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Adult Drug and Alcohol Treatment System 2012 Commissioning Project - Vision Statement

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					            Adult Drug and Alcohol Treatment System 2012
              Commissioning Project: Vision Statement




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Introduction:

The Norfolk Drug and Alcohol Partnership (N-DAP) are taking forward a whole
systems project to redesign and commission the adult drug and alcohol treatment
system. This consultation document outlines the background to this project and the
partnership’s vision for the future drug and alcohol treatment system in Norfolk.



Background:

N-DAP leads on implementing national drug and alcohol strategies and the
commissioning of drug and alcohol services at a local level throughout Norfolk.

Since developing our first Adult Joint Commissioning Strategy in 2008 the
Partnership has been working to maintain and secure its services, whilst at the same
time further developing the provision provided within these, to ensure that for
increasing numbers of people, drug and alcohol related harms are reduced.

This means that:

    •    In 2009/10 an estimated 53% of Opiate and Crack Users (OCU) were in
         effective treatment 1 and 59% of dependent or severely dependent drinkers
         were in structured treatment.
    •    Of those drug clients who are leaving treatment a greater proportion are
         successfully completing their treatment 2 .
    •    The majority of individuals seeking treatment for drug dependency in Norfolk
         wait three week or less to start treatment 3 .
    •    Treatment Outcome Profile (TOP) data demonstrates that treatment reduces
         drug use, re-offending and housing problems and increases employment and
         improves physical and mental health 4 .
    •    For every £1.00 spent on the Norfolk drug and alcohol treatment system in
         Norfolk an estimated £4.54 is gained in cost savings made in terms of
         preventing crime and health problems 5 .

However, the current delivery system has been predominately developed over the
last ten years based on a process of extension and part system redesign, focused on
identified needs and meeting national delivery target and policy expectations. This


1
  Effective treatment = where an individual has been retained in treatment for three months or more or
has successfully completed their treatment prior to three months.
2
  Successful completions in 2009/10 = 38% compared to 46% in 2010/11.
3
  91% of all drug clients waited three weeks for less to start treatment at the end of 2010/11.
4
  N-DAP 2011/12 Needs Assessment.
5
  NTA Value for Money Tool 2011, www.nta.nhs.uk
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means that the system in some parts may be quite complex for service users to
navigate, providers to deliver and partners to commission.

Historically the predominate focus of services has been harm reduction. The current
system does not easily enable the delivery of more ambitious recovery focused client
pathways, which would have the potential to support higher numbers of individuals in
Norfolk to be free from their dependence on drugs and/or alcohol.

By bringing together the main commissioning partners and taking forward a whole
systems commissioning project, N-DAP aims to develop an integrated drug and
alcohol treatment system that delivers high quality recovery focused services, based
on the individually identified needs of substance misusers and increasingly supports
families and friends.

This whole systems approach will also enable commissioners to more effectively use
the funding available, ensuring increased value for money and a cohesive approach
to commissioning across the partnership.

The Project:

The system redesign and commissioning is being taken forward through the
implementation of the N-DAP Adult Drug and Alcohol Treatment System 2012
Commissioning Project. Further information on this, including the governance and
reporting structure can be accessed on the N-DAP website www.nordat.org.uk

The three main project objectives are to:

    •    Join up the current drug and alcohol treatment system commissioning activity.
    •    Re-design and commission the treatment system with the aim of meeting the
         identified needs of the local population.
    •    Ensure the project effectively engages and involves key stakeholders,
         including partners, service users, family and friends.

The effective engagement and involvement of the above groups are central to the
future vision and the commissioning of drug and alcohol services. Therefore, we
have undertaken a five month engagement and development phase, which included:

    •      Five stakeholder and service user Engagement and Development Groups.
    •      The completion of an Adult Substance Misuse Needs Assessment 2011/12.
    •      Commissioner fact finding visits to three other Drug and Alcohol Partnership
           Areas.

The key findings were then collated and developed into initial recommendations that
N-DAP Commissioners have used to develop the partnership’s commissioning
principles and the vision for the future Norfolk Drug and Alcohol Treatment System.

The key themes identified and the evidence base for these has been outlined in
appendix A.


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Commissioning Principles:

N-DAP have developed a set of commissioning principles that underpin the
commissioning activity it conducts.

1.    The aims and successful delivery outcomes contained within Drug Strategy
      2010 6 are at the heart of N-DAP service development and commissioning.

