Role
The NHS
new treatment
landscape
Annette Dale-Perera
Strategic Director of Addictions
and Offender Care
CNWL NHS Foundation Trust
The NHS
No THE
Commissioners
• PCTs
• CCGs: clinical care groups
Provider families
• GP businesses
• Foundation Trusts (acute,
• secondary, community
• non FTs
..........NHS FAMILY..........
The NHS
No THE
Big fish eat little fish........
Commissioners
• PCTs
• CCGs: clinical care groups
Provider families
• GP businesses
• Foundation Trusts (acute,
• secondary, community
• non FTs
What landscape? What needs ?
Heroin and crack
users down……
Cocaine & cannabis
use down…
BUT
Change in drug trends:
• methadone up
Drug use in the last year (BCS) 20011/12
Spice etc
BZP
• methamphetamine up
• ketamine up
• mephedrone up
• GLB/GHB up
• BZP, Spice etc up
GBL/GHB
mephedrone
ketamine
2011/12
cannabis
2009/10
cocaine
methamphetamine
crack
methadone
heroin
0
1
2
3
4
5
6
7
8
What landscape, what needs…
Changing drugs use amongst 16-24 yr olds, less use
BUT
Drug use in the last year (BCS) 20011/12
Some substances associated with
significant harm
ketamine
cocaine
Ketamine: kidney/renal damage
Methamphetamine: psychosis &
severe stimulant dependence
GLB/GHB: very severe
dependency & difficult detox
Mephedrone: episodic psychosis
Cannabis: high THC low CBD =
more psychosis
We don’t look for most new
drugs
16-24 2009/10
methamphetamine
16-24 2011/12
adults 2009/10
adults 2011/12
crack
methadone
heroin
0
1
2
3
4
5
6
……….and alcohol
Slightly fewer % of people now drink alcohol
BUT in 2010/11 in England
• 198,900 primary diagnosis alcohol hospital admissions: 40% increase since
2002/3
• 1.17m alcohol-related hospital admissions 50% increase on 2002/3
• Deaths: 2010, 6,669 deaths directly related to alcohol. 22% increase on 2001.
64% died from alcoholic liver disease.
• Major increase in need eg HMP Wormwood Scrubs; A&E liaison
……….and poly substance use….
Role of NHS in substance misuse
Primary care: promoting healthier lifestyles; SM
prevention and treatment; improving wider health and
wellbeing
Acute hospitals: SM related accidents and
emergencies; treating severe illness and disease (eg
related to SM); related diseases
Community services: health visitors; sexual
health, maternity/midwifery, dentistry etc
Contracted substance misuse services: inpatient; community and Prison
Teaching placements for health professionals:
doctors; nurses; psychologists; pharmacists
Research with universities to develop new
treatments and evidence-based practice.
Shrinking NHS substance misuse
service provision
Re-tendering
• Incumbents less likely to win contracts
• NHS incumbents even less likely: 9% win solo, 30% win
in partnership with voluntary sector
WHY
Resources
• More expensive: CIP & EBITDAR overseen by Monitor, National pay scales,
information & clinical governance infrastructure costs
• Previously little investment to support tendering & performance data
Perceptions
• NHS “not recovery-focussed enough” & too medical or disease model
• NHS “too hooked into NICE”, too many difficult Dr’s ..psychiatrists
• NHS slow to change, all they do is `prescribe’
NARROW VIEW: ALL SERVICES VARY IN QUALITY & COMPETENCE
Does it matter if we lose NHS SMS?
YES
•
•
•
•
•
Loss of NHS staff trained in addiction, not just substance misuse services
Loss university training places (& funding) for psychiatrists/psychologists
Potential loss of local NHS to work with complex health needs inc mental health
Potential loss of research into new substance misuse treatments
Loss focus and competence on health when health needs are increasing:
–
–
–
–
Alcohol detoxification much trickier than opioids
Alcohol cognitive & health impacts are serious and need assessing & treating
Aging population of opiate and crack users with extensive health needs
emerging drug patterns require health input: eg acute health impacts eg Ketamine bladder,
GHB/GBL detoxifications,
– Our mental health services seriously challenged by substance misuse issues: cannabis and
stimulant triggered psychosis, alcohol-related dementia in the elderly,
•
Recovery goals around Health and Wellbeing – NHS links and competency is crucial
Potential loss of system competence in health
Are we future-proofing ourselves ?
Substance use and misuse is changing: it not just some drug use is going down
These drug users do not come to our substance misuse services and will not unless
we provide culturally relevant, targeted services and we are competent
Improving health and wellbeing is likely to be of increasing importance
Alcohol and some new drugs cause acute health harms – new territory
Older substance misusers with chronic health and social problems: management
We have a fault-line in our thinking
Are we too focussed on heroin (and crack) users abstinence? The drive for recovery
from dependence is wholly correct, but leads us to talk recovery at the expense of
reality and what matters to public health. Lets not shoot ourselves in the head.
“Not everybody can: but we can enable everybody to try”
Review of international evidence (William White 2012) indicates just over 50% of
those with dependence achieve recovery, with 30% doing so by total abstinence.
THE NEW LANDSCAPE
• Landscape is not just treatment
• Drug strategy: Recovery but also prevention
inc new drugs
• Alcohol strategy: A&E & acute NHS burden,
binge drinking
• Public health: populations, lifestyle,
smoking, obesity, preventable diseases,
Landscape is how to get population level
lifestyle change: treatment is a small hill.…….
Public health talk and think a different language
The new question of balance is how to get deliver local substance misuse health and
wellbeing strategies – the clue is in the name……….
This not just treatment and recovery: its prevention, early intervention, dealing with acute
harms etc. NHS services need to be integrally involved.