
£208,043
£749,850
ACIST
£70,000
£819,850
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Appendix D Local Authorities which together make Bradford’s ‘Local Outcome Comparators’ (LOC)
Birmingham
Blackburn with Darwen
Blackpool
Bolton
Bournemouth
Cheshire West and Chester UA
Leeds
Leicester
Liverpool
Manchester
North East Lincolnshire
Oldham
Solihull
St Helens
Swindon
Tameside
Tower Hamlets
Wakefield
Coventry
Doncaster
Islington
Kingston Upon Hull
Lancashire
Peterborough
Plymouth
Rochdale
Salford
Sefton
Walsall
Wirral
Wolverhampton
Worcestershire
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Appendix E Substance Misuse Treatment and Recovery System Consultation Results and Findings
Introduction
Aim
The aim of the consultation was to obtain the views of all stakeholders including service users,
providers, health care professionals and the general public, in order to gain an understanding of how
people feel the system is working currently, and what is important for those supported by the
system. These views will be considered along with the rest of the review in order to shape the
future of the system.
Methods
These views were collated using two methods.
•
•
a questionnaire, which respondents could complete either online, or on a paper version
focus groups.
Topics considered
In the questionnaire, there were five questions which sought stakeholders’ views on the system:
1. Do you feel you know enough about the substance misuse recovery system which is
provided locally?
2. Please tell us how we can improve your knowledge of the substance misuse recovery
system.
3. What do you think works well about the local alcohol & drug treatment and recovery
system?
4. What do you think doesn’t work well about the local alcohol & drug treatment and recovery
system?
5. What would you change about the system if you could?
Questions 2 to 5 were open-ended, allowing respondents to contribute as they saw fit. A number of
themes emerged from these responses, and these are discussed in the Results section of this report.
Since the questions were open-ended and each respondent could express themselves freely, some
respondents made comments which fitted into more than one theme.
Additionally, the questionnaire was used to collect a range of background information questions
about each respondent.
The focus groups were asked to consider three of the questions as they appeared the questionnaire namely “what works well with the current system?” “What doesn’t work well about the current
system?” and “what would you change about the system if you could?” Attendees were split into
groups who were asked the above questions and then had to identify which points were of the
greatest importance to them.
Promotion and distribution
The consultation was advertised through a variety of means. These included the local media, with a
news article in the Telegraph and Argus, and social media, with links to the online survey placed on
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HealthyBrad4d Facebook and twitter page. Emails which included the link were sent to various
stakeholders including: service providers; the police; Probation; Prisons; GPs; Housing Related
Support services commissioned by BMDC; and the voluntary and community sector. The
consultation was also advertised on the Bradford Assembly webpage and via a news bulletin on the
Bradford Healthwatch website, where the general public would be able to access the link. Hard
copies of the questionnaire were made available in all Substance Misuse services for staff and
service users to provide their views.
Participation
161 responses were received to the online questionnaire, and there were 436 paper responses.
There were 5 focus groups in total, and over 100 people attended.
Two of the focus groups were run for service users and concerned others.
The first meeting was carried out at a Service User Representation Forum (SURF) open meeting
which was held in Bradford. 40 service users and supporters attended the session. The session was
advertised on the Recovery Guide Newsletter which is available for all service users.
The second service user group was carried out in Keighley 18 Service Users attended the session.
This was also advertised via the Recovery Guide Newsletter, the session was also organised to run
directly after a cook and eat session that service users attend in order for them to come to the
meeting on the same day. It is important to note that the majority of this group attend ‘Progress’,
which is an abstinence service. It can reasonably be concluded that the service is working well for
this group, and this may be reflected in their responses.
Two of the focus groups were for providers; all providers were sent an email to make them aware of
the focus groups.
The first provider focus group was held in Bradford and was attended by 22 people from 8 different
providers; the second was carried out in Keighley which was attended by 14 people from 7 different
providers.
A further focus group was to those who attend the Service User Involvement Group (SUIG). This
group included service users who also use housing associations. In addition to service users, it also
included workers from housing associations who may have limited knowledge of the actual service.
The focus group was advertised via providers of housing related support services to all their service
users and sent to people who had attended meetings in the past. This event was carried out at
Carlisle Business Centre, in Manningham, Bradford. As this group included a number of people are
not in regular contact with the substance misuse system, the groups were also asked to consider the
question: “Please tell us how we can improve your knowledge of the substance misuse recovery
system.” It is important to note that 4 attendees were from a service which has recently been
decommissioned, and this may be reflected in the responses of those attendees.
Questionnaire response rates
The nature of those responding to the questionnaire differed from one method of response to the
other. Whereas 63% (273) of those who carried out a paper questionnaire were service users, 6%
(10) of online responses were completed by service users. The majority of respondents via the
online link were from organisational stakeholders including the police, probation, and voluntary and
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community sector organisations. There was also strong representation from healthcare
professionals and members of the general public.
This contrast was also reflected in the level of response to question 2 of the survey. A far greater
proportion of online respondents provided comments in response to Question 2.
Figure 1: Question response rates
Question
Q1 Do you feel you know enough about the substance
misuse recovery system which is
provided locally?
Q2 Please tell us how we can improve your knowledge of the
substance misuse recovery system.
Response Rate
Paper Responses
Online Responses
Number Percentage Number Percentage
418
96%
161
100%
150
34%
143
89%
Q3 What do you think works well about the local alcohol &
drug treatment and recovery system?
390
89%
141
88%
Q4 What do you think doesn't work well about the local
alcohol & drug treatment and recovery system?
Q5 What would you change about the system if you could?
350
370
80%
85%
132
127
82%
79%
Presentation of analysis of results
Bearing in mind the issues discussed in the section on ‘survey response rates’, the paper responses,
online responses and focus groups are each considered and discussed separately throughout the
rest of this report.
The results collected from the responses to questions 2 to 5 of the questionnaire set out the major
themes that emerged from the consultation. These are presented in tables which follow this format:
Theme
Example(s)
Sample comments
Major
emergent
theme
Specific examples of the topics raised by
respondents
Adapted* comments taken
from responses
* The online and paper questionnaire contained a commitment to treating responses as
‘confidential’. In each instance where a sample comment is included, this has been adapted in order
to maintain that confidentiality, whilst keeping the spirit of the response.
In the sections about online and paper responses, the themes are presented in descending order of
recurrence – ie the issues at the top of the list are those which were raised by the largest number of
respondents.
In the sections on Focus Groups, the results take into account two things. Firstly, whether or not
each respective focus group considered an issue to be one of the ‘most important’ topics they had
been able to identify; secondly, whether or not the issue had been raised by any or all of the other
focus groups.
These results appear as lists in the following format:
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Focus Group 1
Focus Group 2
Service Users
•
List of
issues
•
List of
issues
Focus Group 3
Focus Group 5
Providers
•
List of
issues
•
List of
issues
Focus Group 4
Service User
Involvement
Group
• List of
issues
Demographics and other personal information
In addition to collecting the views of stakeholders, the paper and online questionnaires also asked
respondents to volunteer information about themselves. This information related to:
• Alcohol and drug use
•
Their interest in the survey
•
Where they live
•
Gender
•
Age
•
Ethnicity
•
Physical and mental wellbeing
•
Sexual orientation
In this initial round of analysis, little of this information has been used. It is felt that further analysis
at this level of detail is likely to be very useful after the recommendations of the review have been
considered.
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Results
Question 1: Do you feel you know enough about the substance misuse recovery system
which is provided locally?
Paper responses
335 (77%) of respondents said that they felt they knew enough about the substance misuse recovery
and treatment system provided locally.
Online responses
101 (63%) of respondents said that they felt they knew enough about the substance misuse recovery
and treatment system provided locally.
Focus groups
Focus groups were not asked to consider Question 1
Other Observations
• The difference between paper and online responses is to be expected, given the high
proportion of service users who responded via the paper questionnaire.
•
There is potential for the results of any survey of this nature to be skewed – those most
likely to know about the system may well be those most likely to complete the
questionnaire.
Summary
The majority of respondents felt that they know enough about the system.
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Question 2: please tell us how we can improve your knowledge of the substance
misuse recovery system.