       Aims:
         •       to reduce illicit and other harmful drug use;
         •       to increase the numbers recovering from their dependence.

       Successful delivery outcomes:
             •    freedom from dependence on drugs or alcohol;
             •    prevention of drug related deaths and infection by blood borne viruses;
             •    a reduction in crime and re-offending;
             •    sustained employment;
             •    the ability to access and sustain suitable accommodation;
             •    improvement in mental and physical wellbeing;
             •    improved relationships with family members, partners and friends;
             •    the capacity to be an effective and caring parent.

2.     Services are commissioned on an outcomes focused basis and are developed in
       accordance with:

             •    identified individual needs;
             •    national and local guidance and good practice;
             •    expected quality and performance standards;
             •    effective consultation and involvement of all relevant partners, service
                  users, family and friends and wider communities;
             •    innovative approaches that deliver value for money.

3.     Services will be commissioned in line with the following:
          • a recovery model underpinned by harm reduction;
          • an integrated service provision, which encompasses joint working and
             care planning, information sharing with other agencies and services that
             best meet identified needs;
          • a system pathway that ensures continuity of care for clients;
          • a robust individual person centred provision, that is simple to access and
             use with clients being at the heart of delivery;
          • flexibility in service delivery;
          • geographic equity of access to services;
          • provision of evidence based interventions at all levels of service delivery;


6
 Drug Strategy 2010: Reducing demand, restricting supply, building recovery: Supporting people to live
a drug free life. HM Government (December 2010).
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           •    models of delivery that reduce the potential for duplication and gaps both
                within the system and with wider partner agencies;
           •    evidenced provider performance and data quality returns.


Our vision:

    To have a drug and alcohol treatment system for adults in Norfolk, that
   increases the number of people able to achieve sustained recovery from
 dependence by providing individual support and treatment packages of care.

These will be enhanced by increasing opportunities for individuals to continue
   their recovery within the community and by providing further support to
                          affected family and friends.

We aim to do this by commissioning a single system across Norfolk which:

       •   delivers a client pathway across the county both within community and
           criminal justice settings including prisons;
       •   aims to ensure equity of access to services by enabling flexible delivery
           options across the county;
       •   develops and supports recovery mentors and volunteers as a core part of
           service delivery;
       •   guarantees a simplified pathway into open access support and structured
           treatment services for individuals via a single access and care coordination
           system;
       •   ensures that all service users in structured treatment have an recovery
           focused care plan that is tailored to identified needs and goals, improves
           client outcomes and where agreed includes the needs of their family and
           friends;
       •   delivers a personalised package of care for service users that is jointly
           developed and delivered with a wide range of agencies and services;
       •   ensures that future services will be able to provide a continued focus on and
           services to identified vulnerable groups including those who are in
           unsuitable accommodation or are homeless, children affected by a parent’s
           or significant other’s substance misuse, sex workers and domestic violence
           victims.

We will also:

       •   work with existing and ex-service users to develop a network of peer led
           community recovery support projects with the aim of ensuring continued
           access to support for when the period of structured treatment ends;
       •   seek to further develop alcohol brief interventions across a broader range of
           agencies in the county and particularly within Primary Care. We will aim to
           do this by rolling out alcohol brief interventions training across Norfolk and
           further enhancing current agreements with GPs;


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       •   work with housing support commissioners in the Integrated Community
           Health and Social Care Commissioning Team to increase access to
           appropriate accommodation for those who are at risk in this area and
           explore ways in which to deliver community based detoxification for people
           living in supported housing environments;
       •   commission more robust Family and Friends services across the county
           ensuring easier access and greater levels of support;
       •   explore opportunities with pharmacies to further enhance the services they
           can offer to substance misusers;
       •   continue to ensure that the county has an effective system to coordinate the
           delivery of needle exchange, supervised consumption and shared care
           services;
       •   continue to offer and further develop training to support non-specialist
           workers who have contact with substance misusers in making effective brief
           interventions (for example in supported housing, domestic abuse support
           services and services for older people).



Next Steps:


The feedback from this consultation will be used to further refine and develop the
Partnership’s vision for the future drug and alcohol treatment system in Norfolk.

The final vision statement and a consultation response paper will be published on the
N-DAP website in September 2011.

All future commissioning decisions are dependent on partnership funding levels, this
means that some aspects of the vision contained within this documents may need to
be given a higher priority for development.




