GUIDANCE FOR COMMISSIONERS OF DRUG AND ALCOHOL SERVICES
The Joint Commissioning Panel for Mental Health has developed guidance for commissioning drug- and alcohol-recovery services. What will local potential purchasers of your services look for? What points will influence spending decisions? We summarise key information, and give a link to more.
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The Joint Commissioning Panel for Mental Health is a collaboration co-chaired by the Royal College of General Practitioners and the Royal College of Psychiatrists. Its recent guide will be used by “public-health leaders who will hold responsibility for commissioning these services, Clinical Commissioning Groups, wider local authority commissioners and voluntary- and independent-sector organisations”. So get up to date on what these will be looking for in a service, and ensure that your organisation offers it.
WHY DRUG/ALCOHOL SERVICES ARE IMPORTANT TO COMMISSIONERS
1 Drug and alcohol use can have a significant, negative impact on individuals and wider society. The Drug Strategy 2010 identified that drug and alcohol problems both negatively impact on users and are the “key causes of societal harm, including crime, family breakdown and poverty”.
Crime – drug treatment has been shown to be effective in preventing drug-related offending, with an estimated 5,000,000 offences being prevented in 2010-11 alone. Each year, alcohol is associated with 500,000 recorded crimes in England, 125,000 instances of domestic violence and 1,000,000 assaults.
Family difficulties – about one in five families referred to children’s social services in the UK have a history of alcohol or drugs problems, rising to one in two families on the Child Protection Register and affecting three out of four families involved in care proceedings.
Poverty – the Marmot Review 2010 highlighted to address health inequalities, including an approach to substance misuse to alleviate the impact of alcohol in particular on people living in more deprived settings.
2 Drug and alcohol use can also have a public health impact. Primary harms include transmission of blood borne viruses, including hepatitis B, C and HIV. Estimates suggest that about 216,000 people are chronically infected with hepatitis C in the UK. Harms that can be caused by addiction to drugs or alcohol include: death by overdose, intoxication, accidental injury, suicide and precipitation or exacerbation of mental illnesses such as psychosis. Chronic harms can include: cirrhosis and other liver damage, consequences of injecting (eg, abscesses, vein damage, endocarditis), sexually transmitted diseases, dependence including withdrawal symptoms, hypertension, stroke, coronary heart disease, pancreatitis, depression and anxiety disorders.
3 Considerable economic costs are associated with drug and alcohol use. There were 1,200,000 alcohol-related hospital admissions in 2010/11. It costs NHS England up to £2.7billion a year to treat the chronic and acute effects of drinking. The government’s alcohol strategy indicates that alcohol-related harm costs society £2billion annually. Drug use costs the UK £15.4billion each year, including welfare-benefit costs of about £1.6billion per year.
4 There is a relatively common use of drugs and alcohol among the UK population. Estimates from the 2010/11 British Crime Survey show that 36% of adults aged 16-59 have used illicit drugs, almost 12 million people. Among this group, almost 9% or 2.9million adults had used illicit drugs in the last year. Investment in drug treatment services is widely recognised to have been a factor in the reduction of illicit drug use.
Alcohol consumption in the UK has almost trebled since 1950 with over 7,000,000 people drinking at harmful or hazardous levels (accounting for about 80% of all spending on alcohol). Since 2002/03, there has been a 40% increase in admissions to hospital where the primary diagnosis was attributable to consumption of alcohol.
In addition, the 2002 Co-morbidity of Substance Misuse and Mental Illness Collaborative study concluded that: 75% of users of drug services and 85% of users of alcohol services were experiencing mental health problems; 30% of the drug treatment population and over 50% of those in treatment for alcohol problems had ‘multiple morbidity’; 38% of drug users with a psychiatric disorder were receiving no treatment for their mental health problem; 44% of mental health service users either reported drug use or were assessed to have used alcohol at hazardous or harmful levels in the past year.
