Download Commissioning and the 3rd Sector

Commissioning and the 3rd
Sector
All Party Parliamentary Health Group
Robin Davidson
March 14th 2017
recovery
UK Drug Policy Commission’s consensus
statement (2008); The process of recovery from
problematic substance use is characterised by
voluntarily-sustained control over substance use
which maximises health and wellbeing and
participation in the rights, roles and
responsibilities of society. (UKDPC 2008)
pre-commissioning
range of addiction agencies in a city……..
health funded
• statutory units; complex psychological needs
and mental health.
• shared care with primary care; e.g. OST
prescribing, HIV testing
3rd sector/local auth funded
bespoke city agencies
• housing support, social rehab, harm reduction
psychological support
• sophisticated, locally tailored
mutual aid
• Self supporting, more or less free
• Spiritual Fellowship (12 steps)
• Secular……UK SMART Recovery
problems?
Communication could be poor, at times personality driven,
duplication, multi-agency working could break down, help
seekers sometimes didn’t know where to go,
social/psychological outcomes ill defined.
but
broad roles understood, complex psychological and social
needs met, all types of addiction catered for.
now: commissioning era
value for money
addiction (inconvienient) so is not seen as part of mental health core
business
single treatment systems are commissioned.
NHS is now a smaller provider than CLG and Turning Point.
there is not an NHS run detox/residential facility within the M25 radius
So
huge national agencies (e.g. CGL, and Turning Point) with GPs
expand business by mapping, the mutual aid carrot, cheap, expert
presentations which secure contracts.
and so
experienced well qualified staff for ever lost to addictions addictions…..
Now; (contd)
Obsession with performance data
e.g.
National Drug Treatment Monitoring System
worst kept secret in our sector… words used about data
management “gaming”, “burden”, “made up”, “doesn’t
measure what’s actually happening”, “prescriptive.”
e.g.
Keep chaotic people out ( they don’t leave treatment drug
free).
A drug workers story
Guardian 9th March 2017
My SUD service cut by around 42% over past 6 years.
Our users getting older and sicker.
We are left to manage problems that we are not qualified or
able to deal with. For example we used to have clinical
psychologists who could who treated PTSD, depression,
sexual abuse ..anxiety and the like, their posts were cut last
year.
Now we help keep people alive but not to overcome their
addiction.
We try not to start “chaotic people”, bad for our figures
Shadow health secretary Jonathan Ashworth called for
greater recognition of damage.
what are we losing
small agencies with years of local experience losing out
to national companies e.g. aquarius in Birmingham,
lifeline in Manchester, motiv8 in Douglas.
treatment of complex needs……….
treatment of elderly addicts
treatment of behavioural addictions
dual, triple, multiple-morbidity,
complex needs?
• 40% of the cigarettes smoked in the UK are
smoked by individuals with a psychiatric
disorder, such as depressive disorder, general
anxiety disorder (GAD), post-traumatic stress
disorder (PTSD), schizophrenia, bipolar
disorder……..
From: Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity
Survey Replication
Arch Gen Psychiatry. 2005;62(6):593-602. doi:10.1001/archpsyc.62.6.593
Table Title:
Lifetime Prevalence of DSM-IV/WMH-CIDI Disorders in the Total NCS-R Sample and by Age
Date of download: 10/1/2016
Copyright © 2016 American Medical
Association. All rights reserved.
depression and anxiety
the prevalence of life-time diagnoses of
major depressive disorder (MDD),
substance-induced depression (SID),
anxiety disorder (AnxD) and
substance-induced anxiety (SIA),
Association between depression/anxiety and SUD is generally
thought to be over 60% .
depression and anxiety combined with alcohol use create a
feed-forward cycle of increasing each other's intensity
pensioners and alcohol
Public Health England (May 2016)
• hospital admission by age show that the rate of
alcohol-related admissions is falling in the under 40s
but rising in the over 65s.
• the number of 60- to 74-year-olds treated as inpatients for alcohol dependence and alcohol
withdrawal has almost doubled over the past
decade, from 5,074 in 2005-06 to 9,492 in 2014-15.
Among those aged 75 and older, the figure has risen
from 1,265 to 1,881 over the same period. Both
increases far outstrip the growth in the elderly
Harmful and hazardous drinking
Harmful
Conditions likely and somewhat likely to be
worsened by alcohol in th elderly are;
Gastritis, cirrhosis, dementia, oropharyngeal
cancer, congestive heart failure, ulcers, gout,
diabetes, arrhythmias, hypertension, breast
cancer, depression, stroke, pancreatitis,
paraphrenia.
drugs, alcohol and elderly
• The average person older than 65 takes two to seven
prescription medication daily. Alcohol-medication
interactions are especially common among the
elderly (National institute of Alcohol Abuse and
Alcoholism, 2000)
• 17 % of the UK population is over 65 but uses nearly
40% of prescription medication
• btw 2% of population of Uganda is over 65
Dr T Rao (old age psychiatrist)
“alcohol-related memory problems are hugely underreported and mistaken for Alzheimer’s disease. Ten years
ago I would have been treating no more than three
people at any one time for alcohol-related brain damage.
Now there are at least 10 patients with that in my clinical
service. Most of these patients were originally thought to
have either depression or Alzheimer’s until disclosure of
their history of heavy drinking led to me to change the
diagnosis to one of alcohol-related brain damage. The
average age of these patients has also reduced. In the last
1990s, it was people in their mid-70s. It is now those in
their mid-60s”.
issues for years!
• NHS providers can't look at “mental health problems” until
drinking/drugs have stopped.
• DA staff do not feel skilled to deal with “mental health
problems”
• MH staff do not feel skilled to work with “substance
misuse”
• lack of case coordination so clients have several different
“key workers”.
• poor exchange of information
• assessed by different professionals using different protocols
rather than one “fit for all” assessment
• Dual diagnosis teams pared back, e.g. York
DH advice
• Local services must be developed according to
need with care pathways and clinical governance
guidelines drawn up.
• Specialist workers should provide specialist
support.
• There should be adequate staff training around
dual diagnosis.
• A Care Programme Approach (CPA), including the
concept of a keyworker and full risk assessment,
should be used in clients with dual diagnosis.
interim ideas
• in-house training e.g. IoM, Priory models
• simple combined assessment protocols e.g. iapt
assessment scales
• effective joint treatments, treating the person not the
problem.
• there should be a locally agreed definition of dual
diagnosis shared within an agency and across agencies
• Dual Recovery Anonymous, UKSR
• Proper outcome evaluation not performance
management
the end
[email protected] .uk
thanks to Drs Duncan Raistrick, Gillian Tober and
Luke Mitcheson
Walsingham house, Bristol
• group therapy, workshops, one-to-one therapy, mental
state monitoring, psychiatric review (including
medication), community skills, nutrition and dietary
information, budgeting skills, progression to
independent living skills, and exercise programmes.
• specialist input for psychotherapy, crisis and risk
management planning, including access to Mental
Health Act assessment.
• detoxification monitoring (for Bristol service referrers).
Out of area clients must have already undergone
detoxification.
Combination treatment
• motivational interviewing plus individual and family
cognitive behavioural therapy for patients with
schizophrenia and comorbid substance misuse.
• at 12 months, the treatment was superior to standard care
provided by mental health services in terms of patients’
general functioning, positive symptoms (excess or
distortion of normal functioning, such as delusion and
hallucinations), symptom exacerbations, and frequency of
substance use.
• some gains were lost at the 18 month follow-up, although
improvement in general functioning was maintained as
were improved negative symptoms (diminution or loss of
normal functions, such as affective flattening, anhedonia,
and attentional impairment).