Those who said that they did not know enough about the substance misuse recovery system
were invited to say how their knowledge could be improved. Additionally some respondents
who said that they already knew enough expressed further opinions. These responses were
considered to be useful, and have been included in the analysis of themes as set out below.
Paper responses
Theme
Example(s)
Sample comments
Promotion
through new
means of
communication
Increased advertising through local media, radio,
newspaper, social media e.g. Facebook
Availability of information in other languages
Leaflets
“it could be
promoted better”
Making
information
available
through other
routes
Outreach
More information distributed through Health
centres, surgeries, pharmacies, hostels, Substance
Misuse Services buildings, schools and Job centres
“more promotion
in other services
and at the doctors
etc”
more outreach work to be done to access those
‘hard to reach groups’
“workers could tell
users more about
the services”
Better use of
existing
communication
Use of the website; ensuring that information is upto-date, including information on services and how
to access them.
“I’d like more
information from
the website”
Consistency of
message
Organisations giving out inconsistent messages; a
perceived failure to refer between services
“services need to
work together, not
against each
other”
The role of the
service user
Service users also acknowledged their
responsibility of finding out what is available
Miscellaneous
other
A map of services; branding
own “you can’t improve
people’s
knowledge –
service users need
to makes sure they
use services”
“design a better
way for people to
find out what and
where recovery
services are”
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Online responses
Theme
Example(s)
Sample comments
Training
A greater and more consistent understanding of
what services are available
“more training
about the services
which are available
in the area”
Better use of
existing
communication
Use of the website; advice sessions; ensuring that
the data is kept up to date
“the system needs
a website, and for
it to be regularly
updated”
Promotion
through new
means of
communication
Leaflets
Increased advertising through local media, radio,
newspaper, social media e.g. Facebook.
“more leaflets with
information about
where patients can
go”
Channels of
communication
Information to be distributed through Parish
councils, third sector organisations, GP surgeries,
libraries, community centres, pharmacies, schools,
food banks and supermarkets.
Community events
Events
Education
“literature should
be available in
more public
places”
“it would be useful
if someone could
give presentations,
in the community,
letting people
know about the
system”
Learning sessions for the public and others, covering “people do not
changes in drug use, awareness of substance misuse know enough
and its consequences etc.
about substance
misuse, its effects,
its side effects, and
the long term
problems it
causes”.
Focus groups
There was only one focus group which answered this question. The responses were very
similar to those achieved through the paper and online survey, focussing on the means of
communication (using local media to advertise services, using leaflets or posters) and
channels of communication (making information available in appropriate settings in order to
reach a large audience).
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Other Observations
• Service users wanted to be informed about other services which were available to
them other than the service they were currently receiving, however some did accept
responsibility that they can find out for themselves.
•
Non service users suggested that there was a more formal means of improving
people’s knowledge and awareness through a variety of means including; educating
key stakeholders and carrying out events in the local community.
Summary
There seems to be a general view that services could be promoted better through a variety
of new and existing methods, and that careful consideration needs to be given to where
information about services is made available. On close examination of the comments, there
was a clear demand for information which is clear, accessible to all and jargon free.
Question 3: what do you think works well about the alcohol & drug treatment
and recovery system?
Paper Responses
Theme
Example(s)
Sample comments
People involved Personal qualities which are likely to be conducive “Everyone I have
in delivering
to the treatment of individuals; individual workers dealt with has
the service
mentioned and praised; the value of 1:1 sessions
been pleasant and
helpful.”
“I feel like people
listen to me”.
Personal
experience
Groups, and
the sense of
community
The variety of
support
People’s personal accounts the drug service
“I would be lost
without this
service. It helps
people get back on
track”
Meeting groups as a mutual support network; the “The sense of
existence and availability of groups
"community" in
recovery services is
amazing”
Groups such as Alcoholics Anonymous and Narcotics “there are plenty
Anonymous; 1:1 sessions with key worker; of services, and a
psychosocial interventions; medication.
wide variety of
them”.
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Specific aspects
of the service
Miscellaneous
positive
feedback
The existence of the prescription service; the ease of “the best thing is
access to it; the speed of access to treatment;
the speed with
multiple services under one roof; easy to get to
which you get a
script”
“getting treatment
as quickly as
possible”.
In addition to the above themes, there were a
“everything works
number of responses which were undoubtedly
ok”
positive, but it was not possible to develop any
insight from the comment.
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Online Responses
Theme
Example(s)
Sample comments
The ways in
which
organisations
work together
Relationships between providers; partnership
working
“Services link up
quite well.”
People
involved
Personal qualities which are likely to be conducive to
the treatment of individuals; commitment and
knowledge of key staff
Specific aspects
of the service
Ease of referral; Client focus; Availability of service
through GPs; the speed of treatment; the availability
of prescriptions
The benefits of
the service
The perceived societal benefits of a good system;
Crime reduction
Lack of
awareness of
the service
Insufficient experience of the system to be able to
make a meaningful comment.
“it helps that staff
know the system,
the area, and each
other”
“it’s good that
patients can access
services at their
local GP practice”
“treatment
prevents users
from committing
crime to fund their
habit”
“I don’t know
enough about
this”.
Focus Groups
Focus Group 1
Focus Group 2
Service Users
Variety of services
Variety of services
The gym
The gym
Key workers, 1:1s
Key workers, 1:1s
Safe environment
Safe environment
People involved in
delivering the
service
People involved in
delivering the
service
Structured
programmes
HUB
Structured
programmes
Client Focus
Support relating
Focus Group 3
Focus Group 5
Providers
Variety of services
Support for
concerned others
Cross
organisational
working
Location of
services
Ease of referral
Client Focus
Support relating
to other matters
Needle exchange
Volunteer
opportunities
Variety of services
Support for
concerned others
Cross
organisational
working
Prescribing
People involved in
delivering the
service
Client Focus
Support relating
to other matters
The availability of
support at the
Focus Group 4
Service User
Involvement
Group
Medication
Accessibility
Training
Structured
Programmes
Volunteer
Opportunities
Groups – the
sense of
community
Client Focus
Support relating
to other matters
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Café
Volunteer
opportunities
to other matters
Needle exchange
Training
Acknowledgemen
t of the user’s
own responsibility
GPs
Groups – the
sense of
community
“Support relating to other matters” includes aspects which are not necessarily directly
related to becoming drug free or abstinent from alcohol. These include, for example,
courses to build life skills including healthy eating, opportunities to build social relationships,
and activities to fill the time to break the cycle of drug use. This can also include support on
housing and training, and education to help individuals after an addiction.
Cross organisational working involves the linking up of other services including, for example,
housing support, health care professionals, hospitals, and other services within the system
working together to get the best outcomes for service users.
Other Observations
Service users are most likely to report their workers and the individual service they receive,
and the activities available including the gym and the café. Providers are more likely to
provide more organisational level responses, and refer to matters such as cross
organisational working. This is reflected both in the feedback from focus groups and the
differing responses to online and paper questionnaires.
As can be seen from the analysis of the responses to question 4, some of the positive
qualities recorded here are counterbalanced by others’ negative views of the same aspects
of the system. This needs to be taken into account in considering the summary.
Summary
Many people who contributed to the consultation feel that the people who work within the
system are a considerable strength.
People also like the variety of services available including the groups and the one to one
support they receive from their key workers. There is an overall appreciation that the
system is not merely about issuing medication, and that individuals’ broader needs are taken
into consideration. There was particular focus on the available groups meaning that
individuals felt a sense of community and less isolation, being around people who are in a
similar situation. Respondents also praised the ease of getting treatment and the ability to
get a prescription. The overall existence of the service was paramount to many users.
Online responses tended to focus on how the services work well together in partnership and
the societal benefits with reduction in crime.
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Question 4: What do you think doesn’t work well about the local alcohol and
drug treatment and recovery system?
Paper Responses
Theme
Example(s)
Overall praise
Lack of client
focus
Medication
Appointments
Waiting Times
The
environment in
which services
are delivered
In spite of the nature of the question, respondents
commented that everything works well or took the
opportunity to pay compliment to the system
Singularity of approach to individual problems;
inflexibility
Prescriptions which are too strict; which are given over
an extended period of time; which are given in
inappropriate doses
Late changes to appointments; the perception that the
consequences of missing an appointment are too harsh
The length of time to wait for an appointment to be
made; once an appointment has been made, the failure
of the appointment to start on time.
