Drug and Alcohol Treatment System Review.pdf

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					Nottingham Crime & Drugs Partnership



Treatment System Review
Drug, Alcohol and Criminal Justice




                                       2008


                         1
Contents

Executive Summary                                           4
Proposed model                                              5
Key recommendations                                         9

1.   Background                                             11
     1.1  Outcome                                           11
     1.2  Drivers                                           11
     1.3  Review process                                    13
     1.4  Equality and diversity                            14
     1.5  Governance                                        14
     1.6  National guidance                                 15
     1.7  Local guidelines / research                       17
     1.8  Consultation                                      18

2.    Drug treatment system                                 20
     2.1   Format of the report                             20
     2.2   The treatment journey                            21
     2.3   Four tiered treatment system                     23

3.   Access & engagement                                    24
     3.1  National guidance and research                    24
     3.2  Consultation findings                             27
     3.3  Access & engagement provision in Nottingham       28
     3.4  Good practice                                     30
     3.5  Weaknesses                                        33
     3.6  Effectiveness                                     37
     3.7  Care pathways                                     40
     3.8  Client group                                      40
     3.9  Recommendations                                   41

4.   Structured treatment                                   44
     4.1   National guidance and research                   44
     4.2   The local situation: structured drug treatment   46
     4.3   Consultation findings                            47
     4.4   Good practice / system strengths                 49
     4.5   Weaknesses                                       50
     4.6   Effectiveness                                    53
     4.7   Care pathways                                    54
     4.8   Client group                                     55
     4.9   Recommendations                                  57

5.   Aftercare / continuing care & wraparound               59
     5.1   National guidance and research                   59
     5.2   Consultation findings                            61
     5.3   Local aftercare and wraparound provision         61
     5.4   Good practice                                    63
     5.5   Weaknesses                                       65
     5.6   Effectiveness                                    66


                                     2
       5.7    Care pathways                                                  69
       5.8    Client group                                                   69
       5.9    Recommendations                                                71

6. Criminal justice treatment system                                         72
      6.1    National guidance and research                                  72
      6.2    Consultation findings                                           74
      6.3    Criminal justice drug treatment provision in Nottingham         75
      6.4    Good practice                                                   75
      6.5    Weaknesses                                                      77
      6.6    Effectiveness                                                   79
      6.7    Care pathways                                                   80
      6.8    Client group                                                    81
      6.9    Recommendations                                                 82

7. Families & carers                                                         84
     7.1    National guidance and research                                   84
     7.2    Local situation: carer provision                                 86
     7.3    Consultation findings                                            86
     7.4    Good practice / system strengths                                 87
     7.5    Weaknesses                                                       87
     7.6    Care pathways                                                    88
     7.7    Client group                                                     88
     7.8    Recommendations                                                  89

8. Equality & diversity practice and policy                                  90
      8.1    General                                                         90
      8.2    Corporate commitment                                            91
      8.3    Data collection and analysis                                    91
      8.4    Access to services                                              91
      8.5    Workforce and recruitment                                       92
      8.6    Recommendations                                                 92

9. Alcohol treatment system                                                   94
      9.1    Purpose of the review                                            94
      9.2    National guidance                                                94
      9.3    Interventions explained                                          95
      9.4    Effective interventions                                          97
      9.5    Key principles for commissioning local alcohol treatment systems 98
      9.6    Commissioning standards                                          99
      9.7    Learning from other areas                                        99
      9.8    Summary of consultation findings                                100
      9.9    Current provision                                               101
      9.10 Current system overview                                           101
      9.11 Effectiveness of current treatment system                         105
      9.12 Recommendations                                                   110

Annex A – Drug treatment services in Nottingham                            112
Annex B – Alcohol treatment services in Nottingham                         146
Annex C - Record of activity undertaken for the treatment system review    159


                                       3
1       Executive Summary

The 2008/09 Adult Drug Treatment Plan for Nottingham made a commitment to
review the city’s drug treatment system “to ensure compliance with national
guidance, relevance to local need and increased effectiveness”. Equally, the
Nottingham Alcohol Strategy 2008/11 included an objective to review alcohol
treatment provision in the city against national commissioning frameworks. This
document sets out the conclusions of these reviews and makes key
recommendations to improve Nottingham’s existing drug and alcohol treatment
systems. A new treatment model is proposed based on the findings of the review.

Annual needs assessments have identified ongoing problems of under-
representation of non-opiate users, Black and South Asian individuals, and under-
25s in the drug treatment system. Needs assessments have also highlighted gaps in
treatment options and a lack of integrated care pathways. Radical action is needed to
achieve stretching Local Area Agreement and drug effectiveness targets.

A number of reports and guidance documents have been produced by Department of
Health since 2004 to assist commissioners at a local level to develop and implement
programmes of alcohol interventions that will benefit hazardous, harmful and
dependent drinkers. The review will regain a strategic overview of alcohol services
and examine current treatment provision against the guidance to identify gaps in
local provision.

The proposed new treatment model aims to address these problems by:

    •   Streamlining routes into treatment
    •   Delivering interventions in line with clinical guidelines
    •   Providing treatment options relevant to local need
    •   Developing stronger, more efficient care coordination
    •   Maximising client choice
    •   Developing integrated care pathways to create clear and effective pathways
        of care
    •   Expanding alcohol interventions for hazardous and harmful drinkers

The review is informed by previous needs assessments and existing evidence,
extensive consultation with stakeholders and clinical experts, and a wide range of
best practice guidance and clinical guidelines.




                                         4
Proposed Model
The proposed model for the treatment system is as follows. The model is applicable to the criminal justice treatment system, the wider drug
treatment system and the alcohol treatment system.


                                                             Free-phone                                     Abstinent
  Consortium Outreach / Criminal Justice / Generic Service




                                                             Open Access                               Stable/Maintained

                                                                                                            No ‘on top’




                                                                    Brief Interventions                                                  Continuing Care

                                                                   Structured Treatment                                           Ongoing assessment

                                                              Assessment                                                          Care Plan

                                                              Care Plan                                                           Care Co-ordination

                                                              Care Co-ordination


                                                                                              Menu of interventions

                                                                       Prescribing        Psychosocial           Psychological         Inpatient

                                                                       Residential        Complex                Dual Diagnosis        Self help

                                                                       Non-PDU            Wraparound             Leisure               Mentoring

                                                                       Family therapy     Carers referral        Child referral        Etc
                                                                                                       5
Key points for the proposed treatment system model

•   A consortium commissioning approach to be considered for generic assertive
    outreach provision across the city with no drug or alcohol specific assertive
    outreach

•   Access to the treatment system to be streamlined through referral via generic
    outreach, generic services or the criminal justice system into open access, or
    by self referral to an open access centre base and/or free-phone number
    (available 24/7 and shared across drugs, criminal justice and alcohol)

•   Brief interventions to be available in line with NICE Guidance for those not
    ready or suitable for structured treatment

•   Seamless transition from brief interventions to the allocation of care co-
    ordinator, assessment and care plan in order to improve movement from
    access and engagement to structured treatment

•   Clients to have one assessment, one care plan and one care co-ordinator
    throughout the structured treatment stage of their treatment journey

•   Full range of treatment interventions to be available as ‘menu of options’ for all
    clients, co-ordinated by care co-ordinator

•   Continuing care to be available to those completing treatment and those stable
    on a treatment programme. Care co-ordination will be handed over at this stage
    in the treatment journey although clients will still be able to access the same
    ‘menu of options’




                                         6
While adopting the same general principles as the drug treatment
system model, the alcohol treatment model will follow the 4 tier
framework as set out in Models of Care for Alcohol Misusers:



                                                                 Free – phone

                                                                 Open Access



                                                                                     Identification and Brief Interventions

                                                                                    Primary care, health settings, Probation

                                                                                                  Hazardous
     Consortium outreach / Criminal Justice / Generic Services




                                                                                         Extended Brief Interventions

                                                                                                    Harmful




                                                                                    Community based structured treatment

                                                                                            Moderately Dependant




                                                                                            Inpatient & Residential

                                                                                             Severely Dependant




                                                                                7
Four-tiered framework for alcohol treatment

•    Targeted and opportunistic screening to identify hazardous and harmful
     drinkers to be provided in primary care settings, A&E departments and a range
     of generic services, including Probation. Structured brief advice to be offered to
     hazardous and harmful drinkers to encourage a reduction in alcohol intake

•    Extended brief interventions to be offered to those requiring further support and
     advice

•    Specialised, care-planned structured treatment to be made available to
     dependent drinkers in a community setting

•    Inpatient care and residential rehabilitation to be available for severely
     dependent drinkers

•    A stepped care approach to alcohol treatment to be adopted in line with
     Models of Care guidance, where the least intensive form of treatment is offered
     to service users initially, progressing to more intensive forms if these are
     unsuccessful




                                          8
Key Recommendations
Based on the findings of the review the following recommendations are made in
relation both the drug and alcohol treatment systems:


1. Access to treatment should be streamlined with clear access points.

2. Opening times should be extended in order to be responsive to client need with
   some level of 24/7 provision in order to respond in times of crisis.

