Audit Commission report on substance misuse treatment

Last month, The Audit Commission published their excellent report "Changing Habits: The commissioning and management of community drug treatment services for adults".

Victor Adebowale, chief executive of the drug and alcohol charity Turning Point stated: "It was one of the best argued and clearest reviews of drug treatment I have read in a long time."

In this article, Anni Stonebridge, Performance Manager of North Wales Drug and Alcohol Forum, summarises the report and considers its implications for North Wales.

Introduction

The misuse of drugs, particularly heroin and crack cocaine, has increased significantly over the last 40 years. The impact of the misuse of these harder drugs has been felt not only by the individuals themselves and their families, but more widely in the community as drugs and the supply structures surrounding them provide impetus for crime, social exclusion and anti-social behaviour.

There is a substantial body of evidence that a range of treatment interventions are effective in reducing the harm drug misusers do to themselves and the community. Building effective treatment services can have important benefits for the wider community, and as the political agenda in the last few years has moved from the 'War on drugs' towards promoting treatment for drug misusers, treatment services across England and Wales have been allocated new resources to increase their capacity.

Changing patterns of drug misuse and recent national initiatives - such as the establishment of a National Treatment Agency for England, the Substance Misuse Intervention Branch of the National Assembly in Wales, and new arrangements for the delivery of primary care - will also affect how, in future, drug treatment services are commissioned and provided.

In response to these developments, the Audit Commission have reviewed the current provision of community-based drug treatment services for adults. Their findings and recommendations are contained in the report 'Changing Habits'. This article summarises the Audit Commission report and discusses its implications for substance misuse treatment in North Wales.

Summary

Since the 1960s, a range of drug treatment services across England and Wales has evolved in the last twenty years. The evolution of these services has been largely driven by the NHS, with services also being provided by the independent sector and local authorities.

There are large variations in the range of support services available in each DAT/DAAT area in England and Wales, including harm reduction interventions such as needle syringe exchange schemes, information and advice, through to more structured community based and residential detoxification and rehabilitation programmes. While most residential programmes and self-help networks, such as Narcotics Anonymous, view abstinence from drugs as the key objective, many community-based services recognise 'intermediate' goals, such as reductions in the sharing of equipment or criminal behaviour, as equally valid (although abstinence remains the ultimate objective).

Research is ongoing to increase our understanding of what sort of treatment works best for whom, and why. Whilst there is a lot of work still to be done, there is substantial evidence that many sorts of treatment are effective, therefore to maximise treatment efficacy and decrease the impact of drugs on the wider community it is appropriate to be able to offer drug misusers a wide range of treatment options.

A widely quoted cost benefit equation from the National Treatment Outcomes Research Study (NTORS) calculated a return of more than £3 due to savings in the criminal justice system for every £1 spent on drug misuse treatment. Whilst this analogy may seem a crude way of assessing the many benefits of supporting drug misusers into treatment, specific interventions, for instance the establishment of needle syringe exchange, are thought to have significantly reduced the spread of HIV, and is also combating hepatitis C and B through reducing the need to share syringes and other paraphernalia.

Methodology

The Audit Commission conducted a study of adult treatment services in ten areas of England based on Drug Action Team boundaries, and one area of Wales (South Wales) based on Drug Alcohol Action Team boundaries. The report covers specialist community-based drug services provided by NHS Trusts, Social Services departments, and the independent sector. It also examines the role of the general practitioner in supporting drug misusers, often by prescribing substitute drugs in partnership with a specialist service.

Main Findings

"The complex nature of drug misuse and dependency means that drug misusers often require different combinations of treatment interventions over time and need to be supported along a 'treatment pathway'. Many also have multiple needs. Some have a mental health or an alcohol problem and a proportion have difficulties with their social networks and accommodation. This means that treatment options and support must be carefully matched to different needs. It is crucial that different treatment services are effectively co-ordinated and appropriate support marshalled from a wide range of other agencies, such as housing and mental health services."

The study highlighted the facts below:

• many drug misusers face major health, social, economic and legal problems
• one half of drug misusers' annual £1 billion expenditure on drugs is raised through crime
• policing drug misuse and supporting drug misusers costs taxpayers at least £3.5 billion a year.

Drug treatment services can help people to overcome drug problems, but many drug misusers struggle to get the help that they need. The study found a common set of problems that reduce the scope and quality of care for individual clients. These include:

• long waiting lists and limited treatment options drive potential clients away
• care management often fails to address drug misusers' wider social problems
• some treatment is delivered inconsistently or not in line with good practice

Joint working between treatment services and other agencies is also patchy.