Attempting to recover/abstain whilst in the presence of
those who are still using drugs/alcohol
Sample comments
“everything works
well for me”
“they don’t listen to
clients and what
works for them”
issues too specific to
individuals
“when we are late
they won’t see us”
“when you start
treatment it can
take too long to get
an appointment”
“Being surrounded
by people who drink
or take drugs, it’s
difficult to stay off
drugs and alcohol”
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Online Responses
Theme
Example(s)
Lack of client
focus
Singularity of approach to individual problems;
inflexibility
Medication
Prescriptions which are too strict; which are given
over an extended period of time; which are given in
inappropriate doses
Lack of cross
organisational
communication
Failure to share information between organisations;
a different approach taken by different providers;
providers not knowing enough about each other
promotion of
services
Strong links to question 2 eg the means of
communicating information about services
waiting time
The length of time to wait for an appointment to be
made; once an appointment has been made, the
failure of the appointment to start on time.
Sample comments
“Too much focus
on medication and
not enough on
service users.”
“People are on
medication for
years, and they
shouldn’t be”.
“The service is
disjointed –
patients need to
get their care from
one place”.
“I found it difficult
to get the
information I
needed to start my
recovery”.
“the waiting lists
for treatment
seem long”.
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Focus Groups
Focus Group 1
Focus Group 2
Service Users
Focus Group 3
Focus Group 5
Providers
cross
organisational
working
cross
organisational
working
cross
organisational
working
cross
organisational
working
Not client
focussed
Not client
focussed
Fill time
Fill time
Time constraints
Disjointed- drug/
alcohol services
The system is too
complex
Detox
Detox
(Lack of) Support
relating to other
matters
Education and
training
(Lack of) Support
relating to other
matters
Education and
training
Not client
focussed
Time Constraints
Alcohol
prescriptions
Staff
Education and
training
Waiting times
Slow referral
process / rehab
Aftercare
Red tape
Outreach
Funding
Travel costs
Focus Group 4
Service User
Involvement
Group
Funding
Not client
focussed
Floating support
People involved in
delivering the
service
Staff
Waiting times
Aftercare
Testing
Travel costs
Waiting times
Aftercare
Outreach
HUB
The process
The promotion of
services
Red tape
Rehab
Lack of services
Family support
The system is too
complex
Specific services
The assessment
system
Childcare
Gender specific
services
Other Observations
As pointed out elsewhere in this report, some negative comments were made about aspects
of the system which also attracted praise in question 3. For example, some service users in
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response to question 4 felt that the service is not client focussed, and that there is too much
focus on medication and not enough on what the client needs. Similarly, it was stated in
question 3 that services work well in partnership, whereas the responses for question 4
highlights a lack of cross organisational working.
Summary
From the outset it was considered that questions 4 and 5 may provide the most useful
information in terms of informing how the system might be developed in the future.
It is important to note that even when invited to describe the system in negative terms,
many respondents made positive comments. This was particularly notable amongst service
users, commenting on the service they receive.
The most notable negative theme emerging from the questionnaires was that there is a
perceived lack of client focus. This was expressed in different ways: service users felt that
their views were not listened to, whereas focussed more on the singularity of the service,
being heavily reliant on medication.
On a similar topic, service users feel that prescriptions are too strict. A number of service
users, responding to the paper questionnaire stated that they are unable to attend each day
for medication and described the negative impact this had on their lives. Others wanted
prescriptions that were longer than a week for the same reasons. The online responses
focussed on the length of time people are on medication without support for getting clean,
leading to concerns around the system running as a maintenance program rather than a
recovery program. Similar comments were picked up among the focus groups.
Service users were unhappy of the penalties that are put on them if they are late for an
appointment, resulting in a long wait for a rescheduled appointment. Some respondents
expressed extra frustration whilst late attendance is not tolerated from a service user, it is
not uncommon for key workers to be late for appointments.
Despite a focus in question 3 on service users feeling that they are in a safe environment,
there was a number of responses to question 4 which indicated that people were unhappy
about mixing with people during different stages of recovery. The point was made that it
can be difficult to ‘stay clean’ whilst being around people who are still using substances, and
a number of responses highlighted that people use substances outside the entrance to
important premises.
Online respondents said that there is a lack of communication about other services and what
they all do, and – reinforcing the themes which emerged in question 2 - there was a call for
services to be better promoted.
In the focus groups, some of those who attended identified a lack of aftercare; people felt
that once people were clean there was not much support to help them to stay clean, which
led them to relapse. 4 of the 5 focus groups also identified the lack of cross organisational
working. Notably, the focus group which did not identify this was the group which had little
knowledge or experience of the substance misuse system. Service users identified a need
for help towards childcare and travel costs to ensure that they can attend their sessions.
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Question 5: What would you change about the system if you could?
Paper Responses
Theme
Example(s)
nothing
client focus
In spite of the nature of the question, respondents
commented that everything works well or took the
opportunity to pay compliment to the system
Singularity of approach to individual problems;
inflexibility
medication
Prescriptions which are too strict; which are given over
an extended period of time; which are given in
inappropriate doses
waiting times
The length of time to wait for an appointment to be
made; once an appointment has been made, the failure
of the appointment to start on time
opening times
Out of hours services; evening sessions / shelters; early
appointments
a lack of funding for services
funding
wider
determinants
people
involvedgeneral
groups
cross
organisational
working
Miscellaneous
other
addressing the reasons why people turn to, or continue
to use, drugs; addressing the impact on other aspects of
life
Workers to be more understanding around lateness; to
support users’ desire to ‘get clean’
Content of existing groups; the demand for more
groups
Failure to share information between organisations; a
common approach between different providers;
providers knowing more about each other
Childcare, more gym facilities, payment of travel costs
and many others
Sample comments
“There is nothing I
would change”
“I’d like workers to
be able to cater to
our needs more”
“only methadone is
available there
needs to be a
range”
“people new into
the system can’t
afford to wait for as
long as they have
to”
“open late more
often”
“there needs to be
more money for
services”
“more help with
family life”
“the system needs
more people who
understand users”
“more groups,
dealing with people
at different stages
of their recovery”
“different places
should link up
better”
“we need help with
bus fares as we are
on low incomes”
“open the gym
more”
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Online Responses
Theme
Example(s)
client focussed
Singularity of approach to individual problems;
inflexibility
promotion of
services
Strong links to question 2 eg the means of
communicating information about services
funding
a lack of funding for services
alcohol
Increased demand for alcohol services
Wider
determinants
addressing the reasons why people turn to, or
continue to use, drugs; addressing the impact on
other aspects of life; examining the supply chains
Supporting those who have been (successfully)
treated; investing more in establishing the
practice for supporting people after treatment.
Training; location of services; more volunteers;
day trips for service users.
After care
Miscellaneous
other
Sample comments
“services that really
meet the needs of
clients”
“avoiding that onesize-fits-all approach”
“tell more people
more about what you
do”
“every potential
improvement comes
down to whether
there is enough
funding”
“we need more
groups for people
who have alcohol
problems”
“Work with others to
restrict the supply of
drugs”
“increase the
investment in after
care”
“more services
outside the city
centre, so users don’t
have to go right into
Bradford.”
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Focus Groups
Focus Group 1
Focus Group 2
Service Users
Focus Group 3
Focus Group 5
Providers
Focus Group 4
Service User
Involvement
Group
Access
Integrated service
Floating support
Settings
Recovery housing
Funding
Taxation of
drugs*
Education /
Training
Prescription /
medication
Treatment
Cross
organisational
package
working
Integrated service
Settings
Cross
Recovery housing organisational
Childcare
working
Client focussed
Nationally
Groups
recognised
Aftercare
services
CCG led service to
Outcome
Focussed
meet local needs
Consistency
Data system
Volunteers
Support relating
to other matters
Alcohol
prescribing
*this observation is out of the scope of the review. Comments were excluded from the
analysis of individual questionnaires in instances where those matters related to issues
which were clearly outside of the scope of the review.