3. To utilise existing ‘generic’ assertive outreach provision within Nottingham City to
   identify, engage and refer problem drug and alcohol users into the treatment
   system.

4. There should be improved pathways into structured treatment, including further
   consideration of the benefits of having a single provider or co-located services for
   both open access centre base, care co-ordination function and some structured
   treatment interventions.

5. There should be a single care co-ordination function to act as an anchor for
   clients as they move through the drug and alcohol treatment systems.

6. All treatment options for clients should be made available, including abstinence.

7. Various self-help groups (including abstinence self-help groups) should be
   available.

8. Structured continuing care provision should be explicitly commissioned at the
   appropriate stage in the client journey and be accessible to those who are stable
   on a script or have achieved a controlled drinking goal.

9. Services that are culturally competent to meet the needs of the local problem
   drug using population.


The following recommendations are made with specific reference to the drug
treatment system:


10. Brief interventions should continue to be provided at the access and engagement
    stage of the treatment journey, but are to be aligned with the NICE Guidance
    definition of brief interventions. Activity above the definition of brief interventions
    to be counted as ‘structured treatment’. (The recommended role of brief
    interventions in alcohol treatment has been outlined below)

11. There should be rapid access to treatment for all drug users in line with
    accessibility through the criminal justice route

12. Gaps within structured treatment including psychosocial interventions (the
    mainstay of treatment for non-opiate users), psychological interventions (for
    addressing underlying issues), continuing care and wraparound / activities
    provision should be addressed.



                                            9
The following recommendations are made with specific reference to the
alcohol treatment system:

13. Ensure formal, effective care pathways between supported accommodation
    services and treatment services

14. All gaps in treatment provision should be addressed.

In particular:

15. Targeted alcohol screening and the provision of brief and extended brief
    interventions for hazardous and harmful drinkers should be rolled out as a priority
    across primary care settings, A&E departments and a wide range of generic
    services

16. Expansion of structured alcohol treatment within community settings to meet
    demand

17. Investigate whether alcohol treatment should be incorporated into the Drug
    Intervention Programme

18. Commissioning arrangements to be considered as part of the implementation
    stage of the review, in line with the World Class Commissioning model

19. Clear alcohol treatment pathways to be established to ensure equitable and
    consistent systems of access to treatment for service users

20. Implementation of the stepped care model

21. A clear and unique remit should be established for each service and built into
    service level agreements to avoid confusion and guide service users and service
    providers through care pathways

22. Widespread advertising of alcohol services in community settings and awareness
    raising amongst staff and service managers

23. Standardised processes for screening, assessment and care planning should be
    created to facilitate referral between services and ensure high standards in line
    with national guidelines

24. Diversity data to be collected from all services across the six diversity categories
    to identify under-served groups




                                          10
1.      Background


As set out in the 2008/9 Adult Drug Treatment Plan for Nottingham, the purpose of
this review of the drug treatment system is “to ensure compliance with national
guidance, relevance to local need and increased effectiveness”. The review of
alcohol treatment provision to ensure compliance with national commissioning
frameworks is set out as a key objective in the Nottingham Alcohol Strategy.

The review aims to provide information about the general performance of the existing
drug and alcohol treatment systems, their relevance to local need, fit with current
strategic developments, in order to inform recommendations for improvements. A
range of local data and analysis has been utilised alongside national guidance and
policy, and the results of previous and current consultation with service users, carers
and a range of other stakeholders.

1.1 Outcome

The review has generated a new model for the drug and alcohol treatment
system that is compliant with national guidance, relevant to local need and that
should be in a better position to deliver against the 3 year effectiveness targets
for the partnership.

1.2 Drivers

Ongoing analysis of local need and the effectiveness and performance of the drug
treatment system highlighted problems with the model for the local system, impacting
on our ability to meet the needs of local problem drug user populations.

Several key drivers for the review were identified prior to its inclusion as a key
objective in the Adult Drug Treatment Plan and the Nottingham Alcohol Strategy:

1    Address underperformance against Local Area Agreement (LAA) targets
     and meet drug treatment effectiveness targets for 2008/9 and beyond

The LAA includes stretching and ambitious targets for improving the effectiveness of
drug treatment over the next 3 years.

In order to deliver the proposed 3 year targets in increased effectiveness (08/09 6%,
09/10 9%, 10/11 12% on the baseline year) the treatment system must deliver the
following steps:
      •     Increase treatment penetration into PDU population of heroin and/or crack
            users – this will require improving pathways to treatment and ensuring full
            range of treatment interventions as required to meet local need are
            available
      •     Increase effectiveness (improving retention and successful completion
            performance) – this will require improvements in treatment quality
            alongside better integrated treatment delivery and reduction in duplication.

The Nottingham Crime and Drugs Partnership Board have risk assessed LAA targets
relevant to the CDP and have identified that delivery of the treatment effectiveness
target is a high risk to the partnership.




                                          11
2   Ensure the treatment system is appropriate to meet local need

Annual drug treatment needs assessments highlight important issues indicating
problems within the current drug treatment system that require attention from a
system wide commissioning perspective.

In particular needs assessments over the past 3 years have highlighted that certain
groups of problem drug users are underrepresented in treatment, in particular non-
opiate users, users of Black and Minority Ethnic background and those aged under
25. Annual needs assessments and consultation conducted as part of needs
assessments indicate gaps in the treatment system and a lack of integrated
pathways relevant to these underserved groups.

3   Ensure compliance with a new suite of drug & alcohol clinical guidelines

New clinical guidelines for drug treatment were launched in 2007. Models of Care for
Alcohol Misusers was produced by the Department of Health in 2006, consolidating
research into best practice in delivering local alcohol treatment systems. All
partnership areas should ensure that commissioned systems and service delivery are
aligned with the full range of guidelines. A summary of relevant national guidance
and references of where to obtain the full documents from is included in section 1.6.

4   Maximise cost effectiveness

The Pooled Treatment Budget will not see significant increases over the next three
years and previous budget streams from Neighbourhood Renewal Fund and Local
Public Service Agreement will now need to be picked up. The treatment system
review will enable a review of cost effectiveness of the current treatment system.

5   Alcohol treatment system

The purpose and remit of the review of alcohol treatment services in the city differ
slightly from those of the review of drug treatment services. There is a lack of clarity
and clear understanding about the city’s alcohol treatment system that does not exist
in comparison to the drug treatment system. There is no current and complete map
of alcohol services in the city and misunderstandings and confusion about the range
of treatment options and services available are common. The purpose of the alcohol
treatment system review is to regain a strategic overview of alcohol services in
Nottingham City and consider the existing structure against national guidance and
local need, and with regard to stakeholder feedback.




                                          12
                        Summary of drivers for the review

 •   To address underperformance against LAA target and meet effectiveness
     targets for 2008/9 and beyond
 •   To ensure compliance with new suite of drug & alcohol clinical guidelines
 •   To address gaps in the drug and alcohol treatment system and ensure
     appropriate services are available in line with Models of Care [NTA] and
     Models of Care for Alcohol Misusers
 •   To ensure the drug treatment system is well placed to deliver relevant
     objectives within the 10-Year Drug Strategy [Home Office]
 •   To ensure cost effectiveness of the drug treatment system
 •   To ensure the treatment system is easy to navigate
 •   To address ongoing issues identified in annual needs assessments over a 3
     year period
 •   To reduce duplication between services
 •   To regain a strategic overview of alcohol treatment provision




1.3 Review process

The review has been led by Nottingham Crime & Drugs Partnership (CDP) on behalf
of the Board with full involvement and support from Nottingham City PCT.

The review process has been broken down into a three-phase development
programme as follows:

Stage 1:      Establishing the framework
              Review of the current treatment system and development of the
              function and general principles for a new treatment system model

Stage 2:      Planning
              Developing the form of the new model including full risk assessment

Stage 3:      Implementation
              Implementation of the revised model

Stage 1 of the review process began in June 2008 and is now complete. Stage 1
focused on three key objectives in order to establish a framework for the new model:

1. Reviewing the current treatment system

A range of existing information sources was considered in reviewing the current
system including but not limited to service level agreements, contract monitoring
information, performance management information, service review minutes and file
audits.

New information was also obtained via consultation, bespoke information requests,
file audits and reviews, interviews and shadowing opportunities.




                                        13
2. Ongoing consultation with a wide range of stakeholders and experts

A wide range of existing consultation has been collated and included in the review
including records of service user and carer forum meetings, speak-out events and
expert panels conducted as part of the annual needs assessment process.

There has also been considerable consultation taken specifically for the review
including two stakeholder events (which focused on visioning for the new treatment
system) and questionnaire consultation with a wide range of stakeholders including
services users, carers, service managers, workers, other stakeholders and the wider
community.

