Drug, Alcohol & Mental Health /
Wellbeing - Recovery in Salford
Moving On: Colin Wisely Andrew MacDonald
Salford DAAT / NHS Salford: Presentation To
Neighbourhoods Scrutiny Committee 18 04 2011
National Drug & Alcohol Strategy
Strategy 2 overarching aims:
•
•
Reduce illicit and other harmful
drug use
Increase the numbers recovering
from their dependence
Strategy 3 main themes:
•
•
•
Reducing demand
Restricting supply
Building recovery in communities
Healthy Living
Problem
Drug /
Alcohol use
Recovery
Tier ‘0’ Community
Activity
E.g. self-help
Tier 1 Generic Community Drug &
Alcohol Services e.g. GPs
Tier 2 Semi Structured Community Drug
and Alcohol Services
Tier 3 Structured Case Management
Community Drug and Alcohol Services
Tier 4 Residential Drug & Alcohol
Services –
Detoxification/Rehabilitation
Recovery
Path Tier 1
Recovery
Path Tier 2
Recovery
Path Tier 3
Recovery
Path Tier 4
Current Models of Care Drug and Alcohol
‘Tiered’ Treatment System Features
•
Some drug and alcohol users of all
ages never enter formal treatment
and ‘recover’ in the community
(described as Tier ‘0’) - not all
develop ‘problems’ – also where
longer term ‘recovery’ takes place
– very underdeveloped
•
Case Management / Care
Coordination all age groups Tier 3
- acts as the ‘gatekeeper’ for
complex / coordinated care – an
important feature – but relatively
poor at managing exit because
that is not it’s function
•
Increasingly younger users and
newer types do not identify as
having a ‘problem’ – so require
new services and new thinking on
structures and governance
•
The lack of structure below Tier 3
means when cases closed
recovery journey (highlighted in
green) less coordinated encourages drop out / raises risk
of relapse / overdose / exclusion /
community safety et al
National Issues – Challenge In Salford
•
Shift from acute care model
•
Keeping an ageing population of
problematic drug users healthy
•
Emphasise completion of
treatment
•
•
Emphasise re-engagement of drop
out of treatment
Identifying problematic drug users
ready for treatment and caring for
those in recovery
•
Prevention interventions for
younger drug users at risk of
developing chronic drug and
alcohol problems
•
Establishing family focused
approaches
•
Identifying problematic drug use at
an early stage
Gaps In Current System
• Changing patterns in drugs
markets
• Significant levels chronic
alcoholism in drugs
‘treatment’ cohort
• Needs of those that are
leaving treatment
• Children of problematic
drug and alcohol users
• Need to re-engage
treatment drop-outs
• Complex Alcohol, Drugs,
Mental Health all levels and
co-morbidity
Issues Arising From New Schema
•
Increasingly older (average 40+
nationally but only 34 in Salford)
•
Higher levels mortality and comorbidity in ageing population of
heroin and crack users
•
Declining incidence recorded
younger heroin users
•
Continued growth in the mass
market for cannabis and new and
old stimulant drugs
•
Often combined with alcohol and
tobacco
•
‘Legal highs’ and cocaine use
challenge for mainstream
population
•
Cannabis and Stimulants present
challenge mental health services
•
Future challenge concerns
distinguishing early onset of
chronic drug and alcohol
problems and responding to mass
normative use
•
This implies fine grain profiling of
families and individuals
Shift in Health Needs Using Population
•
Users present to adult services
designed for opiate users
•
Adult services shifting towards
recovery orientation – city
remains over invested in Tier 3
prescribing modalities
•
Majority young people do not
use drugs - those who do many in a brief and normative
fashion
•
Challenge identifying young
people early & distinguishing
brief and normative phases of
use from chronic patterns
•
Challenge communicating
good quality drugs and alcohol
messages to those using in a
brief and normative fashion
•
Challenge to address the
needs young people in families
where adults are problematic
drug and alcohol users
Key Commissioning Messages
• Numbers successful
problem drug user amd non
problem drug user
treatment completions risen
considerably since 2006 unplanned exits stable
• Future financial allocations
calculated - retained in
treatment moderated by
days ‘in-treatment’
• Considerable evidence
base in terms of what works
in recovery
• Re-engaging / Retaining
drop-outs crucial – services
need to reduce relapse
amongst completers
Wholly-attributable alcohol-related hospital admissions and
alcohol consumption in adults (litres per person per year) in
England since 2002 (NHS IC 2010, IAS 2010)
Alcohol Use In Salford
• NDTMS 1: 14 harmful or
dependent drinkers 18 + in
treatment
• NATMS 572 young people
who are primary alcohol
users in Salford
• Further 155 young people
alcohol misuse as an
adjunctive problem to
range primary substances
Young People Drug and Alcohol Use
•
Most young people do not use
drugs, including alcohol, and for
most of those who do their use is
brief and normative
•
First challenge is effective early
intervention to distinguish brief
and normative from chronic
patterns of use
•
More serious challenge
communicating harm reduction
messages to brief and normative
users and engaging with young
people in families where adults are
problematic drug & alcohol users
Offenders – Hidden Alcohol Harm
Pending Nice Guidance 2011
Future Drug and Alcohol Service Provision –
Salford’s View of the National Strategy
•
New strategy emphasises outcomes
drugs and alcohol abstinence
ultimate goal – significantly shift
•
•
•
Current model highly invested in
specialist clinical interventions and
lacks prevention focus or an aftercare
recovery approach