Access
Re brand as one
service
Concerned others
Diazepam detox
Recovery housing
Childcare
Client focussed
Groups
Aftercare
Education /
training
Prescription /
medication
More outreach
Travel costs
Trips / Activities
Access
Funding
Other Observations
The service user focus groups focussed on how they can get a better service including less
harsh penalties for late appointments and more trips and day activities. The providers
focussed on how the service should be run, giving two clear options: one being an integrated
service where a client will receive a treatment package and signposted to all relevant
services rather than just one; and another which suggested that there should be three
services - one for each CCG, which is driven by the needs of their local community. Service
users tended to be of the view that it should be one service and that it should have clear
branding.
Similar themes were identified across all respondents. As with question 4, however, service
users were more likely to praise the service they currently receive and state that there was
nothing that they would change about the current service.
Summary
The main thing people would change, given the chance, would be to increase the focus on
individual clients. This echoes the views expressed in response to question 4. Service users
expressed this in terms of a desire for a service which ‘listens’ more; which offers a range of
medication instead of just methadone; has shorter waiting times to enter the service; and a
more flexible appointments system.
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As previously discussed in question 4 there was a little controversy over what was stated in
question 2. Service users said that the people involved need to be more understanding
around lateness and listen to clients around their desire to get clean, whereas in question 2
the people involved were viewed as the most important part of the service. Despite the
current groups being perceived positively, service users felt there needed to be more. A
small number of service users made the observation that they felt that they were stuck in
their service with no desire for the current service to move them elsewhere, even if that
would benefit their recovery. There was a notable amount of discussion in the responses
around a possible reluctance of workers to move people through the system – some
wondered whether workers’ best interests were served by dealing with greater numbers of
service users; others suggested workers simply may not be aware of the other services that
were available. If this latter point is true, this calls for better communication, better
partnership working and more transparency throughout.
The online responses focussed still more on the promotion of the service to enable better
‘joined up’ working. As with the paper responses the largest element respondents would
change was to make the service more focussed around the needs of the individual client.
Respondents also noted a need for better promotion of services, so that other organisations
and the general public are aware of what is available for those who are misusing substances.
This will enable more people to get the appropriate support they require. A lack of funding
was also noted as something that they would change. It was recognised that there is
potential for a really good service it just depends on whether there is enough funding to
enable this to happen.
Online respondents referred to a need for more alcohol services, and this was apparent in
the provider focus groups which called for prescribing for alcohol addiction. Another issue
raised via the online respondents was to provide a service which addresses the wider issues
as to what leads people to misuse substances and continue to use them, as medicating alone
cannot eradicate the addiction. Likewise, respondents noted the importance of ensuring
that there is a good aftercare system to prevent people from using after they have
completed treatment.
There were a number of lesser-expressed ideas which may still hold some significance about
the way the system operates. These included training for staff, and education for all to aim
to reduce the number of people taking drugs in the future.
The provider focus groups (and in particular focus group 5) looked at what the future of the
system will potentially look like. This will be looked at in more detail if the result of the
review highlights that there needs to be a change in the way the system currently functions.
Other responses from the focus groups suggested a greater demand for detox and recovery
housing, highlighting that current access to such facilities is time-consuming and complex.
Additionally, the groups echoed some of the themes which emerged from the questionnaire
responses. These included aftercare, medication and a need for additional groups.
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Demographics
Problematic Drug Use
Paper responses
75% (323) of all respondents stated that they used substances in a problematic way. 39%
(170) of respondents said that they use drugs only and a further 12% (53) said that they used
only alcohol only with the final 23% use both alcohol and drugs.
74% (241) of those 323 respondents stated that they are a user of the substance misuse
service. This may potentially mean that 26% of respondents use substances but do not
access the service. Alternatively, the gap could be explained by responder error – wherein
the respondent selects the incorrect option from a list - or by individuals not declaring that
they use the service.
Online Responses
89% of respondents to the online questionnaire stated that they didn’t use any substance in
a problematic way. This is expected as there were only a small number of service users who
responded via the online tool.
Respondent interest in the consultation
Paper Responses
Respondents were asked what their interest was in the consultation 63% (273) of those who
responded (paper) were someone who uses the substance misuse system. 11% (46) were a
member of the general public. 8% (37) of respondents did not provide an answer.
Online Responses
There was a much smaller representation of service users in the online responses with only
6% (10.) There was a greater representation of health care professionals (51/32%) 37 (23%)
of which were responding as an individual. In addition to health care professionals there was
a number of respondents from the police and probation services (13/8 %,) and the general
public (30/19 %.) This breakdown was expected with the methods used to promote the
consultation.
The following chart shows the proportion of respondents via each response method. It
highlights the large proportion of paper responses that were service users which dominates
the responses. Police and probation fall under the other category, respondents were given
the opportunity to explain who they were in addition to the police there were members of
the voluntary and community sector and community services.
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Postcode
Paper Responses
61% (266) of respondents (paper) did not provide a postcode area. Of those that did provide
a postcode area there was a spread of people from all across the district 8% (37) were from
BD8, and 4% (17) were from BD5.
Online Responses
22% (36) of online respondents did not provide a postcode, which is a lot less than the paper
responses. 12% (19) were from BD18, 7% (11) were from BD5. As there was a greater
response from health care professionals there were a number of respondents from outside
Bradford District.
Gender
Paper Responses
63% (275) of respondents (paper) were male, 33% were female (144) 4% did not disclose.
This is in line with the gender profile of service users, where there are more males than
females.
Online Responses
There was very little difference between male and female respondents for the online
responses, with slightly more females to males. There were more respondents who did not
disclose their gender with 19% (30.)
The chart below shows the gender breakdown for both methods, it highlights the larger
proportion of males among the paper responses and the greater proportion of those who
did not respond in the online responses.
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Age
Paper Responses
The age breakdown of respondents in particular for the paper responses was higher among
those aged 25-54, which peaked in the 35-44; this is consistent with the age profile of
service users.
Online Responses
19% (30) of the online respondents either didn’t disclose their age or stated that they
preferred not to say. The breakdown was similar to that of the paper responses however
there were more respondents aged 55 and over.
The following chart shows the age breakdown of respondents by response method. It
highlights the high proportion of respondents aged 35-44, and the higher proportion of
online responses who did not disclose their age.
Ethnicity
Paper Responses
79% (345) of paper responses identified themselves as White British this is also consistent
with the profile of service users. However it would have been good to get a better
representation from other ethnic groups across the district.
Online Responses
69% (111) of respondents identified themselves as White British, 5% (8) were Pakistani, and
15% (24) didn’t disclose their ethnicity. There was very little representation from other
ethnic groups.
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Disability/ long standing illness
Paper Responses
58% (251) of paper respondents identified themselves as having a Disability or a long term
illness whether it is physical or mental; 28% (123) specified mental health, 15% said they had
a physical disability/ illness and a further 15% said they had both. 9% preferred not to say
and 7% did not respond.
Online Responses
66% (106) of respondents said they had no physical or mental illness, 24% (38) preferred not
to say or chose not to disclose.
Sexuality
Paper Responses
The majority (347/80%) of respondents identified as heterosexual, 17% (72) preferred not to
say, which left a small proportion who identified as Bisexual or Homosexual.
Online Responses
As with the paper responses the majority of respondents identified themselves as being
heterosexual (116/72%,) with the remainder preferring not to say (21/ 13%) or not disclosing
(24/ 15 %.)
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Appendix F Data Sources
The following data sources were used when compiling this report.
National Drug Treatment Monitoring System (NDTMS) Data sources
Report title
Adult Activity Report (Partnership) – Alcohol and Alcohol and Non
Opiates
Adult Activity Report (Partnership) – Opiates and Non Opiates
Adult Alcohol Performance Report (HTLA) 2013-14 Bradford
Community Criminal Justice Report
Community Criminal Justice Report
Community Criminal Justice Report
Community Criminal Justice Report
Diagnostic and Outcomes Monitoring Executive Summary
(DOMES)
Prevalence Estimates
Recovery Diagnostic Toolkit (Alcohol Clients)
Period
Year 2014-15
Year 2014-15
Year 2013-14
Q1 2014-15
Q2 2014-15
Q3 2014-15
Q4 2014-15
Year 2014-15
Recovery Diagnostic Toolkit (Non-opiate Clients)
Year 2014-15
Recovery Diagnostic Toolkit (Opiate Clients)
Successful Completions and Re-presentations
Treatment Map (Drug Treatment)
Year 2014-15
Year 2014-15
Year 2013-14
Year 2011-12
Year 2014-15
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Appendix G National and Local Drivers and Influences
Working Together to Safeguard Children 2013
Working Together to Safeguard Children 2013 is a set of guidance which informs interagency working to safeguard and promote the welfare of children.