3. Development of functions and general principles for the new model

The development of the function and general principles for the new treatment system
model was undertaken by the CDP commissioning team and PCT commissioning
team with reference to:

         •     National clinical guidelines
         •     Findings of the review of the current system
         •     Stakeholder/consultation feedback
         •     Local needs assessment
         •     Models of care (alcohol and drugs)

Annex C provides further detail on the consultation and audits that have been
undertaken in stage 1 of the review.

Section 1.7 contains further detail on the consultation process and headline findings.

1.4 Equality and diversity

Equality and diversity has been considered in detail in stage 1 of the review, and the
CDP Equality and Diversity Manager has been fully involved in the review process.
Section 8 of the report contains a detailed review of equality and diversity policy and
practice within the current drug treatment system. A full Equality Impact Assessment
will be undertaken on the proposed model during stage 2.

1.5 Governance

Appropriate governance mechanisms for the treatment system review have been
embedded throughout the process with the JCG fulfilling the function of Treatment
Review Board. The regional National Treatment Agency has been involved in the
treatment system review by providing governance and guidance on the process.

The Treatment Review Board took responsibility for:
          • Monitoring the progress of the review against the project plan
          • Informing and guiding the review process from a partnership
             perspective
          • Representing the views of partner agencies
          • Reporting into the CDP Board
          • Making recommendations for the proposed treatment model
          • Communicating on the review to partners and stakeholders
          • Making financial decisions (within the scope of decision making
             responsibilities of the JCG) on the proposed treatment model


                                          14
1.6 National Guidance

A summary of the key national and local guidance considered in the review is
included in this section. More detailed references are made throughout the main
body of the report as relevant.

Models of care for the treatment of adult drug misusers (2006)

Models of Care is the national framework for the commissioning of adult drug
treatment for drug misuse in England. Models of Care sets out the treatment
interventions and pathways that all partnership areas are expected to have available
to meet the diverse needs of the local population. As such, Models of Care is a
crucial piece of national guidance that must be considered when evaluating current
structured treatment provision in the City.

The Models of Care Update 2006 document can be found in full at:
http://www.nta.nhs.uk/publications/documents/nta_modelsofcare_update_2006_moc
3.pdf

Drug misuse and Dependence: UK guidelines on clinical management

The Department of Health issued “Drug Misuse and Dependence: UK Guidelines” on
Clinical Management in 2007 (hereafter referred to as “2007 Clinical Guidelines”) to
replace the ‘1999 Clinical Guidelines’ addition. The most recent edition provides
guidance on the treatment of drug misuse in the UK and is intended for all clinicians
providing drug treatment to individuals (including non-medical clinicians).

The full guidelines can be found online at:
http://www.nta.nhs.uk/publications/documents/clinical_guidelines_2007.pdf

NICE Suite of Clinical Guidelines

The National Institute for Health and Clinical Guidance launched a new suite of
guidelines for drug treatment in 2007 which must be worked to in all partnership
areas. They provide a range of detailed guidance relevant to prescribing
interventions including detoxification, and also useful guidance on psychosocial
interventions.

The NICE guidelines and clinical guidelines are purposefully linked and cross
reference one another.

The full suite of guidelines can be accessed online at:
http://guidance.nice.org.uk

National Drug Strategy

The Home Office launched the new 10 year national drug strategy, ‘Drugs: Protecting
Families and Communities’ this year. The strategy aims to restrict the supply of illegal
drugs as well as reducing demand.

The four strands of the strategy are:




                                          15
           •   Protecting communities through tackling drug supply, drug-related
               crime and anti-social behaviour
           •   Preventing harm to children, young people and families affected by
               drug misuse
           •   Delivering new approaches to drug treatment and social re-integration
           •   Public information campaigns, communications and community
               engagement

The strategy advocates a new approach to treatment with the ultimate goal of
treatment for all clients to ‘achieve abstinence from their drug - or drugs - of
dependency’. The strategy emphasises that this should be achieved by better end-to-
end management through the system and by developing more personalised
approaches to treatment.

The strategy also has a renewed focus on helping drug users successfully integrate
with the community through providing effective continuing care and better support for
those leaving or planning to leave treatment with packages of support to access
housing, education, training and employment.

The full strategy can be accessed online at:
http://drugs.homeoffice.gov.uk/publication-search/drug-strategy/drug-strategy-2008

Scottish Drug Strategy: The Road to Recovery

The Scottish Drug Strategy is a useful document for consideration in drug treatment
commissioning and delivery with a focus on the concept of recovery.

The full strategy can be accessed online at:
http://www.scotland.gov.uk/Publications/2008/05/22161610/0

Models of Care for Alcohol Misusers

Models of Care for Alcohol Misusers (MoCAM) provides a best practice model for the
commissioning of alcohol services based on the commissioning model established
for drug treatment services in Models of Care for Drug Misusers. MoCAM describes
best practice interventions and treatment for four main categories of alcohol
misusers: hazardous drinkers, harmful drinkers, and moderately and severely
dependent drinkers. MoCAM establishes a quality framework and minimum
standards for the management and provision of local alcohol services.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd
Guidance/DH_4136806

Review of the effectiveness of treatment for alcohol problems

The Review of the effectiveness of treatment for alcohol problems provides guidance
on delivering effective interventions at a local level. This document summarises a
wealth of international and national research into effective alcohol treatment
modalities and determines which interventions are likely to deliver the best outcomes
for people with alcohol disorders.

http://www.nta.nhs.uk/publications/documents/nta_review_of_the_effectiveness_of_tr
eatment_for_alcohol_problems_fullreport_2006_alcohol2.pdf




                                         16
Alcohol misuse interventions: guidance on developing a local programme of
improvement (Department of Health, 2005)

This document provides guidance on developing and implementing programmes of
interventions for hazardous and harmful drinkers, including alcohol screening and
brief interventions.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd
Guidance/DH_4123297


1.7 Local guidelines/research


Adult Drug Treatment Plan for 2008/9

The Adult Drug Treatment Plan is the commissioning action plan for the adult drug
treatment system which each partnership area is required to complete annually by
the National Treatment Agency (NTA).

Nottingham City’s Treatment Plan for 2008/9 has a clear focus on the aims and
objectives for the Treatment System Review and has been used to guide the review
process.

Adult Drug Treatment Needs Assessment 2007/8

Local needs assessments are undertaken on an annual basis as part of the
treatment planning cycle. They provide an insight into the types of people who use
drugs and alcohol problematically in Nottingham and what types of drug and alcohol
use they engage in. The information available from needs assessments is vital in
identifying how well the treatment system is equipped to meet local need and has
been a key consideration in the review of current provision.

The full needs assessment is accessible online at:
http://www.nottinghamcdp.co.uk/index.asp?pageid=pageid223.xml

Nottingham Alcohol Strategy

The Nottingham Alcohol Strategy 2008/11 outlines the next steps in the local
response to alcohol-related harm. The strategy identified a need to review the city’s
alcohol treatment system against Models of care for alcohol misusers to ensure
effective treatment for alcohol disorders.

Nottingham Harm Reduction Strategy

The Nottingham Harm Reduction Strategy 2008/11 outlines the strategic objectives
related to reducing drug related harm for drug users, their families and the wider
community. The strategy is supported by several action plans.

Strategic Review of Supporting People funded Drug and Alcohol Related
Accommodation in Nottingham

This review has been completed to inform the Options Appraisals process being
undertaken by Supporting People with the aim to provide information on the



                                         17
performance of existing accommodation and support projects and their strategic
relevance.

Nottingham Standard Assessment Framework

Nottingham City Standard Assessment Framework is a common assessment and
care planning framework for use across all drug treatment services launched in
January 2007. The supporting guidance document provides information on referral
pathways, interventions, need, hidden harm, equality and diversity and harm
reduction among other things.

Crack Down: Tackling Drugs and Community Harm in Nottingham

A local report making recommendations for the improvement of prevention, treatment
and after care services in Nottingham. The report was developed following a local
conference delivered by The African-Caribbean and Asian Forum, Nottingham CDP
and Local Implementation Groups.

The report makes 5 key recommendations:
     Increasing opportunities for peer support
     Using community involvement and empowerment methodologies
     Raising the aspirations of young people
     Reducing stigma around drug treatment
     Person centred care delivered by joined up services: holistic treatment for the
       individual including a whole family approach to support

St Anns Week in Action Report

An evaluation report following work undertaken as part of a Week of Action in St
Anns prepared by the African Caribbean & Asian Forum and Community. The report
makes some recommendations relevant to drug treatment focused on:
    Cultural competence of drug related services
    Peer driven/peer led services
    After care and support

1.7 Consultation

As stated above, extensive consultation has been undertaken as an integral part of
the treatment system review. As well as reviewing an exhaustive list of pre-existing
consultation information and undertaking to consult with services and partners on an
individual basis, two additional stakeholder consultation exercises were undertaken:

Questionnaires

Questionnaires were distributed amongst various stakeholders in order to gain
feedback on the current drug and alcohol treatment systems and gather ideas for the
new model.

