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Bexley Alcohol Services by zhangyun


A Guide to Care Pathways
1. Introduction                                                           4

2. Elements of Integrated care pathways                                   5

3. Local framework of delivery

    (i) Alcohol related information; advice; screening;
        simple brief interventions and referral                       6-7

    (ii) Open access: non care planned alcohol
         specific interventions                                       8-9

    (iii) Community based structured care-planned
          alcohol treatment

           (a) Signpost                                           10-15

          (b) BAGRA                                               16-17

    (iv) Acohol specialist in-patient
         and residential re-habilitation                          18-19

4. Young Peoples services                                         20-21

Appendix A.
Services and pathways flowchart                                   22-23

Appendix B.
Guidance for accessing Young
People’s tier 4 services                                          24-25

Appendix C.
Protocol for the management
of Young People presenting to
A & E with acute intoxication                                             26

Appendix D.
Alcohol Assessment -
brief interventions screening tools                               27-28

                  C   a   r   e   P   a   t   h   w   a   y   s   G   u    i   d   e
                    Models of Care for Alcohol                   Integrated care pathways should be
                    Misuse (MoCAM)1 outlined                     able to provide access to a range
                    the four-tiered framework of                 of services and interventions that
                    provision for commissioning                  meet an individual’s needs in a
                    alcohol treatment and                        comprehensive way and should
                    interventions and the                        be developed because:
                    companion publication, Alcohol
                    treatment pathways: guidance                 ● Alcohol misusers can have multiple
                    for developing local integrated                problems that require effective
                    care pathways for alcohol2
                                                                   co-ordination of treatment
                    details the concept and
                    purpose of developing local                  ● Several specialist and generic
                    integrated care pathways (ICP).                providers may be involved in the
                                                                   care of a client simultaneously or
                    The aim of this guide is to describe           consecutively
                    the local route for each alcohol
                                                                 ● Continuing   and evolving care needs
                    treatment pathway (ATP) to ensure
                    that everyone involved in the process          requiring referral to services at
                    has an agreed understanding of their           different tiers of intervention
                    role and responsibilities at every           ● To provide consistency and parity
                    stage thereby improving the service
                                                                   of approach nationally
                    user’s experience of the treatment
                    journey.                                     ● To ensure access to care is not based
                                                                   solely on individual clinical decisions
                                                                   or historical arrangements.

                    1. Models of care for alcohol misusers (MoCAM) (DoH, 2006)
                    2. Alcohol Treatment Pathways – Guidance for Developing Local
                    Integrated Care Pathways for Alcohol (NTA, 2006)

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Elements of Integrated care pathways
                         Each alcohol intervention should
                         contain a number of elements that
                         provide clarity as to the type of
                         client catered for, what the client
                         can expect services to provide
                         and the roles and responsibilities
                         of the service towards the client.

                         These elements should aim to
                         include the following:

                         ●A   definition of the treatment
                           interventions provided
                         ● Aims and objectives of the
                           treatment interventions
                         ●A   definition of the client group served
                         ● Eligibility
                                     criteria (including
                           priority groups)
                         ● Exclusions criteria or
                         ●A   referral pathway
                         ● Screening      and assessment processes
                         ● Development  of agreed
                           treatment goals
                         ●A  description of the treatment
                           process of phases
                         ● Co-ordination      of care
                         ● Departure planning, aftercare
                           and support
                         ● Onward        referral pathways
                         ● The  range of services with which
                           the interventions interface.