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Appendix A – Engagement and Development Phase Key Findings.

Table key
1 Low Intensity Intervention
2 High Intensity Intervention
3 Alcohol
4 Criminal Justice and Community Safety
5 Public Health and Primary Care


Key point                                                                                                           Evidence Base
                                                                                          Engagement and                    Other evidence source
                                                                                         Development Group

                                                                                       1       2       3    4   5
Access, assessment and care coordination

Current routes into appropriate treatment not always clear. New                                                     Drug Strategy 2010 – Reducing Demand,
system needs to enable access to treatment via single/simplified                                                    Restricting Supply, Building Recovery:
assessment, care planning and coordination systems.                                                                 Supporting People to Live a Drug Free Life. HM
                                                                                                                    Government.

                                                                                                                    Department of Health - Payment by Results
                                                                                                                    guidance.

                                                                                                                    Norfolk Supporting People Strategic review of
                                                                                                                    services for people who misuse substances

The new system needs to be able to facilitate joint care planning
reviews (across a number of different agencies i.e. mental                                                          Older People and Alcohol/Substance Misuse
health, housing, employment, family work) in a more                                                                 Needs Assessment 2009 – NHS Norfolk.
standardised way. Potential for co-located services.

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Key point                                                                                                           Evidence Base
                                                                                          Engagement and                    Other evidence source
                                                                                         Development Group

                                                                                       1       2       3    4   5

The current Drug Rehabilitation Requirements (DRR) system–
clients are successfully completing orders without any real shift                                                   N-DAP Structured Day Programme Review
in behaviour. Issues in care coordination between Probation and                                                     Report – 2011
Structured Day Programme (SDP).

Continuity of care between community and criminal justice
establishments needs to be seamless, including ensuring
effective coverage with county Police Investigation Centres                                                         N-DAP 2010 Adult Substance Misuse Needs
(PIC) and courts.                                                                                                   Assessment

Prisoners discharged from court with no notice – often leads to
time consuming chasing of paperwork and threatens seamless
transition – continuity of care.
Tier 2 non structured services.

Tier 2 – this is essential for building recovery capital.                                                           Tier2 Modality Report - 2009

Further integration between open access and structured
treatment needed.
Tier 3 structured treatment – see flexibly, recovery

Needs to provide a range of interventions in place, with
increased flexibility in delivery options that are built around                                                     Drug Strategy 2010.
identified client needs, at the right point in time and focused on
improving outcomes.
                                                                                                                    N-DAP Structured Day Programme Review
There are issues with how testing is paid for- different across                                                     Report – 2011
the county.

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Key point                                                                                                           Evidence Base
                                                                                          Engagement and                    Other evidence source
                                                                                         Development Group

                                                                                       1       2       3    4   5
Tier 4

Lack of specialist substance misuse in-patient detox beds within                                                    N-DAP 2010 Adult Substance Misuse Needs
the county.                                                                                                         Assessment

Residential rehab process works well if properly matched to                                                         Norfolk Supporting People Strategic review of
need.                                                                                                               services for people who misuse substances

There are examples where community detox works well,
particularly for alcohol clients. Housing options and tier 4 –
potential area to further develop.

An intensive SDP has the potential to provide an alternative to                                                     N-DAP Structured Day Programme Review
residential rehab for some.                                                                                         Report – 2011

Alcohol

Further development of alcohol brief interventions outside of                                                       Great Yarmouth and Waveney Alcohol Strategy
structured treatment system. Especially in primary care.                                                            2011

Big gap in alcohol interventions across criminal justice related                                                    Alcohol use disorders: preventing harmful
service elements (Drug Intervention Programme (DIP),                                                                drinking – NICE 2010.
Counselling Assessment Referral and Thoughcare services
(CARAT)                                                                                                             N-DAP Adult Substance Misuse Needs
                                                                                                                    Assessment 2010.
Roll out hospital alcohol related services
                                                                                                                    Tier 2 Modality Review 2009
Generally high need for alcohol services.



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Key point                                                                                                           Evidence Base
                                                                                          Engagement and                    Other evidence source
                                                                                         Development Group

                                                                                       1       2       3    4   5
Equity of services

Minimal coverage of some interventions within the more rural                                                        N-DAP 2010 Adult Substance Misuse Needs
areas. Outreach key element to delivery in relation to this.                                                        Assessment

                                                                                                                    Tier 2 and SDP reviews.
Need to ensure the diversity is taken into account, difficulties
engaging migrant workers and outcomes not as good as wider                                                          N-DAP 2010 Adult Substance Misuse Needs
population.                                                                                                         Assessment
Flexibility

Service access/delivery times and delivery approaches.