The stakeholder groups consulted via questionnaires included: drug and alcohol
service managers, the drug and alcohol treatment workforce, service users, carers,
wider partner agencies, and the local community. Questionnaires were distributed as
widely as possible through existing networks and then cascaded even further through
the local press and the CDP website. There was a significant response with over 200




                                         18
questionnaires returned relevant to the drug treatment element, and over 160
relevant to the alcohol treatment element.

Stakeholder events

Two stakeholder consultation events were held. The first event was held in June and
was attended by around 50 delegates from across the field including service users,
carers, the CDP Independent Advisory Group, the community, the drug and alcohol
treatment workforce, service managers and wider partners. The first event focused
on visioning ideal drug and alcohol treatment systems based on local need, national
best practice and national guidance.
Delegates invited to the first event were invited to the second in September where
the findings, recommendations and proposed new model were presented and then
debated. Delegates had a window of a week to provide any additional feedback and
comments to inform the final proposal.

Copies of blank questionnaires or outcomes from the stakeholder events can be
made available on request to the CDP.

Clinical consultation has been available through Dr Stephen Willott, Clinical Lead for
the CDP, and Dr. Phil McLean and Dr David Rhinds, Consultants with
Nottinghamshire Healthcare Trust, have also been consulted.




                                         19
2.       Drug Treatment System
As stated in the introduction to this report, the objective of the review of the drug
treatment system is to ensure that the treatment system model is able to deliver
effective and evidence based drug treatment that will meet the needs of our local
drug using population. In order to establish this and make recommendations for any
changes, a detailed review of the current drug treatment system has been
undertaken in stage 1 of the treatment system review.

The following chapters provide a comprehensive summary of the findings and
recommendations of stage 1 of the review in relation to the drug treatment system.
These findings and recommendations are based on the review of current treatment
provision in the city and consultation feedback against a backdrop of national
guidance (in particular Models of Care, National Clinical Guidelines, and the NICE
suite of guidance) and local need.

In order to be service user focused, the review of the drug treatment system has
been undertaken within the context of the client journey through the treatment system
(see 2.2 below).

2.1 Format of the report

Sections 3 - 5 contain analysis of national guidance, consultation findings, review
findings and recommendations for the various elements of the treatment system in
line with the treatment journey:

     •   Access and engagement
     •   Structured treatment
     •   Aftercare and continuing care (combining the community integration and
         treatment completion stages of the treatment journey – see below)

There is a separate section for the criminal justice treatment system (section 6) in
order to capture the different delivery mechanisms and experience for clients whose
treatment journey is directed through the criminal justice route.

Sections 7 and 8 look at cross cutting issues:

     •   Families and carers
     •   Equality and diversity policy and practice

Section 9 contains analysis of alcohol treatment provision in Nottingham.

It is equally important to acknowledge what has not been considered in the review of
the current drug treatment system:

     •   Tier 4 in-patient and residential rehab provision has not been included as this
         agenda is being considered as part of a regional commissioning framework.
         Further work to understand the level of need for such provision in Nottingham
         will be undertaken as part of the treatment system review.

     •   The hidden harm and needs of the children of adult drug misusers is not
         considered in this review as it does not directly impact on the treatment
         system model. However, information on hidden harm has been obtained


                                            20
       through the data collection for the review and will be utilised in the detailed
       analysis to be undertaken as part of the annual adult drug treatment needs
       assessment.

   •   Attempts were made to look at the cost effectiveness of the current treatment
       system as part of the review but conclusions were not always useful. It will be
       more appropriate to consider the cost effectiveness of the proposed model in
       stage 2 of the review.

   •   The transition from young peoples to adult’s services was noted as an issue
       that should be explored by the review. Information was obtained on the
       uptake of adult treatment services by those under the age of 25 and is
       included in the main analysis. Further work on transitional issues is being
       undertaken as part of the adult drug treatment needs assessment.


2.2 The Treatment Journey

In Models of Care the National Treatment Agency provides a conceptual framework
for the treatment journey in order to consider the treatment system in terms of the
client experience and journey.

Models of Care breaks the treatment journey up into 4 overlapping components:

   •   Treatment engagement
   •   Treatment delivery
   •   Community integration
   •   Treatment completion




                                                Continuing Care




                                    Treatment
           Engagement                Delivery               Completion




                                                  Continuing Care




Models of Care acknowledges that while some people might progress through the
treatment system in a linear way, there are many that are likely to access these main




                                         21
elements of the treatment journey in a variety of combinations through their time in
treatment.

The NTA treatment journey highlights key elements that should be available and
delivered to clients at each stage of the treatment system and have provided a useful
commissioning framework that has been used in this review of current provision:

Engagement:

   •   The treatment system needs to have clear routes of access and engagement,
       and must be able to get people into treatment rapidly.
   •   At the engagement phase people need to be assessed and directed into the
       appropriate treatment interventions.
   •   People may need support at this stage to encourage and support them in
       accessing treatment.
   •   Some interventions that might be available at this stage include: brief
       psychosocial interventions, needle exchange, outreach, advice & information,
       and CJIT.

Delivery:

   •   The treatment delivery stage refers to structured treatment. It is this element
       of the treatment journey that counts towards our partnership targets for drug
       treatment.
   •   Effective treatment delivery should help the client make improvements in
       reducing their substance use, improving health & social functioning, and
       reducing offending.
   •   Some interventions that might be available at this stage include among
       others: prescribing, structured day programmes, structured psychosocial
       interventions, and inpatient detox.
   •   Treatment should focus on the ultimate goal of abstinence from drugs and
       where appropriate abstinence from alcohol but can include maintenance.


Integration:

   •   Whether clients are still in treatment or exiting treatment they should have
       access to social support to maximise on the positive gains of treatment. This
       might include things like access to housing support, educational support and
       employment opportunities, and diversionary activities.
   •   Whether this is provided by drug treatment services as part of key working, a
       separate service within the drug treatment service, or, by external agencies
       this support should be easy to access for all clients.

Completion:

   •   The treatment journey should work towards successful completion of
       treatment with clear pathways and exits from the treatment system.

   •   The ultimate goal of treatment for all drug users and problem/dependent
       alcohol users should be for drug-free abstinence. Where this is not possible
       treatment should facilitate them in stable and less harmful drug or alcohol
       use.



                                         22
   •     Interventions provided to support completion of treatment might include
         aftercare, continuing care, pathways to non-specialist support, and pathways
         to self help.


2.3 Four Tiered Treatment System

Models of Care also sets out a four tiered commissioning framework for drug
treatment. While we recognise the importance of the tiers in terms of commissioning,
we have attempted to the put the client at the centre of this review and so have
largely ignored the tiers in favour of the treatment journey model above.

However, there are times where it is necessary or particularly helpful to refer to the
tiers of treatment and so a very brief summary is included below. For further detail
please refer to the full Models of Care document.

Tier 1          Generic non-drug specific services and groups who are not a
                commissioned part of the treatment system but may have contact with
                substance users. For example GPs, community and voluntary sector
                groups, housing, ‘generic’ community outreach. Tier 1 interventions
                include provision of drug-related information and advice, screening
                and referral to specialised drug treatment.

Tier 2          Typically low threshold unstructured services provided from within the
                drug treatment system at the stage of access and engagement,
                aftercare and for children effected by adults drug misuse. Tier 2
                interventions include provision of drug-related information and advice,
                triage assessment, referral to structured drug treatment, brief
                psychosocial interventions, harm reduction interventions (including
                needle exchange) and aftercare.

Tier 3          Structured treatment provision provided from within the drug treatment
                system. Tier 3 interventions include provision of community-based
                specialised drug assessment and co-ordinated careplanned treatment
                and drug specialist liaison. Structured treatment is the part of the
                treatment journey that counts toward partnership targets. Structured
                treatment us available locally in both treatment and aftercare stages of
                the treatment journey.

Tier 4          Tier 4 interventions include provision of residential specialised drug
                treatment, which is care planned and care coordinated to ensure
                continuity of care and aftercare. Typically inpatient detox or residential
                rehab these interventions are also considered to be structured
                treatment.




                                           23
3       Access & engagement
This section looks at the access and engagement phase of the treatment journey. It
first summarises relevant national guidance and research, local delivery, and
consultation findings, and goes on to identify the particular strengths, weaknesses
and effectiveness of access and engagement provision locally.

This section also considers harm reduction provision as the specialist harm reduction
service in Nottingham is located within the access and engagement stage of the
journey.

While a significant point of access to treatment is delivered through the Criminal
Justice Intervention Team (CJIT) this is not considered in this section but is covered
in detail in section 6.

3.1 National guidance / research

The following is a summary of national guidance in relation to access and
engagement within the drug treatment system.