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    Local framework of delivery - Tier 1
                                                            Queen Mary’s Hospital -
                    These are                               Accident and Emergency
                    defined as: the
                                                            ● Targeted screening and assessment
                    identification                           for those drinking in excess of DH
                                                             guidelines on sensible drinking and
                    of hazardous,                            for those who may need treatment
                                                             using the FAST and AUDIT screening
                    harmful and                              tools*.

                    dependent                               ● Provisionof simple brief interventions
                                                             of hazardous and harmful drinkers
                    drinkers;                                using the Think/Drink booklet and
                                                             the drinks diary.
                    information on                          ● Referralof those requiring more
                    sensible drinking;                       than simple brief interventions for
                                                             specialised alcohol treatment. Issue
                    simple brief                             of the local services leaflet maybe
                                                             appropriate for self referral.
                    to reduce
                    harm; and
                    referral of
                    those with

                                                            * See Appendix D - Alcohol Assessment

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Queen Mary’s Hospital -                        Police custody suite
Urgent Care Centre
                                               ● Targeted screening and assessment
● Targeted screening and assessment             for those drinking in excess of DH
 for those drinking in excess of DH             guidelines on sensible drinking and
 guidelines on sensible drinking and            for those who may need treatment
 for those who may need treatment               using the FAST and AUDIT screening
 using the FAST and AUDIT screening             tools*.
                                               ● Provisionof simple brief interventions
● Provisionof simple brief interventions        of hazardous and harmful drinkers
 of hazardous and harmful drinkers              using the Think/Drink booklet and
 using the Think/Drink booklet and              the drinks diary.
 the drinks diary.
                                               ● Issue of the local services leaflet for
● Referralof those requiring more               those requiring more than simple
 than simple brief interventions for            brief interventions.
 specialised alcohol treatment. Issue
 of the local services leaflet maybe
 appropriate for self referral.                Local pharmacists, health
                                               trainers and housing
                                               support workers
GP Surgeries
                                               ● Targeted screening and assessment
● Targeted screening and assessment             for those drinking in excess of DH
 for those drinking in excess of DH             guidelines on sensible drinking and
 guidelines on sensible drinking and            for those who may need treatment
 for those who may need treatment               using the FAST and AUDIT screening
 using the FAST and AUDIT screening             tools*.
 tools*.                                       ● Provisionof simple brief interventions
● Provisionof simple brief interventions        of hazardous and harmful drinkers
 of hazardous and harmful drinkers              using the Think/Drink booklet and
 using the Think/Drink booklet and              the drinks diary.
 the drinks diary.                             ● Issue of the local services leaflet for
● Referralof those requiring more               those requiring more than simple
 than simple brief interventions for            brief interventions.
 specialised alcohol treatment. Issue
 of the local services leaflet maybe
 appropriate for self referral.

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    Local framework of delivery - Tier 2
                                                            The Welling Alcohol
                    These are defined                       Service Provision (WASP)

                    as: alcohol                             This is a user led service that offers
                                                            a drop-in facility to support alcohol
                    specific advice;                        misusers during recovery. Staff
                                                            are able to offer alcohol-specific
                    information                             information; advice and support,
                                                            and referral to local services
                    and support;
                    extended brief                          Alcoholics Anonymous
                    interventions                           This is a mutual aid group that offers
                    to help alcohol                         regular meetings for dependent
                                                            drinkers whether or not in treatment
                    misusers reduce                         or in recovery. The groups offer
                                                            alcohol-specific information, advice
                    alcohol-related                         and support and can provide
                                                            information on local services.
                    harm; and
                    assessment and                          Queen Mary’s Hospital –
                    referral of those                       Gastroenterology Clinic

                    with more serious                       All new referrals are screened
                                                            for alcohol misuse as part of the
                    alcohol-related                         collaborative in-patient clinic provided
                                                            by Signpost, and given alcohol-specific
                    problems                                information, advice and support;
                                                            extended brief interventions to
                    for care-planned                        reduce alcohol related harm; alcohol
                                                            specific assessment and referral of
                    treatment.                              those requiring more structured
                                                            alcohol treatment.