Service must be flexible and built around the client – outcomes.                                                    Drug Strategy 2010.

Recovery

Recovery, underpinned by harm reduction, needs to be in place
at each step in a treatment journey, but with a particular element                                                  Drug Strategy 2010
at treatment exits.

Need to develop recovery mentors and champions. Service                                                             N-DAP Adult Substance Misuse Needs
users coming into treatment need to be able to see recovery.                                                        Assessment 2010.

Further development of volunteers where appropriate.
                                                                                                                    N-DAP Structured Day Programme Review
Abstinence focused delivery limited. Current service                                                                Report – 2011
specifications geared towards harm reduction.



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Key point                                                                                                           Evidence Base
                                                                                          Engagement and                    Other evidence source
                                                                                         Development Group

                                                                                       1       2       3    4   5
Housing

Difficulties accessing certain types of housing provision. Clients                                                  N-DAP 2010 Adult Substance Misuse Needs
need to be able secure the right accommodation to met their                                                         Assessment.
needs.
                                                                                                                    Supporting People Substance Misuse strategic
The work of the Homeless Outreach Team could be more                                                                Review 2011.
focused in delivering crisis intervention into hostels etc to help
avoid eviction.
Family and Friends

More family and carers support needed/family services under                                                         N-DAP 2010 Adult Substance Misuse Needs
developed.                                                                                                          Assessment

                                                                                                                    N-DAP Family and Friends Strategy.

                                                                                                                    Drug Strategy 2010.
Primary Care (GPs) Shared Care

Shared care works well where good working relationships                                                             N-DAP 2010 Adult Substance Misuse Needs
between substance misuse services and GPs exists. Although                                                          Assessment
this is not available county wide with some rural areas having
poor access. Some surgeries have limited the number of clients
that they are willing to prescribe.

GP screening and early intervention – not enough in place or
being completed.

Better collaboration with GPs needed

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Key point                                                                                                           Evidence Base
                                                                                          Engagement and                    Other evidence source
                                                                                         Development Group

                                                                                       1       2       3    4   5
Needle Exchange and Supervised Consumption

Coverage generally good, however there is scope to widen in
terms of accessibility and uptake increase.

Issues with clients not completing full BBV related vaccinations                                                    N-DAP Adult Substance Misuse Needs
or treatment                                                                                                        Assessment 2010.

Current Needle Exchange and Supervised Consumption
coordination working well.
After care/ peer led support.

Limited aftercare/peer led recovery support activities post formal                                                  N-DAP Adult Substance Misuse Needs
treatment completion.                                                                                               Assessment 2010.

Ensure development of advocacy, mentoring and volunteer                                                             Tier 2 Modality Review 2009
work.
Other

Greater links between adult substance misuse services and                                                           N-DAP 2010 Adult Substance Misuse Needs
children and family services needs to be factored into the new                                                      Assessment
system design.

Clarity regarding the parameters and boundaries of services is                                                      Tier 2 Modality Review 2009
needed.

There is a danger that clients are being put back into work too                                                     N-DAP 2010 Adult Substance Misuse Needs
soon, emphasis needs to be placed on ensuring people are                                                            Assessment
supported to be work ready at a manageable pace – greater
joint working with the DWP, training commissioners and
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Key point                                                                                                           Evidence Base
                                                                                          Engagement and                    Other evidence source
                                                                                         Development Group

                                                                                       1       2       3    4   5
providers.

Women – issues identified for women accessing some                                                                  N-DAP Structured Day Programme Review
modalities of care, SDP and Tier 4 inpatient or residential rehab                                                   Report – 2011
(sometimes due to parenting responsibilities). Sex workers,
women in insecure accommodation and those victim to                                                                 N-DAP 2010 Adult Substance Misuse Needs
domestic violence are particularly vulnerable groups                                                                Assessment

                                                                                                                    Tier 2 Modality Review 2009
Substance misuse provision for older people remains generally
underdeveloped                                                                                                      Older People and Alcohol/Substance Misuse
                                                                                                                    Needs Assessment 2009 – NHS Norfolk.




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