Models of Care

Access and engagement provision makes up the first stage of the treatment journey.
The NTA sets out the aims and objectives of the engagement stage of the treatment
journey which are to:

    •   Engage people rapidly into the treatment system
    •   Retain them in treatment once they have entered
    •   Asses clients to ensure treatment can be tailored to their needs
    •   Provide motivational work focused on maximising engagement with treatment

The NTA states that a range of interventions to support engagement should be
commissioned at a local level, including brief interventions, services for the children
of drug users, advocacy and support arrangements, engagement and follow up
provision.

Access and engagement provision typically fits within Tier 2 of the NTA’s tiered drug
treatment system, with such interventions often being relatively unstructured, low
threshold and flexible when compared to Tiers 3 and 4 of structured drug treatment.

The NTA specifies what Tier 2 access and engagement interventions should be
commissioned in each partnership area:

    •   Triage assessment & referral to structured drug treatment
    •   Interventions to motivate and engage drug misusers into the treatment
        system
    •   Brief psychosocial interventions (including brief interventions for specific
        target groups for example high-risk and other priority groups)
    •   Liaison and support for generic providers who may have contact with
        substance misusers
    •   Outreach services to engage clients into treatment and re-engage people who
        have dropped out of treatment




                                          24
Harm reduction interventions (including overdose prevention, needle exchange,
blood borne virus vaccination and harm reduction advice and information) are also
typically defined as Tier 2 interventions. Harm reduction interventions should be
available throughout the treatment journey including at the access and engagement
phase. Harm reduction interventions are explicitly covered in this section as specialist
needle exchange services are commissioned as part of access and engagement
provision locally.

Drug misuse and dependence UK guidelines on clinical management

The new UK Guidelines on Clinical Management provide further detail on brief and
structured psychosocial interventions considered within Models of Care. We would
expect to see those brief psychosocial interventions defined in the guidelines at the
point of access and engagement:

   •   Drug-related advice and information
       ‘Keyworkers provide patients with appropriate advice & information
       about their drug misuse, its consequences and the treatments available.
       This will assist patients in making informed choices about what their
       treatment goals should be and which type of treatment and support is
       likely to help them.’

   •   Advice and support for social problems
       ‘Keyworkers may provide practical support or referral for patients with
       social problems. These may include housing, childcare and child
       protection, employment and education.’

   •   Harm reduction
       ‘Specific advice and techniques for reducing the harm from drug misuse
       should be provided, such as advice on safer injecting techniques and
       minimising risk of overdose.’

   •   Motivational interviewing and other motivational enhancement
       techniques
       ‘These include a collection of therapeutic principles, a set of counselling
       techniques, and more generally, a style of interaction in which the
       therapist takes the position of a collaborative partner in discussions with
       the patient about their drug use. […] Motivational enhancement may be
       used to improve patient engagement in, and adherence to, treatment.’

   •   Complementary and alternative therapies
       ‘These may aid the building of therapeutic alliances and enable patients
       to learn relaxation techniques. […] Complementary and alternative
       therapies should […] be seen as an adjunct to drug treatment but are
       not a mainstay of treatment itself.’

NICE Clinical Guidelines

The UK Clinical Guidelines are closely linked to and reference the new suite of NICE
guidelines published in 2007.

We would expect to see access and engagement services providing a range of the
above psychosocial interventions as brief interventions. As stated within the NICE
Drug Misuse: Psychosocial Interventions guidance; such interventions should be



                                          25
used opportunistically in a variety of setting for people not in contact with drug
services and for people in limited contact with drug services.

The NICE guidelines provide a detailed explanation of what constitutes a brief
intervention stating that these interventions should:

   •   Normally consist of two sessions each lasting 10-45 minutes
   •   Explore ambivalence about drug use and possible treatment, with the aim of
       increasing motivation to change behaviour, and provide non-judgemental
       feedback.

Referencing the NICE guidance, the UK Clinical Guidelines acknowledge that for
people not in contact or in limited contact with drug treatment brief interventions are
likely to produce real benefits.

Safer Nightlife

The Safer Nightlife guidelines updated this year contain guidance on how
partnerships should engage and provide harm reduction advice and information to
‘clubbers’.

They recommend that two functions should be provided through local treatment
system: engaging promoters and staff and providing outreach to clubbers, stating:

‘There is an important role for drug and alcohol treatment agencies to engage with
club promoters and staff to address the following key issues:

   •   To provide owners and promoters with information on trends in local drug use
       and associated harms
   •   To ensure that owners and promoters have access to relevant, up-to-date
       and user-friendly drug education literature which can be made available to
       clubbers
   •   To provide advice and training to staff on how to recognise and respond to
       drug-related intoxication
   •   To advertise services provided by their agency’

Local partnerships ‘should consider commissioning local drug and alcohol agencies
to provide education or outreach services to clubs in their area. In making this
assessment they should consider to what degree these services achieve the
following objectives:

   •   Better management of incidents
   •   Greater confidence of pubs and clubs in managing drug use
   •   Behavioural changes by clubbers in relation to drug and alcohol use
   •   Take up of services by clubbers
   •   A reduction in incidents of drug related harm in pubs and clubs and in relation
       to road safety after clubbing
   •   Enable clubbers to better assess the risks to them from drug and alcohol use.’

The Safer Nightlife Guidelines are accessible online from:
http://drugs.homeoffice.gov.uk/news-events/latest-news/safernightlife




                                          26
National Drug Strategy

The updated National Drug Strategy (2008) notes that the previous 1998 strategy
was focused on helping as many drug users as possible to access treatment. The
2008 National Drug Strategy specifies that the drug treatment system now needs to
improve access for under-represented groups and those with complex needs by:

     ‘Addressing unmet treatment needs and barriers to treatment, which may
     include the needs of young people, women, crack or poly-drug users,
     particular black and ethnic or other minority communities, sex workers or
     parents with dependent children.’

The new strategy retains a focus on the need to provide harm reduction services
and state that drug treatment systems should:

     ‘Continue to promote harm minimisation measures including needle
     exchange and drug-assisted treatments that encourage drug users to enter
     treatment, in order to reduce the risk of overdose for drug users and the risk
     of infection for the wider community.’

The strategy also recognises the importance of psychosocial interventions including
the brief interventions applicable to access and engagement provision, stating that:

     ‘A recent review of psychosocial interventions for those with problems
     related to a number of drugs has found positive evidence for the impact of
     brief interventions including self-help, contingency management and
     behavioural couple’s therapy for drug-specific problems.’

Scottish Drug Strategy: The Road to Recovery

The Scottish Drug Strategy (2008) emphasises that crisis services that offer
‘improved and timely access with increased out of hours availability’ should be
available within the drug treatment system. Such provision could be a key function of
access and engagement services and would improve accessibility for people
presenting in times of crisis.

As with other guidance referenced above the Scottish Drug Strategy also recognises
the importance of psychological and psychosocial interventions and makes clear that
clients need access to such psychological care at all levels.


3.2 Consultation Findings

Through the consultation mechanisms discussed in section 1 several key issues
relevant to the access and engagement stage of the treatment journey were
identified.

The most commonly identified issues were as follows:

1. Although many people felt that it was fairly easy to find out about services for
drug users, consultation indicated that more widespread advertising and promotion of
services is required to enable service users to clearly identify the range of services
and treatment options available in the City are required, empowering service users.




                                         27
2. There is widespread duplication across outreach provision (both drug specific and
‘generic’ outreach). Outreach provision should be very low threshold and deal with
immediate needs and referral to the treatment system only.

3. It is not always easy to know where to go in the treatment system and the
treatment system should be easier to access for the first time. Access to the drug
treatment system should be streamlined possibly with a single access point into the
treatment system.

4. Opening hours are not appropriate in order to respond to clients presenting need
and so should be expanded. There was a common view that there should be some
24/7 provision to respond to users in times of crisis.

5. At the point of access and engagement, service users require flexible support to
address their immediate needs and establish an empathic relationship with a worker.

6. With regard to referral to structured treatment it is essential that services are
quick and easy to access, waiting times to structured treatment should be as short as
possible and there should be ‘rapid access’ for all.

7. All services need to be culturally competent and consultation confirms that this is
a priority that should be built into the City’s treatment model.

Consultation findings are considered throughout the following analysis of current
provision.


3.3 Access and Engagement Provision in Nottingham

Locally the access and engagement stage of the treatment system is provided by
seven services:

   The Health Shop
    A PCT provided service, The Health Shop provide a comprehensive specialist
    needle exchange in line with band a of the Nottingham City Needle Exchange
    Strategy (see the Nottingham Harm Reduction Strategy). The Health Shop
    provide a wide range of specialist harm reduction services for problem drug
    users including wound care, overdose prevention training, steroid services,
    complimentary therapies and BBV testing and vaccination. The Health Shop also
    provides a psychological service for clients who have underlying issues related to
    their substance use or sexuality. The service is jointly funded by Nottingham City
    PCT, Nottingham CDP and Nottinghamshire County DAAT.
    The Health Shop also provides a sexual health service for all Nottingham City
    residents (not limited to drug users) at the same premises.