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Probation (Equinox)                           Signpost

This service works with clients               Harm reduction services are available
within the criminal justice system            to all clients consisting of;
to provide; alcohol-specific
information, advice and support; brief        ● alcohol-specific information,
interventions to reduce alcohol                 advice and support; extended
related harm and referral to                    brief interventions to reduce
appropriate services.
                                                alcohol related harm.
                                              ● Pabrinex  Administration Programme -
                                                5 day course of pabrinex injections
Joint Antenatal Clinic                          containing a range of vitamins
(Willow)                                        including thiamine, vitamin C
                                                and vitamins B6 and B7.
This is a collaborative out-patient
clinic between midwifes, Signpost
and Social Services for clients who
are pregnant offering alcohol-specific        Bexley Alcohol & Drug
information; advice and support; brief        Alliance (BAADA), Peer
interventions to reduce alcohol               Support Group
related harm and referral to
appropriate services.                         This is a mutual aid group that meets
                                              on a weekly basis offering alcohol and
                                              drug specific information and advice
                                              along with support for users in
Drug & Alcohol Team                           recovery.
(Care Management)

The service is primarily responsible
for referrals to residential placements
at specialised inpatient facilities
within the statutory, independent
and voluntary sector. Also provides
alcohol-specific information, advice
and support; brief interventions to
reduce alcohol related harm and
referral to appropriate services.

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     Local framework of delivery - Tier 3
                                                               Aims and objectives
                     This is defined as:                       of treatment.

                     the provision of                          Reduction of physical, psychological
                                                               and social problems directly
                     community-based                           associated with alcohol use.

                     specialised                               ● Reduction in harmful or risky
                                                                 behaviours associated with alcohol.
                     alcohol misuse                            ● Attainmentof controlled or
                                                                 non-dependent use of alcohol.
                     assessment, and
                                                               ● Abstinence    from alcohol.
                     alcohol treatment                         ● Improvement   in service users
                                                                 overall personal, social and
                     that is care co-                            family functioning.
                     ordinated and                             ● Development   of a working
                                                                 relationship with clients to facilitate
                     care-planned.                               them self assessing and seeing
                                                                 a range of options and lifestyle
                                                                 choices available to them.
                                                               ● Facilitate the clients in gaining
                     SIGNPOST                                    insight into the damage associated
                                                                 with continuous dependent use
                                                                 of alcohol.
                     Treatment provided.
                                                               ● Provide  structured treatment
                     The alcohol service provides                modalities to include family and
                     treatment intervention to alcohol           significant others involved in the
                     users who are physically dependent          service users life.
                     on alcohol and those with alcohol
                     related brain damage and associated
                     complex physical health issues that
                     are specific to alcohol.

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The Aims
Client group.                                 Referral pathway

Any client who is physically                  Referrals can be made by the
dependent on alcohol. Physically              client (self-referral) or by any
dependent is defined as using                 other involved professional. A
alcohol daily and experiencing                self-referral clinic is operated on
physical withdrawal symptoms                  a Wednesday morning at the service.
when not drinking. Also those
with alcohol related brain damage             Referrals will be responded to
and other complex physical                    within 2 working days.
problems specific to alcohol use.
                                              At the time of referral duty staff
                                              will be responsible for responding.

Eligibility criteria.                         All referrals will be directed to the
                                              self-referrals clinic. If it is not possible
● Alcohol   users aged 18 and over.           for a client to attend this clinic an
                                              appointment for triage assessment
● Resident
         of the London                        will be offered within 5 working days.
 Borough of Bexley.
● Thosewho are of No Fixed Abode              Home visits to undertake
 (NFA) in the Borough of Bexley.              assessments can be arranged when
                                              a service user is physically unable
● Alcoholmisusers using alcohol               to attend the service. Where
 as their primary substance.                  possible initial triage screening will
● Thosewith complex substance                 be undertaken by telephone. Physical
                                              as well as psychological/mental health
 misuse problems.
                                              factors that prohibit attendance must
                                              be supported and corroborated by
                                              the service users GP or appropriate
Exclusions criteria                           professional, in order for the service
                                              user to be eligible for a home visit.
Those assessed as posing a current            Home visits are undertaken in line
and real risk to staff, other service         with SLaM’s Home Visiting Protocol.
users, and the community if treatment
were undertaken (SLaMs clinical               Referral decisions are communicated
guidelines will provide more details).        by the triage worker, in writing, to the
                                              referrer following allocation meetings.