Key elements of the guidance:
Safeguarding children - the action we take to promote the welfare of children and protect
them from harm - is everyone’s responsibility. Everyone who comes into contact with
children and families has a role to play.
Safeguarding and promoting the welfare of children is defined for the purposes of this
guidance as:
•
protecting children from maltreatment
•
preventing impairment of children's health or development
•
ensuring that children grow up in circumstances consistent with the provision of safe
and effective care; and
•
taking action to enable all children to have the best outcomes.
For children who need additional help, every day matters. Academic research is consistent in
underlining the damage to children from delaying intervention. The actions taken by
professionals to meet the needs of these children as early as possible can be critical to their
future.
Children are best protected when professionals are clear about what is required of them
individually, and how they need to work together.
This guidance aims to help professionals understand what they need to do, and what they
can expect of one another, to safeguard children. It focuses on core legal requirements and
it makes clear what individuals and organisations should do to keep children safe. In doing
so, it seeks to emphasise that effective safeguarding systems are those where:
•
The child’s needs are paramount, and the needs and wishes of each child, be they a
baby or infant, or an older child, should be put first, so that every child receives the
support they need before a problem escalates;
•
All professionals who come into contact with children and families are alert to their
needs and any risks of harm that individual abusers, or potential abusers, may pose
to children;
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•
All professionals share appropriate information in a timely way and can discuss any
concerns about an individual child with colleagues and local authority children’s
social care;
•
High quality professionals are able to use their expert judgement to put the child’s
needs at the heart of the safeguarding system so that the right solution can be found
for each individual child;
•
All professionals contribute to whatever actions are needed to safeguard and
promote a child’s welfare and take part in regularly reviewing the outcomes for the
child against specific plans and outcomes
The Care Act 2014
As from April 2015, a new law will be introduced about care and support for adults about
will have to do and what support people can expect. There are currently many laws that
govern care and support and the Care Act now combines these into one Act.
The main change of the Act means that a person’s wellbeing is now priority and it supports
people to be back in control of their own care. It will make clearer what the council have to
provide.
The Act also focuses on:
•
Giving better information on helping make better choices and support to
keep people as independent and in control of the own lives as possible
•
Carers – they will be entitled to an assessment and some will be entitled to
support
•
A change to how people are assessed for support and care that follows a
national criteria so that the entire country follow the same eligibility rules
The Care Act requires local authorities to help develop a market that delivers a wide
range of sustainable high-quality care and support services that will be available to
their communities.
When buying and arranging services, local authorities must consider how they might
affect an individual’s wellbeing. This makes it clear that local authorities should think
about whether their approaches to buying and arranging services support and
promote the wellbeing of people receiving those services.
Local authorities should also engage with local providers, to help each other
understand what services are likely to be needed in the future, and what new types
of support should be developed. To do this, authorities should engage with local
people about their needs and aspirations.
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A wider range of high quality services will give people more control and help them to make
more effective and personalised choices over their care. They should therefore get better
care that works for them.
Safeguarding Adults
The Care Act 2014 sets out a clear legal framework for how local authorities and other parts
of the system should protect adults at risk of abuse or neglect.
Local authorities have new safeguarding duties. They must:
•
lead a multi-agency local adult safeguarding system that seeks to prevent abuse and
neglect and stop it quickly when it happens
•
make enquiries, or request others to make them, when they think an adult with care
and support needs may be at risk of abuse or neglect and they need to find out what
action may be needed
•
establish Safeguarding Adults Boards, including the local authority, NHS and police,
which will develop, share and implement a joint safeguarding strategy
•
carry out Safeguarding Adults Reviews when someone with care and support needs
dies as a result of neglect or abuse and there is a concern that the local authority or
its partners could have done more to protect them
•
arrange for an independent advocate to represent and support a person who is the
subject of a safeguarding enquiry or review, if required.
Any relevant person or organisation must provide information to Safeguarding Adults Boards
as requested.
Offender Rehabilitation Act 2014
The adult sentencing framework is broadly governed by the Criminal Justice Act 2003 (the
2003 Act). The Act makes a number of changes to the release arrangements set out in the
003 Act for adult offenders serving custodial sentences of less than 12 months and those
serving sentences of between 12 months and 2 years.
In particular the Act:
•
Applies arrangements for release under licence to offenders serving fixed-term
custodial sentences of more than 1 day but less than 12 months
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•
Introduces new supervision arrangements for offenders released from fixed-term
custodial sentences of less than 2 years so that all offenders are supervised in the
community for at least 12 months.
•
Creates a new court process and sanctions for breach of supervision requirements
for offenders serving fixed-term custodial sentences of less than 2 years.
•
Introduces for offenders released from custody a new drug appointments condition
for the licence or supervision period, and expands the existing drug testing
requirement for licences to include Class B drugs and makes it available during the
supervision period.
•
Introduces a requirement that any juvenile who reaches his or her 18th birthday
before being released from the custodial element of a Detention and Training Order
(DTO) should spend at least 12 months under supervision in the community.
•
Introduces a requirement that contracts or other arrangements made under the
Offender Management Act 2007 for the supervision or rehabilitation of offenders
must state what provision, if any, is intended to meet the particular needs of female
offenders.
The Act also makes some changes to the arrangements for community orders and
suspended sentence orders. In particular it:
•
Creates a new rehabilitation activity requirement for community orders and
suspended sentence orders and in doing so abolishes the supervision and activity
requirements.
•
Introduces new arrangements for the designation of responsible officers in relation
to the supervision of offenders and makes clear that the responsibility for bringing
breach action lies with the public sector.
•
Introduces new arrangements for offenders serving community orders or suspended
sentence orders to obtain permission from the responsible officer or the court
before changing their place of residence
Employment
As referenced in a recent Department of Work and Pensions Review Document looking
into the impact on employment outcomes for those with alcohol and drug issues12, long12
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448830/employmentoutcomes-drug-alcohol-obesity--independent-review.pdf
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term conditions such as drug addiction and alcohol dependence, can seriously affect
people’s chances of taking up and remaining in rewarding employment. The document
showed that within England alone:
o
1 in 15 working-age benefit claimants is dependent on drugs such as heroin
and crack cocaine
o
1 in 25 working-age benefit claimants are suffering from alcohol dependency
•
Assuming these ratios have remained broadly constant since the research was
conducted, this analysis suggests that around 280,000 working-age benefit claimants
are suffering from addiction to opiates, and 170,000 from alcohol dependency (as of
August 2014).
•
Within the Work Programme, the Department for Work and Pensions (DWP) will
continue to test ways of improving employment outcomes to inform future
interventions. A qualitative evaluation of Recovery Works and Recovery and
Employment will be completed in early 2016.
•
As the roll out of Universal Credit expands, we will examine how the easement in
conditionality can improve claimants’ engagement with treatment and improve
employment outcomes.
•
On 1 September 2014, DWP began the formal trialling of key aspects of Universal
Support in partnership areas across the UK. Through greater collaboration, the trials
are testing more integrated service delivery systems to identify and support those
claimants who need help to access services and build their digital and financial
capability. This will help them to make and manage a claim for Universal Credit and
move them closer to being able to secure and remain in employment. We will draw
on learning from these trials, and look to introduce innovative elements of
integrated service delivery that are in line with the developing framework for
Universal Support. The trials will last for 12 months.
•
DWP will continue to work closely with PHE to support the employment dimension
of recovery. This will include promoting effective practice for Jobcentre Plus, Work
Programme providers, local authority commissioners and treatment providers.