   The Homeless Healthcare Team
    A PCT provided service; The Homeless Healthcare Team deliver a wide range of
    healthcare interventions to the homeless population in Nottingham (not limited to
    drug users). The management of The Homeless Healthcare Team is shared with
    The Health Shop. The service is jointly funded by Nottingham City PCT,
    Nottingham CDP and Nottinghamshire County DAAT. This service is not
    explicitly commissioned as part of the drug treatment system.




                                         28
   Chill Out Sound Support
    A PCT provided service, Chill Out Sound Support work specifically with drug
    users who use drugs on a mild to problematic recreational basis and do not work
    with injecting drug users. The service provides outreach and health promotion
    within the night-time economy as well as structured interventions for their client
    group. Only the outreach element is considered within this section of the review
    and the service is considered more fully within the structured treatment section.
    The service is jointly funded by Nottingham City PCT, Nottingham CDP and
    Nottinghamshire County DAAT.

   Compass The Point
    Compass The Point is delivered by a large national voluntary sector provider.
    The service delivers Tier 2 access and engagement provision for Nottingham
    City residents only. The service is commissioned to provide an open access drop
    in (offering brief interventions), a needle exchange (in line with band b of the
    Nottingham City Needle Exchange Strategy), and assertive outreach in key areas
    of the city. The service is funded solely by Nottingham CDP.

   Phoenix Futures
    Phoenix Futures is delivered by a large national voluntary sector provider. The
    service delivers assertive outreach in two key localities of the City and brief
    interventions. The service is now funded solely by Nottingham CDP.

   BAC-IN
    BAC-IN is a small local voluntary sector provider commissioned by Nottingham
    CDP to provide brief interventions to users from Black, South Asian and Dual
    Heritage communities. The service provides a range of brief interventions, care
    coordination and self-help groups and has a strong abstinence focus. The
    service is funded jointly by Nottinghamshire County DAAAT and Nottingham
    CDP. There is some conflict between the commissioning remits of the City and
    the County.

   HLG
    HLG provides an access and engagement service for homeless and vulnerably
    housed drug users within Nottingham City. The service also provide enhanced
    care co-ordination for the client group if they are already accessing treatment and
    helps support integrated working between housing and drug treatment agencies.
    The service is funded solely by Nottingham CDP.

Within the current treatment system these services deliver a wide range of
interventions in line with recommendations in Models of Care including:

    •   Needle exchange
    •   Harm reduction and health promotion
    •   General healthcare and nursing
    •   BBV testing and vaccination
    •   Outreach within the community, night-time economy and prison in-reach
    •   Complimentary therapies
    •   Mentoring
    •   Advocacy
    •   Phone support
    •   Self-help groups
    •   Advice and information
    •   Brief psychosocial interventions including motivational interviewing and CBT


                                          29
   •   Drop in
   •   Relapse prevention
   •   Basic drug awareness training
   •   Establishing links with community groups
   •   Housing support

Access and engagement services in Nottingham are also providing some
interventions that are outside of the remit of typical access and engagement or Tier 2
interventions including:

   •   Care planned key working
   •   Structured psychosocial and psychological interventions
   •   Case co-ordination

In some cases this has been a direct commissioning response to meet need and in
other cases has developed organically, but these specific issues are covered in
further detail in section 3.5 below.


3.4 Good Practice

The review of the current treatment system has highlighted a range of good practice
across access and engagement provision. This evidence of good practice is
corroborated by national guidance and / or an indication of particularly effective or
innovative provision.

In particular it is important to note that there are examples of some excellent work
happening with clients on an individual level across access and engagement
provision.

Good practice within access and engagement provision includes:

Wide open door into the treatment system

Significant work was undertaken in Nottingham over the last 3 years to widen access
to the drug treatment system through expansion of access and engagement
provision in particular through assertive outreach. This was appropriate to local need
and contributed to the objective of the 1998 National Drug Strategy referenced
earlier, which was to help as many users as possible to access treatment.

This expansion has contributed to dramatically increasing the numbers in structured
drug treatment over the past three years to 2,178 in 2007/8, and it is estimated that
over 3,000 clients were in contact with the treatment system (including clients in
contact with access and engagement services).

While this expansion of access and engagement services has clearly been effective
in engaging with a significant proportion of the problem drug using population, it has
created problems of it’s own in terms of care pathways, duplication of provision, and
competition between providers. These issues are explored in further detail in section
3.5 below.




                                         30
Outreach within the night-time economy

Chill Out Sound Support provide outreach within the night-time economy and links
between the drug treatment system and the night-time economy (including bars,
pubs, clubs and one off events). This type of outreach provision and engagement
with the night-time economy is identified as best practice within the 2008 updated
Safer Nightlife Guidelines and Chill Out Sound Support is given as a model of good
practice in this area (see 3.1).

As Nottingham City has an expansive night-time economy and a high student
population, it is evident that such provision would meet the needs of a large number
of drug users.

Links with housing, hostels and homeless client group

Several access and engagement services have been commissioned to make links
with housing and hostel providers, and deliver services for the particularly vulnerable
group of homeless drug users.

HLG provide enhanced care co-ordination for homeless or vulnerably housed drug
users who are already in treatment and provide brief interventions and onward
referral for those not in treatment.

The Homeless Healthcare Team provide health services for the homeless population
(not limited to drug users) and have recently been merged with The Health Shop who
also provide harm reduction services (needle exchange and BBV testing and
vaccination) via satellite clinics at City Centre hostels.

Enhanced care co-ordination

As mentioned above HLG provide an enhanced care co-ordination function for
homeless or vulnerably housed clients who are in drug treatment, working closely
with drug treatment and housing workers to provide clients with an integrated
package of care. Care coordination is transferred when clients are successfully
engaged with drug treatment and in appropriate accommodation. Bac-In also provide
a care co-ordination for their clients.

Such care coordination and integrated care is consistently identified through
consultation feedback as a gap in the wider drug treatment system.

It should be noted that while commissioners recognise the value of this provision, it is
not considered to be appropriately located within access and engagement services.

Culturally specific provision

BAC-IN provide culturally specific drug treatment interventions for drug users of
Black, South Asian and Dual Heritage origin in Nottingham. Such provision is
required locally in order to address the cohort of users from Black, South Asian and
Dual Heritage backgrounds that are identified as underserved by drug treatment in
local needs assessments.

Bac-In provide a range of self-help groups and have a strong abstinence ethos which
clearly benefits their client group. Providing services which offer abstinence as a
clear treatment objective are identified in recent national guidance as a key element
of treatment provision and were a common need identified through consultation.


                                          31
Bac-In also provide 24/7 phone support in order to support their client group in times
of crisis to prevent relapse. This type of provision was consistently identified as a
need through consultation with stakeholders and is identified as good practice within
the Scottish Drug Strategy.

It is to be noted that as Bac-In provide services specifically for Black, South Asian
and Dual Heritage drug users there is an inequity of provision with no similar support
(self-help groups, 24/7 crisis support, abstinence focus) being available for drug
users of other ethnicities.

Outreach provision

Assertive outreach provision to engage with clients not currently in contact with the
treatment system has been expanded over the last two years with significant levels of
investment.

Such provision is commissioned to be embedded within the local communities they
serve and be based on community intelligence. These services are also targeted to
identify and engage with identified underserved groups locally such as stimulant
users and users from Black and Minority Ethnic backgrounds.

Consultation has indicated that assertive outreach and services provided in an
outreach setting are important to the drug treatment system and should be
strengthened.

While the principles of such outreach provision appear sound, the effectiveness of
current outreach provision is not clear and there appears to be significant duplication
across drug and ‘generic’ outreach provision (further discussion is included in section
3.5 below).

Harm Reduction Provision

There is high quality harm reduction provision within the access and engagement
stage of the treatment system. The Health Shop provide comprehensive harm
reduction interventions including specialist needle exchange, health promotion
campaigns, wound care, overdose prevention training, basic health care, sexual
health, and BBV testing and vaccination. The Homeless Healthcare Team provides a
comprehensive package of healthcare interventions including non-medical
prescribing, neo-natal and pre-natal services, and general healthcare.

Compass The Point and Pharmacy Needle Exchange provide lower level needle
exchange provision and all access and engagement services provide harm reduction
advice and information to some degree.
NICE Guidelines state that during routine contacts and opportunistic contacts with
treatment services staff should provide information and advice to all people who
misuse drugs about reducing exposure to blood borne viruses. This is echoed by
local consultation with indicated that harm reduction should be a core element of all
interventions across the treatment system.

While the BBV testing and vaccination provision at The Health Shop is of a high
quality, the number of referrals to and the actual number of tests and vaccinations
remains low as highlighted in the 2007/8 Needs Assessment and Nottingham City
Harm Reduction Strategy. Feedback from service providers indicates that this is due



                                          32
to the fact that BBV testing and vaccination has to be via referral to The Health Shop
and cannot be provided in-house by other access and engagement services.