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     Local framework of delivery - Tier 3
                     Screening and                                    ● set the goals of treatment
                     assessment process                                 and milestones to be achieved
                                                                        (taking into account the views
                     The following are offered by the                   and treatment goals of the alcohol
                     service:                                           misuser and developed with their
                                                                        active participation)
                     ● Tier    2 assessment
                                                                      ● indicate the interventions planned
                     ● Briefinterventions including
                                                                        and the agencies and professionals
                       motivational interviewing
                                                                        responsible for carrying out the
                     ● Onward     referral or offered                   interventions
                       full tier 3 assessment                         ● make  explicit reference to risk
                     ● Baseline assessment of current                   management and identify the risk
                       alcohol use and dependence                       management plan and contingency
                     ● In-depth   assessment                            plans
                                                                      ● identifyinformation sharing (what
                     ● Physical/psychological/social/

                       nutritional health checks                        information will be given to other
                                                                        professionals and agencies and under
                     ● Investigationsi.e. blood tests, hepatitis        what circumstances identify the
                       B & C testing, and vaccination                   engagement plan to be adopted with
                     ● Risk assessments, including                      alcohol misusers who are difficult to
                       family risk assessments                          engage in the treatment system
                     ● Mini    mental state examinations              ● identifythe review date (the date of
                     ● Health    promotion                              the next review meeting is set and
                                                                        recorded at each meeting)
                                                                      ● reflectthe cultural and ethnic
                     Development of agreed                              background of the alcohol misuser,
                     treatment goals                                    as well as their gender and sexuality
                                                                      ● make  clear who is the named
                     Care plans are completed in line
                     with SLaM’s Care Planning                          keyworker who has agreed to be
                     Procedures. Staff are encouraged                   responsible for drawing up the care
                     to supplement this guidance with                   plan with the service user, involving
                     the recommendations contained                      any others as appropriate, and who
                     in MoCAM for an effective care                     will monitor the care plan and
                     plan as follows:                                   ensure its review

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Care plans are reviewed on a                        ● Detox     lasts between 5 and 10 days
regular basis with a recommended
                                                    ● Detox  medication is prescribed as a
frequency of every 6 sessions.
The review should cover the                           reducing regime during this time.
following areas:                                    ● The  home detox nurses offer clients
                                                      6 to 12 aftercare sessions. These
● relevance    of care plan                           sessions are for ongoing support
● effectiveness
             of care plan                             and relapse prevention work with
  and outcomes                                        a view to onward referral to tier
                                                      3 & 4 aftercare services.
● any   unmet need
● client   satisfaction with the care
                                                    Harm reduction services
                                                    ● Clients will have an assessment
Description of the
                                                    ● Clientswill have a mutually
treatment process
                                                      agreed treatment plan
All clients receive full psycho/social              ● Interventions,including counselling,
interventions and will be referred,                   motivational interviewing, CBT,
if required, to general medicine.                     relapse prevention work

Shared care home                                    ● Alcohol  education and awareness
detoxification.                                       training including blood tests,
● Clients are offered a full assessment               breathalysing, sensible drinking.
● Clients
                                                      SADQ, physical consequences
         have a mutually agreed
                                                      and psychometric testing
  treatment plan
                                                    ● Engagement    and length of time
● Detox  is carried out in the client’s
                                                      in the service will be part of the
  home in conjunction with their
                                                      goals of the client’s individual
  GP, who takes medical responsibility
                                                      treatment plan.
  for the client
● Signpost   home detox nurses provide
  initial assessment followed by daily
  visits for five days. The client identifies
  a nominated responsible carer for
  the home detox period.