Integrated co-commissioning approach
future investment in recovery
highlights drugs and alcohol to
downsize Tier 3 services and increase
throughput towards recovery
•
Tier 3 limited drug free outcomes stasis - drop out and re-engaging little progress wider treatment
domains i.e. how well individuals
function in community, family
Implies an upscale of Tier 2 service to
managing stable drug users post Tier 3
treatment – the same applies to alcohol
users
•
Need to commission services for niche
needs of service users and existing
drug and alcohol services offer a more
‘one size fits all’ approach
Future Drug and Alcohol Service Provision –
Salford’s View of the National Strategy
•
Process of building a recovery
community well underway and
task is integrating and enhancing
existing local efforts
•
Evidence base for this largely
comes from the USA summarised
by White and Kelly (2010)
•
Need for better provision for
young people particularly the
under 25s, which cross cuts the
drugs, alcohol and young people
strategies
•
Key shift involves early
intervention in chronic drug and
alcohol problems identifying
future Problematic Drug Users and
Problem Drinkers
•
Clear signal to re-design criminal
justice drugs interventions to
improve efficiencies and outcomes
in relation to HMP through care
and the ‘gripping’ of high crime
causing drug and alcohol users
•
Overall, new design will
emphasise integrated drug and
alcohol provision which has the
capacity to flex to individual need
as appropriate
NICE recommends Children’s and Adults’ commissioners jointly
commission specialist services young people to age of 25 or 30
•
Pattern and culture of drinking,
and the social circumstances of
this group, are often different to
those of older adults
•
Children and young people less
likely to have alcohol dependence
than adults but hazardous drinking
behaviours (binge-drinking)
•
Full NICE clinical guideline
managing alcohol dependence
highlights multi-systems, multilevel approach - integrated alcohol
services for children and young
people
‘One Size Fits All’ does not fit Salford Children, Young People, Adults and
Families – Integrated Service required for all ‘levels’ of complexity in Salford
• Level ‘0’ Recovery Community,
Neighbourhood / Health
Improvement Teams / Self Help /
WWW based provision
• Level ‘1’ Lifestyle / Wellbeing
Gateway and Generic Services
• Level ‘2’ Lifestyle / Wellbeing
Gateway and Semi Structured
Services, with External Care
Coordination to manage those
cases exiting structured treatment
• Level ‘3’ Structured Services
with Specialist External Care
Coordination for Structured and
Highly Structured Treatment and
Interventions
• Level ‘4’ Highly Structured
Services including all Residential
Detoxification and Rehabilitation
across Recovery Provision
Tiered
Treatment
4
&
Chronic Care
3
2
1
0
Prison
Enters
Treatment
IBA CJS
Crime
Re-enters
treatment Re-enters
treatment
Drop out
Relapse
Extended
IBA / Group
Detoxified
4
Sustained
3
Recovery
2
Relapse
Child of
Problem
Drinker
1
Abstinent
Recovery 0
4
3
2
1
0
Recovery
RECOVERY
GRIP
TEAM
CLUB
Move on
RECOVERY specific
art,cooking, budgets
UNIVERSAL:
Breakfast club etc
INTERVENTIONS
Fitness,groups,
FAMILY & CARER
WELFARE & BUDGET
ETE
HOUSING
RECOVERY CLUB
Ideal Recovery Treatment System
Under 25s
Tier 1 universal advice and information harm reduction
Tier 2 targeted groups counselling / IBA LAC/ SSD / SMART / school
Tier 3 remodelled under 25s service to deflect joiners to adult system
Tier 4 limited demand – some migrate to adult 17 years, some at 30
Transition
Key fault line between Under 25s and Over 25s
Determined by risk / need
Therefore most over 18s
Over 25s
Changing drug markets
Alcohol/Cocaine users (‘bounded’ and ‘unbounded’ poly-substance use)
Improve assertive approaches
Establish ‘chronic’ case management approach
Establish improved aftercare
Tier
Integrated Drug & Alcohol Services
Population
Current £
Future £
0
General Population of Early / Unmet / Recovery:
communication / self awareness –
knowledge – efficacy – help / Recovery
Community Activity
125,200
(30,000 drug
users)
60K
?
1
Prevention / Screening / Generic / Targeted
Outreach / Brief Interventions
58,320
(10,000 drug
users)
204K
?
2
Triage / Non Complex Care Coordination /
Aftercare / Step Down / Needle Exchange /
Harm
Reduction
/
Extended
Brief
Interventions / Low Intensity IAPT / Housing
/ Acute / Criminal Justice / GP Services
49,680
(5,000 drug users)
940K
?
3
Complex Care Coordination / Gate keeping /
Community Medical Services / Prescribing /
Community Detoxification / High Intensity
IAPT / Housing / Acute / Criminal Justice /
GP Services
17,200
(2500 drug users)
4,151K
?
4
Complex and Non Complex Residential
Detoxification and Rehabilitation
17,200
(2500 drug users
934K
?
125,200 Problem
drug/alcohol
users
£6,129K
£6,129K
Total
Timeline 2013 Integrated Services Tender
Drugs and Alcohol Recovery System
2011
2012
2013
Agree new
Recovery Specifications
Tender new
Recovery System
Establish new
Recovery Services
Apr – June 2011
Move On Service at
Gloucester House
provides input into
specification
Jan – Mar 2012
Tender scoring, supplier
KPIs and contract
documentation
Pre tender documentation
Jan – Mar 2013
Transition period from
‘As-Is’ to ‘To-Be’
service
Apr –June 2011
Initial draft of tender
specification
Apr – Oct 2012
Tender process,
April 2013
New service model starts
Apr – Sept 2011
Benchmarking
with
external suppliers
Sept – Oct 2012
Contract discussions and
tender
award
confirmed
July – Sept 2011
Final draft of tender
specification
Nov – Dec 2012
Contingency period
Sept – Dec 2011
Sign
off
of
tender
specification