Data from The Health Shop for the first part of 2008/9 suggests that the level of
testing and vaccination may have been under-reported to some extent in 2007/8.


3.5 Weaknesses

While there is evidently much good practice within the access and engagement stage
of the treatment system, there are also some challenges facing effective delivery. In
the main part these challenges are created by problems with the treatment system
model rather than service delivery and so should be addressed within any new
treatment system model.

Duplication with structured treatment

Although movement across the treatment system does not always follow a
prescribed treatment journey there is obviously expectation that access and
engagement provision should be focused on the start of a client’s treatment journey
prior to client’s engagement with structured treatment.

Analysis of clients in contact with access and engagement services shows a high
level of duplication with structured treatment, with at best over a third of clients in
contact with access and engagement services also in contact with structured
treatment. In some services this figure far exceeds a third, rising up to 90% at the
highest.

There are several factors which appear to contribute to this duplication:

   •   The high number of clients in contact with both needle exchange and
       structured treatment providers indicates that there are significant cohorts of
       clients who continue to inject illicit drugs while in structured drug treatment.
       The majority of these clients are in prescribing interventions which
       demonstrates that clients are ‘using on top’ of their script and may suggest
       suboptimal dosing within prescribed treatment. This is covered in further
       detail in section 4.5 below.

   •   The remit of assertive outreach providers to ‘re-engage’ those clients who
       have dropped out of or are at risk of dropping out of structured treatment will
       mean clients are engaged with both access and engagement services and
       structured treatment while they are successfully re-engaged.

   •   The contracting arrangements and duplicity of services means providers are
       sometimes ‘chasing targets’ in order to meet contractual requirements when
       clients may not be suitable or in need of their ongoing support.

   •   Provision of continuing care within access and engagement services
       (discussed further below).

   •   Provision of care co-ordination within some access and engagement services
       (discussed further below).




                                          33
Duplication across access and engagement provision

There appears to be wide spread duplication across access and engagement
provision. This is likely to be due to the wide range of access and engagement
services commissioned, who are providing similar services (for example brief
interventions, outreach and needle exchange) yet each with a narrowly defined client
group. As stated in section 3.4 the expansion of access and engagement provision
was undertaken over the last three years in order to bring as many drug users as
possible into the treatment system.

Analysis of referrals in and out of access and engagement services shows a
significant level of referral between access and engagement services. This type of
referral is not appropriate, creating confusing care pathways that do not align with the
treatment journey.

Consultation feedback via questionnaires and the stakeholder event supports this
finding with some drug treatment workers and the majority of service managers
reporting duplication between access and engagement services.

In particular there is felt to be duplication across outreach provision in the City with
both drug specific outreach and ‘generic’ outreach services trying to engage with the
same vulnerable client groups. This creates a duplication of effort and resource and
leads to confusion in which services should be attempting to engage with which
clients as evidenced through file audits and feedback from providers.

Models of Care states that where appropriate, ‘generic’ outreach services should be
supported by the treatment system in order to deliver some interventions to drug
users which may include outreach provision.

Consultation feedback also highlighted a feeling of some duplication of needle
exchange provision between The Health Shop and Compass The Point. Although it is
best practice to maximise the availability of clean injecting equipment it is
acknowledged that commissioning arrangements create a certain level of competition
between these two services. It is also important to acknowledge that client accessing
Compass The Point are being disadvantaged in that Compass are not able to offer
the comprehensive level of needle exchange provision that The Health Shop are able
to due to commissioning arrangements (Compass The Point are commissioned to
provide a lower intensity ‘Band B’ needle exchange service in line with the local
Needle Exchange Strategy).

Links with community groups and non-drug specific organisations

Models of Care states that access and engagement services should provide liaison
and support for ‘generic’ providers who may have contact with substance users.

Locally the majority of access and engagement providers are contracted to build and
maintain links with a wide range of community groups and non-drug specific
organisations, with the aim to maximise referrals from these agencies into the drug
treatment system.

Analysis of referrals into access and engagement services show a limited number of
clients are referred via community groups and non-drug specific organisations with
the majority being self referrals or referrals from other services within the drug
treatment system.



                                          34
This demonstrates that the current work to maximise referrals from such sources is
not proving to be effective and may also hint at a lack of clear easy to navigate
referral pathways into the treatment system via access and engagement provision.

Addressing wraparound issues and continuing care

Case file audits indicate that drug use is not always considered where clients are in
limited contact with access and engagement services. This is probably appropriate to
the aims and objectives of access and engagement brief interventions where it is
important to address the client’s immediate needs and establish an empathic
relationship.

While drug use is not routinely addressed access and engagement services are often
comprehensively addressing client’s wraparound or continuing care needs.

In particular there is strong evidence that access and engagement provision is
meeting the needs of clients requiring access to accommodation or improved
housing, access to benefits and education, and interventions to aid relaxation (for
example complimentary therapies).

As previously established, a significant proportion of clients in access and
engagement provision are also accessing structured treatment interventions.
Coupled with the significant work to address wraparound needs this suggests that
access and engagement services are often enhancing structured treatment by
providing continuing care for clients who are in a structured treatment programme.
This indicates that access and engagement services are plugging the gap in
continuing care and wraparound provision within the current treatment system. It may
also suggest that structured treatment providers do not have capacity to address the
full needs of clients on their caseload.

While this work will obviously be of benefit to clients, it is not in line with the aims and
objectives of access and engagement and would be more appropriately
commissioned elsewhere in the treatment system.

Structured psychosocial versus brief psychosocial

As highlighted in section 3.1, NICE Guidelines on psychosocial interventions
recommend that opportunistic brief psychosocial interventions should be provided for
those drug users in limited contact with the drug treatment system and should be
focused on harm reduction and motivation. The guidance states that such
interventions should consist of around 1-2 sessions of between 10 and 45 minutes
each. It is clear that these interventions would be most applicable to the access and
engagement stage of the treatment journey.

If we consider access and engagement as the first stage in the treatment journey,
then clients should be engaged and receive brief interventions inline with NICE
Guidelines at this stage and then, if requiring treatment beyond brief interventions,
moved through into structured treatment provision.

From analysis of local delivery it is apparent that clients are often accessing access
and engagement provision at a high level with fairly regular and long appointments
over a sustained period of time. Clients are often in contact with access and
engagement services for a significant length of time and provider feedback suggests
this can range anywhere from 6 weeks to 18 months. Appointments can be as
frequent as 4 times per week and may last anywhere up to one and a half hours


                                            35
each. Such interventions will often be focused on structured psychosocial
interventions including motivational interviewing, care planned keyworking and
building therapeutic alliances.

All access and engagement services (excluding the Homeless Healthcare Team) are
contracted to complete a fairly detailed triage assessment and a care plan for all
clients who engaged with their service beyond the first couple of events, as set out in
the Nottingham Standard Assessment Framework. Many but not all services will also
assign clients a keyworker at the point of a care plan being drawn up and all are
required to provide regular care plan reviews.

Models of Care describes structured drug treatment as being a structured
programme of care centred on the client’s care plan, as agreed following a
comprehensive assessment of need.

This demonstrates that access and engagement services are in many cases
providing a function that could be considered as structured psychosocial
interventions but that this is not commissioned, recognised or reported as such. This
is most evident in Compass The Point, Bac-In, Phoenix Futures and HLG and file
audits show clients are having some positive gains from such work.

It should be acknowledged that access and engagement services are likely to be
providing this intense level of intervention at least in part due to the lack of clearly
identified structured psychosocial interventions within the wider drug treatment
system. It is to be assumed that many clients who are not suitable for prescribing
interventions but requiring structured treatment are likely to be having their needs
met within access and engagement services. See section 4 for further discussion.

This will be the case particularly for non-opiate users who are not suitable for
prescribing interventions (the mainstay of our structured treatment provision) and this
is supported by the findings of the 2007/8 Needs Assessment which showed a higher
proportion of non-opiate users in contact with Tier 2 provision. NICE Guidance states
that ‘psychosocial interventions are the mainstay of treatment for the misuse of
cocaine and other stimulants, and for cannabis and hallucinogens’ and these are well
acknowledged gaps within structured treatment provision.

There is a long history of confusing and unclear commissioning arrangements to
distinguish between brief and structured psychosocial interventions in the City which
continue to the present day. For example Chill Out Sound Support provide the same
type of interventions using the same techniques as Compass The Point, yet this is
considered to be structured drug treatment in the case the first and brief interventions
in the case of the later.

Opening times

Access and engagement services do provide some evening and weekend provision
although in the whole this is limited and does not cover late nights or Sundays. Bac-
In operate normal office hours however they provide evening self-help groups and
24/7 phone support and crisis support.