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     Local framework of delivery - Tier 3
                     Co-ordination of care                           ● Identifywhere the client needs to
                                                                       develop alternative coping strategies
                     Where more than one agency is
                                                                     ● Identify an unmet need in the
                     involved in a client’s care Signpost will
                     negotiate with the partner agency to              following areas – alcohol use,
                     agree the co-ordinating care lead.                psychological, physical, social
                                                                       and legal.
                     Where the client is on CPA and                  ● Educate  the client in the importance
                     engaged with mental health services
                                                                       of aftercare and any needs that
                     Signpost will endeavour to ensure
                                                                       may arise following discharge
                     that Mental Health Services take the
                     care co-ordination lead.                        ● Outline all the services and aftercare
                                                                       options that are available to the
                     Signpost will take the lead role where            client
                     it is the only agency involved.
                                                                     ● Develop the plan, using the identified
                                                                       needs as a starting point
                                                                     ● Identify
                                                                              who is responsible for which
                     Departure planning,
                                                                       element of the plan
                     aftercare and support
                                                                     ● Identifywho is the on-going care
                     The development of an appropriate                 co-ordinator
                     package of aftercare and support
                                                                     ● Review  the plan and the process of
                     should take place in the final phases
                     of the treatment episode.                         developing it. Ensure that the client
                                                                       feels ownership of the plan and felt
                     The service adopts the following                  it was a collaborative process.
                     10 step process:                                ● Copy  relevant professionals into the
                                                                       plan, with clients appropriate
                     ● Identify the client’s high-risk

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     Local framework of delivery - Tier 3
                                                                   Exclusions criteria
                     BAGRA                                         It is important that clients are able to
                                                                   attend all appointments alcohol free,
                     Treatment provided                            but equally this must be something
                                                                   that the client feels confident can be
                     The service provides assessment, key          achieved without creating any physical
                     work, group work and counselling for          discomfort. Where this is not possible
                     clients who have problems with their          the service will refer the client to get
                     drinking.                                     help to reduce their drinking to
                                                                   enable them to use these services.

                                                                   Clients who pose a risk to the well
                     Aims and objectives                           being of either staff or other clients.
                     of treatment

                     To improve understanding of alcohol
                     units, its impact on health, relapse          Referral pathway
                     prevention and harm reduction and
                     provide therapeutic support to                The service provides assessments
                     achieve either abstinence or                  for problems related to alcohol use
                     controlled drinking.                          based on an appointment system.
                                                                   Although clients can drop-in, they
                                                                   should be aware that the service
                                                                   normally operates a waiting list. A
                     Client Group                                  referral can either be made by the
                                                                   client or on the client’s behalf by
                     Residents of Bexley aged 18 and over          another agency. An external referral
                     who are not physically dependent              form is available for this process.
                     with a primary alcohol problem.
                                                                   Where the referral is appropriate the
                                                                   client will be offered an assessment
                                                                   when a care plan will be agreed.
                     Eligibility criteria
                                                                   The service will write to the client
                     ● Alcohol   users aged 18 and over.           to confirm an appointment and
                                                                   endeavour to offer an assessment
                     ● Resident
                              of the London                        within 3 weeks of contact.
                      Borough of Bexley
                     ● Ableto be alcohol free for a                If the client’s needs are not
                      minimum of 2 days a week                     immediately appropriate for this
                                                                   service they will assist the client
                      without experiencing any
                                                                   to access another service.
                      withdrawal symptoms.

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Screening and                                   ● Stress    management
assessment process                              ● Anger    management
The following are offered by                    ● Life   skills
the service:                                    ● Coping     skills
● Triage   Assessment                           ● Open     support
● Comprehensive     assessment                  ● Relapse      prevention
  and care plan                                 ● Gender       specific issues
● Risk    assessment                            Homeopathy, aural acupuncture and
● Onward  referral where not                    workshops on nutrition are also
  appropriate for service
● Brief   intervention                          Clients can attend the group
● Advice
                                                programme for up to a year
           and information
                                                depending on support needs.
● Agency  information and
  confidentiality policy
● Health    promotion

                                                This service offers a weekly fifty
Development of agreed                           minute session for an initial period
treatment goals -                               of 8 weeks. This can be extended
Care plans are completed for                    following review where the client
all clients which include the                   still requires help to change alcohol
agreement of treatment goals.                   use or maintain abstinence.