•
Employment can bring a number of benefits for people with substance misuse
issues. These include increased and more sustainable independence and increased
income. These wider benefits in turn can enable improved health and well-being,
confidence and motivation, wider social networks etc. Moving someone into
employment also contributes significantly to ’invest to save’ objectives even where
post-employment support is required to help the individual keep their job which is
outlined in the government roadmap , Putting Full Recovery First13, for building a
new treatment system.
13
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/98010/recoveryroadmap.pdf
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City of Bradford Metropolitan District Council (CBMDC)
Below are descriptions of the Purpose, Values, Priorities and Principles of City of Bradford
Metropolitan Council.
CBMDC Purpose is:
•
“Working with people and partners for a healthier, caring, more prosperous and
sustainable Bradford District.”
•
“Bradford Council is the democratically elected local Government for the whole
district. We exist to serve the people, communities, organisations and businesses of
the district by representing and working with them to protect and improve the
quality of life for all. We do this by providing community leadership, services,
resources, information and expertise.”
CBMDC values are:
•
Honesty, trust and respect
•
Fairness and equality
•
Value for money
•
Innovation and improvement
CBMDC Priorities 2015-16:
14
•
The ‘Understand Bradford District’ (UBD) report14 provides a comprehensive analysis
of Bradford District. It has been designed to inform work on prioritisation as well as
share accurate and reliable analysis of the District with Bradford’s stakeholders –
citizens, partners and businesses – to help build a collective understanding of the
District.
•
The report draws together a range of evidence and intelligence produced by the
Council and partners into one document that highlights key issues and opportunities
for the District.
•
The UBD summary presents the executive summary and chapter highlights from the
full report. It includes a focus on issues raised throughout the analysis that have an
impact across more than one thematic area. In particular it aims to highlight the key
http://observatory.bradford.gov.uk/Bradford_UBD/
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drivers that are shaping the current position of the District and its future
opportunities and challenges.
•
The full report includes an introduction on the people and places of the district, as
well as thematic chapters on:
o
Education
o
Employment and Skills
o
Economic Activity
o
Health and Wellbeing
o
Social Care and Financial Exclusion
o
Housing
o
Environment
o
Safer and Stronger Communities
The full report also acts as a front door to other analysis and includes links to supporting
notes that explore particular issues in more detail.
An “in your pocket” guide presents key statistics drawn from the analysis that will be kept up
to date on a quarterly basis
Despite the financial challenges that the district faces CBMDC are determined to keep
working with partners and citizens to make it a better place and to achieve the objectives of:
o
Good schools and a great start for all our children
o
Better skills, more good jobs and a growing economy
o
Better health, better lives
o
Safe, clean and active communities
o
Decent homes that people can afford to live in.
These priorities have been reflected in spending decisions over the last four years. They
continue to underpin the Executive’s budget proposals for 2015-16 even though these have
been developed within the context of very tight financial constraints and rapidly increasing
demand.
Under such circumstances, even some priority areas will have to see budgets reduce and
different approaches to getting results being adopted. Nevertheless, CBMDC are determined
to ensure that they get the best outcomes they can with the resources at their disposal.
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Some priority services have been protected from specific savings proposals but all services
are expected to work efficiently and play their part in reducing costs and identifying new
ways of working. Those areas protected for the purposes of this budget proposal will be
subject to on-going scrutiny to ensure that the resources at their disposal are used to the
maximum effect and that costs are reduced and efficiency improved wherever possible.
Principles
The priorities reflect a number of key principles:
•
Protecting, as far as possible given reduced resources, services and support to the
most vulnerable people with the greatest needs and at highest risk of harm.
•
Doing the things we have to do by law for example, making sure children at risk of
harm are protected.
•
Making sure that services give value for money, maximise efficiency and make the
most of all the available resources in Bradford District.
•
Tackling poverty, reducing inequality and targeting resources where they make the
most difference.
•
Promoting independence and choice for service users.
•
Providing resources to help services to change over time.
•
Taking action early to stop problems getting worse or from happening in the first
place.
•
Looking to the future not just the short-term.
•
Exploring innovative ways of delivering and sustaining services.
•
Keeping local taxes and charges fair.
•
Being honest, open and transparent about the choices being proposed.
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Bradford City, Bradford Districts, Airedale and Craven Clinical Commissioning Groups
The 3 CCG`s which are responsible for buying and contracting healthcare services for the
people of the Bradford Districts are:
•
•
•
Airedale, Wharfedale & Craven CCG
Bradford City CCG
Bradford Districts CCG
NHS England has set out its proposals for how the NHS budget is invested in order to secure
sustainable models of care over the next five years. There is a requirement for NHS
commissioners to co -design a five year strategy that sets out a clear plan on how
commissioners, local authorities and NHS providers will work together to deliver services
over the next 5 years within financial constraints.
The 5 Year Forward View(2014-19) for the Bradford District and Craven Health and Care
Economy15, has been developed with a collective vision to create a sustainable health and
care economy that supports people to be healthy, well and independent. The key priorities
of this strategy are to:
•
Promote self-care and illness prevention and improve the general health and wellbeing of the population of Bradford District and Craven
•
Transform primary and community services and place the patient at the centre of
their care
•
Implement a 24/7 integrated care system across health and care economy
•
Develop and deliver a sustainable system wide model for urgent care services
•
Develop and implement a system wide model for delivery of planned care
interventions.
The key health and well-being challenges that are linked to drug and alcohol misuse are
chronic conditions and their outcomes. In the main, these are a consequence of unhealthy
lifestyles; it is also clear that social, economic and environmental factors either have a direct
impact on health status or exacerbate existing ill-health. The specific outcomes that are
affected include:
• Hazardous and harmful drinking and the increasing impact of this upon A&E
attendances and hospital admission.
• Premature deaths from liver disease for the under 75s,
• Premature deaths from cardio vascular disease
• Premature deaths from respiratory disease
15
http://www.bradforddistrictsccg.nhs.uk/wp-content/uploads/2014/08/Bradford-and-Craven-five-yearforward-view.pdf
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• Infant mortality
• Mental Health
Community Safety Plan 2013-16
•
The Bradford District Community Safety Partnership brings together a variety of
statutory, non-statutory and voluntary organisations with a shared commitment to
improving public confidence by reducing crime, disorder and substance misuse in
the District.
•
The organisations are committed to working together as a partnership to tackle the
issues that really matter to the local communities, such as burglary, robbery and
anti-social behaviour and to ensure that people feel safer in their homes,
neighbourhoods, towns and Bradford City Centre.
•
In the light of national reductions in public spending, close collaboration and
integrated working by all partners is made all the more important and the partners
will continue to work together on this plan, building on previous successes, to
stimulate an even greater contribution to improving the confidence of local citizens,
reducing crime and antisocial behaviour, and most importantly, improving the
quality of life for all.
•
The statutory, annual Strategic Assessment for 2013 concluded that there has been
little change in the key Strategic Priorities and District Priorities as set out in the
2012 Community Safety Plan. These are:
•
o
Reducing Crime and Re-offending
o
Neighbourhoods and Communities
o
Drugs and Alcohol
In order to ensure the maximum effectiveness of the partnership, the following key
principles will be considered:
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o
Prevention and early intervention
o
Involving Communities
o
Building Resilience
o
Tackling root causes
o
Intelligent targeting of resources
o
Supporting Victims & Witnesses
Police and Crime Plan 2013 -18
•
The Police and Crime Commissioner for West Yorkshire is responsible for the Police
and Crime Plan 2013-18 which sets the strategic direction for policing and crime
prevention across West Yorkshire, but importantly sets the strategic direction for
wider community safety bringing partner agencies together to achieve a shared
vision of making sure communities in West Yorkshire are safer and feel safer.
•
The key priorities of the Police and Crime Plan are:
o
Communities in West Yorkshire are safer and feel safer
o
Crime and re-offending is reduced
o
Anti-social behaviour is reduced
o
Victims and witnesses are supported
o
Local, regional and national threats, risks and harm are tackled
o
Criminal justice system is effective and efficient
Housing and Homelessness Strategy for Bradford District 2014-19
•
This strategy sets out the vision, priorities and approach for meeting the housing
needs of the residents of Bradford district, and for tackling and preventing
homelessness. It is a partnership-led strategy, recognising that many different
agencies and organisations have a part to play in responding to the housing
challenges facing the district - which closely mirror the district’s economic
challenges. The vision for housing needs to be delivered in the current climate of a
growing population, changing patterns of living, economic pressures and reduced
resources, making it even more important than ever to be clear about what is
needed and how this is achieved.