• two-thirds of GPs do not have easy access to specialist support and one-half are reluctant to prescribe substitute drugs
• poor links with mental health services, housing services and prison mean that drug misusers with complex problems often struggle most to get the help that they need

The Government's national drug strategy gives high priority to expanding and improving drug treatment services…

• an additional £167 million is being provided for treatment services over the next three years
• a new National Treatment Agency in England aims to improve the quality and accessibility of care.

… and offers drug action teams new opportunities to improve the effectiveness of local services

• collecting better information about local needs, service performance and costs, to inform purchasing decisions
• strengthening care management and co-ordination between treatment services and other agencies
• improving support to primary care and using new funding flexibilities to recognise increases in the workload of GPs who are supporting drug misusers.

The National Treatment Agency and central Government need to make parallel improvements in the national framework:

• increasing understanding of what treatment works by addressing research gaps and promoting the existing evidence base
• developing a national framework for performance measurement and staff training
• ensuring that the funding regime allows local agencies more flexibility to tailor services according to local needs.

By working together, national and local agencies can develop a more coherent response to the needs of problem drug misusers. Failure to do so will be costly. Without adequate support, many drug users will become trapped in a cycle of drug dependency and drug-related crime.

Improving performance

Commissioners of drug treatment services need to work together to develop a more coherent response to the needs of drug misusers. Many drug action teams have already established commissioning group,s but many need to do more to ensure that:

• Local arrangements are well co-ordinated with other key partnerships and agencies who work with drug misusers - recent proposals to merge Crime and Disorder Reduction teams and Drug Action Teams offer new opportunities to review the strengths and weaknesses of local arrangements.
  
  
• Key agencies give sufficient priority to drug treatment. Health commissioners - by far the largest purchasers - commonly spend just 1 to 2 per cent of their budgets on drug treatment, and the costs of failing to treat drug misusers generally fall on others - typically the criminal justice system.
  
  
• Purchasers focus on new money and the use of existing resources. In one area, for example, the use of a £100,000 allocation from the Health Action Zone initiative was discussed at length while the performance of the (more costly) 'mainstream' drug services was not reviewed at all.

The study highlighted the need for commissioners to have access to quality information to allow them to consider whether they are devoting the right type and level of resources to drug treatment services, both about the performance of existing services and the type of support that drug misusers need. Better information about the costs and performance of services must also be collected routinely to identify pressure points and shortfalls.

Conclusion

The report explains that:

"Initially, an incremental approach to change is likely to be the best way forward, concentrating on key blockages, such as long waiting times and gaps in service provision. But getting more drug misusers into treatment is likely to be a high priority in most areas and some services have already adopted successful approaches that others could follow."

"…More effective care co-ordination will be the cornerstone for helping people through the maze of local services. Approaches in related field provide models. The care programme approach (CPA) for example, is used in mental health services to achieve better co-ordination, with specialist mental health teams taking the lead. A single plan sets out the contributions required from each service and a single worker keeps in touch with the service user and makes sure that all the necessary elements of care are delivered."

"…New approaches to the delivery of care will pose new challenges for treatment staff and demand new competencies. A new framework of training and qualifications for the sector as a whole can be developed most effectively at a national level. In the short term, new initiatives are needed to strengthen the knowledge base and expertise of those working in the sector and to improve workforce planning to address the current shortfalls in staff."

Implications for North Wales

North Wales Drug and Alcohol Forum (DAAF) is a multi-agency partnership including members from substance misuse treatment services, Police, Probation, Social Services and independent and voluntary sector agencies. Despite its name and acronym, it is one of five Welsh Drug and Alcohol Action Teams.

1. Access to treatment services
In North Wales, mainstream community drug and alcohol services are provided by North West Wales NHS Trust and North East Wales NHS Trust (which currently provides substance misuse services for Conwy & Denbighshire Trust area).

Whilst the NHS community teams are well developed as regards nursing input, there is concern regarding a lack of resources and support for GPs from the specialist medical component of the service. The issue is currently being addressed by the Joint Commissioning Group (a sub-group of the North Wales DAAF) in partnership with the two NHS Trusts.

In terms of access to treatment, a framework for monitoring waiting times and caseloads is currently being developed in the same group. Service specifications have been set out in a Joint Commissioning Agreement.

Local efforts to reduce waiting times currently include offering alternative treatment options (from the independent sector), and offering group intervention to sustain motivation during waiting times. It is acknowledged that this area is in urgent need of further consideration.

2. Joint working
Substantial investment has been made by North Wales Police and Probation Service to develop the Criminal Justice Intervention Service (CJIS), who specialise in arrest referral and Drug Treatment and Testing Orders (DTTOs). Compared to other areas in Wales, the North was quick to establish arrest referral, and in the first year soon outstripped the anticipated achievement level for DTTOs.