                                                Counselling in the evening is also
                                                available and one evening support
Group programme                                 group.

The first stage group offers an initial 6
week intervention with three groups
a week being run. At the end of this            Aftercare
the care plan is reviewed and the
client can decide to continue a                 A footballl structured programme
further six weeks or if they are ready          is linked to the service called
to be abstinent they can attend the             Airfootball which is available to
second stage programme which offers             clients helping participants to build
a maximum of four groups a week.                self esteem and confidence; gain
                                                fitness and develop team building
There are both structured and open              and communications skills.
groups . In the structured groups we
will cover topics such as;                      There is also a service user group
                                                which meets regularly.

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     Local framework of delivery - Tier 4
                                                                The unit bases its theoretical
                     This is defined                            framework on motivational
                                                                enhancement therapy, utilising the
                     as residential,                            harm reduction model and promoting
                                                                health behaviour change.
                     specialised                                The multi-disciplinary team comprises
                     alcohol                                    of doctors, nurses, clinical
                                                                psychologists, occupational therapists,
                     treatments                                 drug and alcohol workers and
                                                                administration staff.
                     which are care-                            Alex 1
                     planned and                                A 16 bed unit based in The Bethlem
                     co-ordinated                               Royal Hospital, which offers detox
                                                                treatment over two to four weeks for
                     to ensure                                  men and women suffering primarily
                                                                form alcohol dependence.
                     continuity                                 The primary function of the unit is to
                     of care and                                provide medically supervised
                                                                prescribing, high level intensive
                     aftercare.                                 assessment, care and treatment
                                                                incorporating the principles of
                                                                relapse prevention and solution
                     The Acute Assessment Unit                  focussed therapy to those clients who
                     Inpatient services                         require medically assisted withdrawal
                                                                from alcohol. The unit aims to offer
                     A 14 bed rapid response unit for           an individual treatment approach
                     drug and alcohol misusers with             promoting abstinence enabling clients
                     chaotic and complex substance              to maintain change.
                     misuse patterns based in The
                     Maudsley Hospital. The primary             Group work is available that
                     function of the unit is to offer 10-14     addresses issues such as health
                     day inpatient detoxification and           education, self-awareness, relapse
                     stabilisation treatment, providing         prevention and stress management.
                     medically supervised prescribing, high-    There will be one to one sessions
                     level intensive assessment, care and       with an allocated key worker (twice
                     treatment with brief intervention          weekly) and an Occupational
                     therapy to those patients who require      Therapist on site arranges activities
                     stabilisation or detoxification from       such as art and pottery.
                     harmful substances.

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Residential rehabilitation

It is recognised that people with
alcohol misuse may require an
intensive programme of support and
care that cannot realistically be
delivered in a community or
outpatient setting. Access to
specialist inpatient and residential
rehabilitation is available via the
following route:

Following an assessment by a Care
Manager in the Bexley Drug and
Alcohol Team clients can be referred
to residential rehabilitation
placements at specialist facilities in
the statutory, independent and
voluntary sector.

Residential services for drug and
alcohol clients offer intensive and
structured programmes delivered in a
controlled, residential environment.

Residential services may take the
client from their local community to
anywhere in the country.

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     Young People’s Substance Misuse Services
                    Over-arching principal                       Tier 2 and services

