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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).