•
The objectives are:
o
More homes
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•
o
Safe and healthy homes
o
Affordable homes
o
Support independence and prevent homelessness
The benefits to citizens, stakeholders and organisations will include:
o
Increase in net additional homes provided
o
Reducing number of long term empty homes
o
Increase in the number of private sector homes where housing conditions
have been improved through intervention measures
o
More homes adapted
o
Increase in the number of new affordable homes delivered
o
More energy efficient homes in the district and fewer people living in fuel
poverty
o
Increase in average incomes across the district
o
Improvement in the number of housing advice cases which successfully and
sustainably prevent people becoming homeless
o
Reducing number of homeless people placed in bed and breakfast
accommodation and shorter stays in temporary accommodation
o
Targeting support at those who need it most and at the right time.
Families First
•
Families First is a Bradford programme, funded by the Government, in response to
the National Troubled Families Programme ,running from 2012 to 2015, which will
work with families facing serious problems, to “turn their lives round”. They will be
offered a joined-up ’menu’ of support, looking at the needs of the whole family, not
just of individual members. The programme is also designed to last beyond the end
of the funding, by making long-lasting changes to the way that different agencies,
such as the Council, Police and Health Services, work together, in order to improve
services and get better value for money.
•
Families First aims to support families who are experiencing a mixture of difficulties
in their lives. The key targets, as set by the Government, are to:
o
o
o
reduce truancy,
cut levels of crime and anti-social behaviour,
support all over 16s in the families into work
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o
o
o
o
o
o
The programme aims to deal with other problems that the families
may be facing including:
debt and financial difficulties,
housing problems,
health issues,
substance abuse
domestic violence.
Joint Health and Wellbeing Strategy (JHWS) - to reduce health inequalities 2012-1716
•
The JHWS for Bradford outlines how the district aims to contribute to the
improvement of local resident’s health, wellbeing and quality of life. The Joint
Strategic Needs Assessment (JSNA)17 provides a strategic examination of “need”
across the Bradford District and provides the evidence-base to inform the JHWS, in
particular helping to identify the key priorities for Bradford District. In turn, the
JHWS priorities and key areas for action will inform the next JSNA and form a cycle
of development for the district.
•
The priorities outlined in the JHWS will require strong partnership working to ensure
that improvements are made to health and wellbeing, through implementation of
current strategies and action plans in the priority areas. The JHWS outlines how key
organisations across Bradford District work together to identify and meet the unique
needs of the district’s population. The Government envisages that the JSNA and
JHWS will enable commissioners to plan and commission integrated services that
meet the needs of their whole local community, in particular for the most vulnerable
individuals and the groups with the worst health outcomes. Joining up
commissioning and integrating services for the benefit of the population are
therefore important priorities for the Health and Wellbeing Board in Bradford
District, and are reflected in this strategy.
•
The aim of the JHWS is to give local partners a set of jointly agreed priorities to work
on together in the new health and social care system. In doing so, it will provide a
clear direction for improving health and wellbeing and reducing health inequalities
in Bradford District and will underpin local action and commissioning plans from
2013 to 2017.
•
The associated Health Inequalities Action Plan (HIAP)18 aims to outline how Bradford
District will reduce inequalities in health and wellbeing for the population and is a
key part of the development of a strategy for health and wellbeing.
16
http://www.observatory.bradford.nhs.uk/Documents/Bradford%20and%20Airedale%20Joint%20Health%20and
%20Wellbeing%20Strategy%202013.pdf
17
http://www.observatory.bradford.nhs.uk/pages/jsna.aspx
18
http://www.observatory.bradford.nhs.uk/Documents/Bradford%20and%20Airedale%20Health%20Inequalities%
20Action%20Plan%202013.pdf
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•
Within the HIAP, Priority 17 refers to the reduction harm from preventable disease
caused by tobacco, obesity, alcohol and substance abuse, and references the PHE
standards focussing on successful completion of drug treatment.
The National Treatment Agency (NTA) & Public Health England (PHE)
•
The National Treatment Agency (NTA) was created as a Special Health Authority in
2001 to improve the availability, capacity and effectiveness of drug treatment in
England. The NTA's role was to ensure treatment services in England delivered on
both the public health and criminal justice agendas, reflecting the interests of the
Department of Health (DH), responsible for funding the NHS as well as public health
services, and the Home Office, the lead Whitehall department on drugs policy and
crime reduction.
•
On the 1st April 2013 Public Health England (PHE) was established to bring together
public health specialists from more than 70 organisations, including the NTA, into a
single public health service with an aim to protect and improve the nation's health
and wellbeing, and reduce health inequalities. Substance Misuse services can
contribute to the reduction of premature death and illness and help to address
health inequalities.
•
PHE are responsible for:
•
making the public healthier by encouraging discussions, advising government and
supporting action by local government, the NHS and other people and organisations
•
supporting the public so they can protect and improve their own health
•
protecting the nation’s health through the national health protection service, and
preparing for public health emergencies
•
sharing our information and expertise with local authorities, industry and the NHS,
to help them make improvements in the public’s health
•
researching, collecting and analysing data to improve our understanding of health
and come up with answers to public health problems
•
reporting on improvements in the public’s health so everyone can understand the
challenge and the next steps
•
helping local authorities and the NHS to develop the public health system and its
specialist workforce
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•
•
19
PHE will focus on securing improvements against seven priorities19:
o
tackling obesity particularly among children
o
reducing smoking and stopping children starting
o
reducing harmful drinking and alcohol-related hospital admissions
o
ensuring every child has the best start in life
o
reducing the risk of dementia, its incidence and prevalence in 65-75 year
olds
o
tackling the growth in antimicrobial resistance
o
achieving a year-on-year decline in tuberculosis incidence
PHE continues to have a lead role in substance misuse and will support
commissioners and providers with guidance, best practice and provision of data
through National Drug Treatment Monitoring System (NDTMS).
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/366852/PHE_Priorities.pdf
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Appendix H Available Data Novel Psychoactive Substances (NPS)
This document looks at potential data regarding Novel Psychoactive Substance (NPS) use,
particularly in inpatient data over a 5 year period coving April 2009 to March 2014.
SystmOne data
Novel Psychoactive Substance Misuse is coded in SystmOne using the read code XabbR. A
search was run on this read code and failed to bring back any results. A more generic
‘misuse of drugs’ search was also run using a variety of codes but only a handful of patients
were found.
Inpatient admissions
Hospital inpatient data was searched on any admission type (elective or non-elective) using
the following ICD10 codes in either a primary or secondary diagnosis position to determine
admissions relating to NPS over the last 5 years:
ICD10 code
F13
F15
F16
F18
F19
Y11
Y12
Y13
Y14
Descrition
Mental and behavioural disorders due to use of sedatives or hypnotics
Mental and behavioural disorders due to use of other stimulants, including caffeine
Mental and behavioural disorders due to use of hallucinogens
Mental and behavioural disorders due to use of volatile solvents
Mental and behavioural disorders due to multiple drug use and use of other psychoactive
substances
Poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and
psychotropic drugs, not elsewhere classified, undetermined intent
Poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not
elsewhere classified, undetermined intent
Poisoning by and exposure to other drugs acting on the autonomic nervous system,
undetermined intent
Poisoning by and exposure to other and unspecified drugs, medicaments and biological
substances, undetermined intent
Annual admissions
Between April 2009 and March 2014 there were a total of 622 admissions (annual average of
124 admissions) relating to NPS where a patient had a valid Bradford postcode. Hospital
admissions relating to NPS have increased year on year in the last 5 years, from 62 in
2009/10 to 183 in 2013/14.
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Annual total admissions related to Novel Psychoactive
Substance use
Total admissions
200
183
154
150
108
115
2010/11
2011/12
100
62
50
0
2009/10
2012/13
2013/14
Gender
Approximately 60% of admissions are male. This difference has remained relatively similar
in the last 5 years apart from in 2010/11, when there was roughly a 50/50 spilt.