                    All professionals working with young         Youth orientated services, offered by
                    people are involved within the               practitioners with some drug and
                    Health Advisory Service (2001) four-         alcohol experience and youth
                    tiered framework tiered model and all        specialist knowledge, should be
                    have a contribution to make.                 working at this level. The aim and
                                                                 purpose of this tier is to be
                                                                 concerned with reduction of risks
                                                                 and vulnerabilities, reintegration and
                    Tier 1 and services                          maintenance of young people in
                                                                 mainstream services.
                    The purpose of generic and primary
                    services within this structure is to         Counselling is provided through The
                    ensure universal access and continuity       Youth Engagement Service to
                    of care to all young people. In              young people from the groups
                    addition, it aims to identify and screen     recognised as vulnerable to develop
                    those with vulnerability to substance        problematic substance misuse i.e.
                    misuse and identify those with               excluded from school, looked after,
                    difficulties in relation to substances. It   children of drug users etc.
                    will be concerned with education
                    improvement, maintenance of health,          The specialist substance misuse
                    educational attainment and                   worker within the Youth
                    information concerning substances,           Offending Team works with
                    within a general health improvement          young offenders identified with
                    agenda. These should be seen as              substance misuse problems. All young
                    mainstream services for young                offenders are screened for substance
                    people.                                      misuse and referred onto the
                                                                 specialist worker to provide more
                    The Health Promotion                         intensive support.
                    Specialist for substance misuse
                    provides support for schools to              Bexley Moorings, a carers
                    deliver substance misuse education           organisation, offers a specialist to
                    and devise drug policies.                    work with young people affected by
                                                                 parental substance misuse and
                    Training is provided to professionals        provide support and access to other
                    working with young people to use the         services.
                    Substance Misuse Awareness
                    Raising Tool (SMART). This
                    assists professionals to identify early
                    signs of substance misuse during the
                    normal course of their work through
                    screening to ascertain whether
                    further support and services are

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Tier 3 and services                           An opiate prescribing service is
                                              provided by the adult community
Young people’s specialist drug                drug and alcohol service, Signpost
services and other specialised                to under 18s. This service will work
services, which work with complex             closely with the specialist in the Child
cases requiring multidisciplinary team-       & Adolescent Mental Health Trust to
based work, should be working at this         ensure the service is caters for the
level. The aim of Tier 3 services is to       young person.
deal with complex and often multiple
needs of the child or young person            Provision of specialised foster
and not just with the particular              placements with individually
substance problems. Tier 3 services           tailored training support for foster
also work towards reintegrating and           carers.
including the child in their family,
community, school or place of work.           Guidance is in place that introduces a
                                              staged process for accessing tier 4
A child psychologist within the Child         residential treatment for under 18s
and Adolescent Mental Health                  (see Appendix B).
Trust provides specialised cognitive
behaviour based therapy to young
people identified with a primary
substance misuse related problem.

Tier 4 and services

Tier 4 services provide very specialist
forms of intervention for young drug
misusers with complex care needs. It
is recognised that, for a very small
number of people, there is a need for
intensive interventions, which could
include short-term substitute
prescribing, detoxification and places
away from home. Such respite care
away from home might be offered in a
number of different ways, such as
residential units, enhanced fostering,
and supported hostels.

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     Appendix A – Bexley Alcohol Service Provision
                                           Tier 1 service
              Service User presents to any of the following and has an assessment or
                                         referral to Tier 2
                     Hospital                                          Voluntary
        General                                                                        Justice
                     (A&E,                 Mental                      Sector;
        Practice and                                                                   (Equinox
                     Urgent                Health        Self Referral (MIND,
        other health                                                                   and
                     Care                 Services                     Bexley
        setting                                                                        Custody
                     Centre)                                           Carers)

                                                                   Tier 2 service
                                        Open Access alcohol                 services and outreach
                    • Bexley and Greenwich Resource for                     • Alcoholics Anonymous (AA)
                      Alcohol (BAGRA)                                       • Hospital - QMS Gastroenterology clinic
                    • Welling Alcohol Service Provision
                      (WASP)                                                • Community Support Service:
                    • Drug & Alcohol (Care Management)                        housing related support
                      Team                                                  • Signpost

                Tier 3 service
                Individual need and problems identified
                Personal care package and plan

                •      BAGRA                                                                       Peer Support
                •      Signpost                                                                    Group (BAADA)

          Tier 4 service
          Detoxification and Rehabilitation

          •         Acute Assessment Unit, SlaM
          •         Other providers commissioned as needed

22                       C   a    r   e     P   a    t     h   w    a   y   s      G   u   i   d   e
                                  Tier 4
                          and co-ordinated
                          alcohol treaments

                                  Tier 3
                      specialised alcohol misuse
                    assessment, and care planned
                        and care co-ordinated
                          alcohol treatment

                                  Tier 2
     Alcohol-specific advise, information and support;
    brief interventions and assessment and referral of
    those with more serious alcohol-related problems
                for care-planned treatment

                                  Tier 1
Identification of hazardous, harmful and dependent drinkers;
   referal of those with alcohol dependence, information;
 simple brief interventions to reduce alcohol-related harm.