The CJIS have recently released some case studies to make initial illustrations of the outcomes of the project, and a full report is anticipated later in 2002. In other areas, joint working has been instrumental in establishing a number of projects granted funds from the Drug and Alcohol Treatment Fund (a National Assembly funding stream).

North Wales DAAF have also embarked on an ambitious multi-agency venture entitled the DAWN Project. In collaboration with National Association for the Care and Rehabilitation of Offenders (NACRO), and the Society of Voluntary Associations (SOVA), CAIS - the largest independent drug and alcohol agency in North Wales - has embarked on a programme to establish rehabilitation services for substance misusers.

The project aims to develop three multi-agency centres across North Wales, supported by a network of allied resources to enable substance misusers to access multi-agency support, particularly regarding employment and education.

The project ethos is to provide increased cohesion between the various provider agencies in order that clients can quickly and easily access help - from basic advice, through guidance with housing, to counselling and specialist medical intervention.

To date, the project has invested, with the help of the Lottery Fund, in centres in Wrexham and Colwyn Bay, with a further development under discussion for Bangor. A web of satellite centres is also being developed in the more rural areas of North Wales.

3. Expanding and Improving Drug Treatment Services
In 2000, the National Assembly for Wales released its eight-year draft strategic plan for substance misuse. Then covered by the Social Inclusion Unit (now by the Substance Misuse Intervention Branch) within the Assembly, the Welsh strategy has four key aims (broadly reflecting those of the English strategy), but crucially differs from it by the inclusion of alcohol.

The strategy is accompanied by direct Assembly expenditure into the drug and alcohol sector, via the Drug and Alcohol Treatment Fund (DATF). The aim of the fund mirrors the treatment aim of the strategic plan - to enable people with substance misuse problems overcome them and live healthy and fulfilling lives, and in the case of offenders, crime free lives.

In 2002, the additional funding level for Wales as a whole amounts to approximately £3 million, with North Wales receiving £560,000. (To put this into perspective, the NWDAAF Annual Report for 2001 recorded a total of £4,833,634 annual expenditure from the partner agencies of the NWDAAF across all four aims, including the DATF 2001 at £411,000).

To date, North Wales has invested the DATF in approximately forty new projects. Currently, this investment is illustrated by 19 active new posts achieved by DATF grants to member agencies of the NWDAAF.

4. Links between Local Services and the National Assembly
Since its inception, the new Substance Misuse Intervention Branch (SMIB) in the National Assembly for Wales has been actively strengthening links with North Wales. It is understood that SMIB plan to conduct a large scale review of treatment services on a Wales-wide basis, although the timeframe for the study has not yet been determined.

In April 2002, the NWDAAF made the decision to conduct a joint review of all North Wales treatment services as a response to the report of the Audit Commission. It is anticipated that the local review will be closely linked to the national review.

5. Improving the Effectiveness of Local Services
Since 2000, the North Wales DAAF has been active in establishing performance management systems for all projects in North Wales allocated funds from the National Assembly's DATF Fund. This has been possible because a proportion of the fund was ring fenced each year for the NWDAAF to support a research post with the core remit of monitoring and evaluation.

Following the development of the Joint Commissioning Agreement for drug and alcohol treatment services, the NWDAAF plan to improve performance and strengthen care management/co-ordination between treatment services. Regular joint review and performance management meetings will commence in March 2002.

Concern has been raised in the Local Action Teams regarding the utility on a local basis, of the Wales-wide review of services anticipated from SMIB. There is also concern regarding the capacity of the SMIB team to take on such a large piece of work, given that from April 1st 2002 Peter Jones and his team in the Social Deprivation Branch no longer address substance misuse issues. The entire workload from the branch is now placed on the small SMIB team.

As explained above, it is proposed that the NWDAAF now commission a local review of current service provision, which will enable us to make a detailed comparison of service delivery across the three NHS Trust areas. A key stage in the review will be to survey the information management systems of each agency, and determine the most efficient way for agencies to handle data demands.

The review will include mapping the extent of current services, looking at the quality of care provided, and will include an examination of waiting times and access/allocation procedures within each service, care co-ordination, and outcome monitoring.

The intention of the review is to highlight the condition of our treatment services, and provide a baseline from which to analyse future performance. With anticipated increases in investment from the DATF Fund next year, the findings of the review will assist the DAAF to target resources in an appropriate and timely manner.

In January 2002, the NWDAAF agreed a proposal to establish a 12-month research post, and it is envisaged that the review would be serviced by this post, housed within the NWDAAF Team.

Anni Stonebridge
April 24th, 2002