Annual admissions related to Novel Psychoactive
Substance use - gender
109
Total admissions
120
93
100
80
60
40
57 51
38
74
67
61
48
24
20
0
2009/10
2010/11
Male
2011/12
2012/13
2013/14
Female
Age
The majority of the admissions fall between 15-49 year olds, with the highest total
admissions in 25-29yr olds (n=107) and 30-34yr olds (n=102).
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Admissions related to Novel Psychoactive Substance use, 5 year age breakdown - 2009/10 to
2013/14
120
107
94
Total admissions
100
102
88
80
63
60
47
35
40
21
20
15
7
11
5
6
6
7
7
0
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84
>85
Age
Ethnicity
Nearly two thirds of admissions relating to NPS are patients who describe their ethnicity as
British, with the second highest group being 'any other white background '(11%). This group
may represent the Central European Population of Bradford.
Ethnicity recorded
British
Any Other White Background
Pakistani
Not Given
Any Other Ethnic Group
Not Stated
Any Other Black Background
Caribbean
Any Other Asian Background
White And Asian
Bangladeshi
Indian
Irish
White And Black Caribbean
Any Other Mixed Background
White And Black African
Total
413
71
42
37
19
14
<5
<5
<5
<5
<5
<5
<5
<5
<5
<5
Discharge method
The main discharge method is to a patient’s usual place of residence (approximately 90%).
There are a variety of other discharge methods which contribute small numbers to the total
admissions, with ‘ward for general patients’, ‘temporary place of residence’ and ‘ward for
patients who are mentally ill’ being the only types with over 5 admissions in the last 5 years.
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Discharge method
Usual Place Of Residence
Not Known
Ward For General Patients
Temporary Place Of Residence
Ward For Patients Who Are Mentally Ill
Not Finished At Episode End
Patient Died Or StillBirth
Penal Establishment Or Police Station
LA Part 3 Residential Accommodation
Non-NHS Run Hospital
Non-NHS Run Residential Care Home
High Security Psychiatric Accommodation
Medium Secure Unit
Ward For Maternity Patients Or NeoNates
Total
552
20
13
11
7
<5
<5
<5
<5
<5
<5
<5
<5
<5
Primary diagnosis
Analysis of the primary diagnosis of each admission provides an idea as to the main reasons
patients are being admitted to hospital. ‘Mental and behavioural disorders due to substance
misuse’ and ‘accidents and injuries’ are the two highest diagnoses (136 and 130 respectively)
and together account for 40% of total NPS related admissions
Primary diagnosis description
Mental and behavioural disorders due to substance misuse
Accidents & Injuries
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
Other complications of pregnancy
Other mental / behavioural disorders
Other diseases of the digestive system
Diseases of the skin
Other cardiovascular disease
Other diseases of the genitourinary system
Factors influencing health status and contact with health services
Diseases of the musculoskeletal system
Communicable diseases
Chronic Kidney Disease
Pregnancy with abortive outcome
Other respiratory disease
Diseases of the eye
Stroke
Other diseases of the nervous system
Total
136
130
78
76
46
30
16
14
9
9
8
7
6
6
5
5
5
5
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Appendix I Criminal Justice Review
Commissioning Review of West Yorkshire Drugs Intervention Programme
In March 2014 a report was prepared on behalf of the Office of the Police and Crime
Commissioner following a review of the West Yorkshire Drugs Intervention Programme.
The aims of the review were to assess the current position and highlight forthcoming policy
and structural impacts and their risks to inform the future commissioning of the Drug
Interventions Programme. There were a total of 23 recommendations to address the issues
identified within the report as follows:
Strategic Agreement
R1. The future focus of the PCC drugs and alcohol resource should be to formally move away
from the name DIP which denotes an isolated project towards supporting ‘criminal justice
interventions’ to reduce offending associated with drug and alcohol use.
R2. A wider definition of the remit of the criminal justice intervention should be agreed to
also include:
• Class A, Alcohol, cannabis, violent crime and disorder
• With a wider focus on entry points to identify and engage with offenders to include
increased early intervention and pre-custody work in the community
R3. Drugs and alcohol should be reflected as a priority within key strategic partnership plans
such as Health and Wellbeing Plan and JSNAs.
R4. Strategic agreement across five districts and key drug and alcohol commissioners should
be sought on:
• The definition of the remit of criminal justice interventions (R2)
• Including criminal justice interventions as part of the integrated drug and alcohol
commissioning of services
• Should form part of the strategic priority and element of DIP/drug criminal justice
commissioning
• Agreement across commissioners to maintaining resource commitment to drug and
alcohol services (R7)
R5. Strategic agreement to new pathways and their interface with criminal justice drug and
alcohol services should be gained. Support should be given to providers to establish how
‘new’ delivery will integrate especially at cell intervention level. Opportunities should be
explored for achieving greater value for money through re-design and skilling to ensure
holistic assessment and pathways to people with multiple and complex needs
Commissioning and Resource
R6. There should be continued investment in criminal justice interventions in drugs and
alcohol services with the aim of reducing reoffending of drug and alcohol misusing
offenders. The following attached to the funding:
• Clarity on definition of DIP/CJ element
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• Focus on reducing re-offending and indices to support - focus on offence type
• Robust management of what is commissioned without creating complex and resource
intensive data management systems
• Common performance measures across all 5 districts
• Minimum standards for commissioning (R11)
R7. Commitment should be given by other commissioners to continue investment in drug
and alcohol services to current levels (R4)
R8. The resource should focus on reducing the following offences: acquisitive crime, disorder
and violent crime
R9. The funding formula for district based delivery of drugs and alcohol criminal justice
interventions should be re profiled according to levels of drug and alcohol related crime.
R10. The funding formula for drug testing should be re profiled according to level of drug
testing undertaken.
R11. A set of minimum standards should be developed for inclusion in service specifications
relating to criminal justice expectations and offence types.
R12. Commissioning should be undertaken on a District basis using existing structures within
the parameters of the resource minimum standards (R6)
Performance Management
R13. Targets should be attached to the funding which relate to reduction of re-offending and
should common to all Districts
R14. A wider set of performance indicators to reflect the target should be reviewed on a
quarterly basis
R15. Clarity should be given by each District regarding the governance arrangements for the
funding and criminal justice interventions to tackle drug and alcohol related offending. It
should be clear which district partnership body will take responsibility. As Districts move
towards an integrated drug and alcohol commissioned model it is suggested that all drug
and alcohol performance should be considered by one partnership rather than fragmented
lines of accountability across a number of partnerships (R4)
Service Delivery
R16. Networking opportunities should be developed for the sharing of good practice and
exploration of opportunities for collaborative work and commissioning across West
Yorkshire Districts and commissioners (R4)
R17. Districts should explore further with West Yorkshire Police the increased and effective
use of incentives (Brief Intervention Leaflets, Penalty Notices, Conditional Cautions, etc.) to
support engagement and early identification also ensuring there is adequate provision of
rehabilitation and diversionary options (R16)
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R18. Drug testing where appropriate should continue with a focus on acquisitive crime. The
link between drugs and offending type should continue to be periodically reviewed to
ensure that testing is appropriate to crime. The legal parameters of non West Yorkshire
Police administering the test should be explored.
R19. Having CJIT staff covering custody suites full time should be reviewed with exploration
of a more efficient way for staff to engage with clients. This should include consideration of
the identified teething problems in super cells and exploring opportunities for added value
from working with the new Custody Health and Liaison and Diversion staff to enable
integrated triage. (R5)
R20. Opportunities for creative and proactive engagement by West Yorkshire Police and
drug and alcohol services should be encouraged (R16, R19)
R21. Consistent information sharing agreements should be established with key West
Yorkshire wide stakeholders such as West Yorkshire Police, Courts and Police. Consistency of
information sharing around timely sharing of information with drug and alcohol services
should be considered at all the key entry points including custody, court and prison.
R22. Further explore innovative approaches and what further interventions are required in
delivering a targeted approach to ‘frequent flyers’
R23. Further explore with Youth Offending Service opportunities for joint work around early
identifications and interventions with drug and alcohol using offenders
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