    C   a   r   e     P   a   t   h   w   a   y   s   G   u   i   d   e   23
     Appendix B
                                                               Tier 4 Services
                    Guidance in                                Traditionally tier 4 services have been
                    accessing tier 4                           viewed as residential treatment
                                                               focusing on rehabilitation. Residential
                    substance misuse                           treatment is expensive and outcomes
                                                               are often poor. Amongst the adult
                    services for young                         population it is estimated that
                                                               approximately 30% of clients leaving
                    people in Bexley                           rehab relapse within 12 weeks of
                                                               leaving rehab. While this data is not
                                                               currently available for young people,
                    Introduction                               anecdotally, it is clear that most young
                                                               people leave rehab early and do not
                    This guidance has been developed to        maintain changes they have
                    provide a structured process to            implemented whist in rehab.
                    support young people in Bexley who
                    may require specialist substance           The NTA is advising commissioners
                    misuse treatment. They have also           to consider accessing mainstream
                    been designed to support                   support for the delivery of Tier 4
                    professionals to understand the            services, by applying Tier 3 provisions
                    conceptual components of young             in a mainstream residential setting.
                    people’s substance misuse services         This may include placing a child in
                    and the full range of interventions        supported housing, foster care or
                    that can be offered at Tier 4.             using paediatric inpatient services to
                                                               stabilise a young person.
                    Numbers of young people in Bexley
                    requiring this type of treatment have
                    been low. However, for the small
                    number of young people in Bexley           Staged process for accessing
                    who may require this intensive,            tier 4 treatment in Bexley
                    specialist treatment it is important to
                    have a clear process for assessing         All young people who have been
                    their need and an understanding of         identified by services at tier 1 or 2
                    how Tier 4 services are provided in        (or by parents/carers) as requiring a
                    the borough.                               tier 4 intervention must be assessed
                                                               by the senior substance misuse
                                                               worker at CAMHS.

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This worker will then offer the                It is anticipated that a creative
young person a series of sessions to           package of care would be offered
determine the exact level of need and          in the first instance that would
may also use other resources in the            consist of:
community to support a package of
care e.g. diversionary activities from         • Specialist foster care
TYAP or the Youth Service, one to
one support from YES.                          • Intensive support in the community
                                               • Diversionary activities
The young person will then be
                                               • Support for parents/carers.
assessed by the staff grade
psychiatrist to further determine
the level of need and supply
pharmacological interventions if               This is a notional process, that is
appropriate.                                   open to review and aims to offer
                                               a framework that may be useful
If residential treatment is still being        to a range of professionals when
sought by the client, a Young People’s         considering the complex substance
Substance Misuse Panel will be                 misuse needs of a young person
convened. This will be composed                under 18 years of age.
of the following professionals:

• Senior substance misuse worker
• Staff grade psychiatrist
• Adolescent Team manager
• Team Manager of Substance
  Misuse Care Management Team
• Assistant Direct, Children and
  Young People’s Services
The panel will determine the exact
needs of the young person and
discuss funding arrangements if
residential rehab is considered the
only option for the young person.

                         C   a     r   e   P    a   t   h   w   a   y      s   G   u   i   d   e   25
     Appendix C

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                                                            Appendix D

C   a   r   e   P   a   t   h   w   a   y   s   G   u   i   d   e        27
     Appendix D

28          C   a   r   e   P   a   t   h   w   a   y   s   G   u   i   d   e
If you would like to know more about the services the Council provides,
or would like either a translation of this document or the information
in a different format, please call our Customer Contact Centre on
020 8303 7777 and press 0, quoting reference: 602869/12/08

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