5 These harms, impacts and costs can be reduced through effective treatment, with important economic savings. Where provided by trained and experienced staff, the evidence base for drug and alcohol treatment is strong. From a purely economic point of view, investment in effective treatment and recovery services makes sense for commissioners as they seek to ensure good value for the public purse. Even rationing body Nice, the National Institute for Health and Clinical Excellence, produced a Costing Report for implementing such services indicating that:
>> total savings through implementing the guideline attributable to healthcare were estimated as being almost £4 million
>> an extra £37million of savings to society were estimated outside of the NHS in the criminal justice system
>> at an individual level, research has shown that for every £1 spent on treatment, an estimated £2.50 is saved
>> good quality drug and alcohol services also help people to achieve their recovery potential and as such benefit individuals directly; intervening early can reduce the chances of ongoing misuse and consequent harms, thus reducing future demand on the use of NHS and other public services.
10 KEY MESSAGES TO COMMISSIONERS
1 Investment in drug and alcohol services gets results. Treatment, as part of a coordinated public health approach is proven to be cost-effective for health services and society as a whole. Disinvestment brings with it a risk of reversing the progress made over recent years.
2 A strong evidence base exists for the range of interventions that are effective in substance misuse. Commissioning should be based upon this evidence using NICE quality standards.
3 To be effective, the treatment system should be equipped to respond to the full range of complexity of need represented by those who misuse substances.
4 A skilled workforce, working under appropriate supervision and providing care within national competence frameworks, is key to delivering good outcomes.
5 Collaboration and partnership gets results. The NHS and voluntary sector have a contribution to make in the delivery of drug and alcohol services.
6 Commissioning of drug and alcohol services should be based upon accurate and up to date information about local needs.
7 Commissioners should ensure that local services have clear leadership, both clinical and managerial, and that services comply with professional and service standards.
8 Commissioning of drug and alcohol services should be outcome based and make use of available data and information.
9 Services should place recovery at the centre of their approach and commissioners should recognise recovery as central to their commissioning and strategic decision making.
10 Treatment is not simply about patients – it should address the needs of families and carers, and work with patients’ wider social networks.
At long last, recognition seems to be given to people dependent on drugs other than heroin and crack cocaine. “Most secondary care services tend to concentrate their interventions on people with addictions to drugs such as heroin, crack cocaine and alcohol. However, other substances, for example emerging club drugs and prescribed drugs, may be among those for which people are treated,” the guide explains.
"Given the complexity of these problems and the range of needs, services are required to collaborate with other parts of the health, social care and criminal justice systems. This is especially the case when providing services to people with co-morbid illness, because they are often excluded from general mental health services. One of the functions of drug and alcohol services is to work with this group.”
Where Drug & Alcohol Action Teams are in operation, these introduced Local Area Single Assessment and Referral Systems – Lasars – as part of a national pilot of drug recovery Payment by Results. The core function of Lasars is to assess and set a tariff, refer and, in some cases, review achievement of outcome. They might also reduce the number of assessments that an individual has to undertake to access services.
IMPLEMENTING GOVERNMENT STRATEGIES
The drug strategy: Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life. Commissioning which leads to good drug and alcohol services will support delivery of the national drug strategy. By commissioning for outcomes and recovery, commissioners can enable services to:
>> enable people to be free from dependence on drugs or alcohol
>> prevent/reduce drug related deaths and blood borne viruses
>> improve mental and physical health and wellbeing
>> contribute to a reduction in crime and re-offending
>> improve the ability of patients to access and sustain suitable accommodation
>> improve the ability of patients to gain and maintain appropriate employment and/or training as part of their recovery
>> provide accurate information on drugs and alcohol through substance misuse education.
These are among some of the central elements that the drug strategy seeks to deliver.
The government’s alcohol strategy. Effective alcohol services will support the delivery of the objectives described in the alcohol strategy. Commissioners should commission services that will:
>> contribute to a reduction in the number of alcohol-related deaths
>> a reduction in the number of adults drinking above the NHS guidelines.
These are some of the central elements that the alcohol strategy seeks to deliver that specialist alcohol services can contribute to.
WHAT WOULD A GOOD DRUG AND ALCOHOL SERVICE LOOK LIKE?
Addiction Today readers will know the answer to this already – but to learn what is suggested by the Joint Commissioning Panel for Mental Health, and incorporate this into your business plans and advocacy to your local commissioners, access 25 pages of information, including 57 literature references, at www.jcpmh.info/resource/guidance-for-commissioners-of-drug-and-alcohol-services.