Feedback via consultation indicates that longer opening hours and some 24/7 crisis
provision is lacking within the current treatment system. Access and engagement
services should provide the most flexible hours of accessibility in order to be able to
respond to clients presenting to treatment at the point of most need.



                                          36
The Health Shop close at lunchtimes for 1 hour due to health and safety issues with
the building, which is likely to result in some injecting drug users not being able to
access injecting equipment at the point of need.

Self-help

A range of national guidance places increased emphasis on the need for all clients to
have access to self help and mutual aid provided either within or outside of the drug
treatment system.

Locally Bac-In provide the most comprehensive self-help provision and make the
most referrals into established self help groups such as Narcotics Anonymous and
Alcoholics Anonymous. Self help groups and referral to self help groups by other
access and engagement services are very limited.


3.6 Effectiveness

The key functions of access and engagement provision as stated in national
guidance are to:

   •   Identify and engage drug users
   •   Provide easily accessible services
   •   Provide brief interventions including motivation to change
   •   Refer into and support engagement with structured treatment.

Each of these objectives must be successfully provided for access and engagement
provision to be considered effective.

Identify and engage drug users

Two access and engagement providers have a specific remit to provide assertive
outreach services for problem drug users. These providers are contracted to identify
and engage key cohorts of treatment naïve problem drug users into the drug
treatment system. The services are required to give a primary focus to those groups
identified as underserved by drug treatment in local needs assessments; in particular
users from Black and Minority Ethnic backgrounds and stimulant users.

Analysing the current system indicates that drug treatment outreach provision may
not be effectively delivering these stated objectives. In particular feedback from
outreach providers indicates that it is difficult to identify treatment naïve drug users
through street outreach. Many of the individuals engaged are from a cohort that have
already been through and know the treatment system or are already currently in
structured treatment.

Furthermore, demographic analysis of the clients in contact with drug specific
outreach suggests that such provision is not successfully engaging the cohorts of
underserved problem drug users that it was intended to reach:

   •   Typically around 15% of the client group is of non-white ethnicity across all
       access and engagement provision (excluding Bac-In) with no evidence to
       suggest that outreach provision is more successful at engaging with problem
       drug users from Black and Minority Ethnic backgrounds.




                                          37
   •   The number of stimulant users in contact with access and engagement
       services is also fairly low across the board with no significant increase in the
       numbers of stimulant users in contact with the outreach providers.
   •   Typically older age groups are engaged via street outreach.

This is incongruent with feedback from the community which suggests that there are
cohorts of young individuals who are problem drug users in their community and with
local epidemiological studies which identify populations of problem drug users not in
contact with treatment.

Accessibility

A key objective of access and engagement provision is to make drug treatment as
accessible as possible to a full range of drug users.

As stated earlier in this section there are a wide range of access and engagement
providers commissioned in order to provide a large gateway into the treatment
system and make access as easy as possible for clients.

Those access and engagement services operating from a centre base provide open
access drop in provision and outreach services provide assertive street outreach and
detached outreach at specific venues to engage with specific client groups. These
access and engagement services are able to take interventions to drug users where
they are needed within the community and can provide home visits and local access
to clients who cannot access fixed site services.

As referenced above some evening and Saturday opening times are offered although
these are fairly limited and no late night or Sunday hours are routinely offered.

All clients self referring to access and engagement services or contacted via
outreach are offered an immediate appointment with a worker. Service Level
Agreements state that those who are referred from a third party must have an initial
appointment within 48 hours and a triage assessment within 10 days.

Service users responding to the Treatment System Review Questionnaire indicated
that by far the most common way people found out about services was by word of
mouth from another drug user, with people finding out about drug services via some
sort of outreach being the second most common way.

The majority of service users responding to the treatment system review
questionnaire felt it was easy to find out about drug services in Nottingham however
almost half of those responding felt it was confusing knowing which service to go to
for help. This suggests that although drug users are aware of services it is not easy
to initiate first contact or navigate the treatment system indicating that the current
configuration of access and engagement provision is not completely effective.

Brief interventions

Access and engagement services should provide brief psychosocial and harm
reduction interventions for those clients not yet ready for or not requiring structured
treatment. Such interventions should be focused on advice and information, harm
reduction and motivation as recommended by national guidance.




                                          38
There is evidence that access and engagement services are providing quality brief
interventions in order to engage clients and maintain engagement with the treatment
system.

However, as covered in more detail in 3.5 above, it is apparent that the interventions
being provided are beyond that of brief interventions. Access and engagement
services may be back-filling for the lack of structured psychosocial interventions,
continuing care and wraparound provision within the drug treatment system.

Consultation demonstrates that the majority of drug users are motivated to engage in
drug treatment by the desire to stop or reduce their drug use in order to achieve a
better lifestyle, and that this cessation or reduction in drug use translates into their
main goal of treatment.

It is important to be able to address client’s goals and motivation to change at the
earliest possible stage in the treatment journey: Therefore access and engagement
provision should identify and address client’s drug use providing brief interventions to
support a reduction in use, or motivation and referral to structured treatment to
achieve their objectives in the longer term.

Scrutiny of access and engagement provision through case file audits demonstrates
that drug use is not routinely addressed in care plans or interventions, and there is
mixed evidence of motivational work to encourage further engagement with treatment
in order to reduce their drug use.

Referral to and retention in structured treatment

A key objective of access and engagement provision is to support and motivate
onward referral into structured drug treatment interventions and services. Locally
many of the access and engagement services are specifically targeted to make
significant onward referrals into structured drug treatment services.

Analysis of onward referrals across access and engagement provision over 2007/8
and quarter 1 2008/9 shows that referrals into structured drug treatment are lower
than expected.

This indicates that there is a breakdown in the pathways from access and
engagement to structured treatment services and also hints at the gaps in structured
treatment – particularly for non-opiate users.

In case file audits in a number of access and engagement services, particularly
where clients are engaged in needle exchange, clients were provided with
signposting information to structured drug treatment rather than a supported onward
referral. This further demonstrates that the pathway from access and engagement
into structured treatment is not effective.

For clients to move through into structured treatment within the current treatment
system configuration they must be referred into a new system. It is perhaps
unsurprising if this is not successful as it is not a seamless transition nor does it
enable clients to maintain any therapeutic relationships they have established with
the service or keyworkers.




                                          39
3.7 Care Pathways

The review of access and engagement provision indicates that care pathways
throughout the treatment system are neither clearly commissioned nor working
effectively:

   •   There is evidence of clients being referred between access and engagement
       services as their client ‘status’ changes, often with no continuation of care.
       This further supports the finding that there is duplication across access and
       engagement provision with too many providers serving too narrow a remit of
       client group.

   •   The majority of referrals into structured treatment are through self referral or
       via referral from another provider within the drug treatment system indicating
       that the system is not easy for non-drug specific agencies to refer into.

   •   There is lower than expected onward referral from access and engagement
       provision to structured treatment provision. Where such referral is made it is
       not always in an integrated or supported way with no evidence of the
       Standard Assessment Framework being implemented and in some cases
       only signposting being offered.

   •   Access and engagement services are effective in referring to a wide range of
       wraparound treatment providers in order to meet the needs of the individual
       clients. This further supports the suggestion that in some cases access and
       engagement services are providing a continuing care function and enhanced
       care co-ordination rather than an access and engagement function.

   •   Referrals to self-help groups are low across access and engagement
       provision, with the exception of BAC-IN, and this is against the trend of
       national guidance and strategy.

   •   There is mixed evidence of services working in an integrated way where
       clients are in contact with multiple services. The best evidence of services
       working in an integrated way is when the client has a specific need that
       requires involvement from a specialist agency – for example dual diagnosis,
       housing, or child protection. Integrated working appears to be least effective
       when clients are in contact with more than one drug treatment service (be that
       another access and engagement service or a structured treatment service).

   •   While evidence of integrated working is not always strong there are a range of
       joint working protocols in place between providers which demonstrates that
       services are attempting to establish appropriate mechanisms to provide
       integrated care.


3.8 Client Group

A wide range of clients are in contact with access and engagement services which is
supported by the fact that there are services commissioned to engage with specific
client groups in particular homeless and vulnerably housed (HLG and Homeless
Healthcare Team) and Black, South Asian and Dual Heritage (Bac-In).




                                         40
However, overall the range of clients engaged with access and engagement services
largely reflects that of the wider treatment population.

Gender

The majority of clients in access and engagement services are male (on average
around 30% of clients are women). The number of women engaged is significantly
higher than the proportion of women estimated to be problem drug users (19%).

Ethnicity

The majority of clients in contact with access and engagement services are white (on
average around 15% of clients are of non-white ethnicity excluding Bac-In
clients).When compared with structured treatment (where 17% of the client group are
of non-white ethnicity), access and engagement services appear no better at
engaging with Black and Minority Ethnic users than structured treatment (with
exception of Bac-In).

Age

The biggest age group represented in access and engagement services are aged 25-
34, however there a significant proportion of 18-24 year olds in contact with access
and engagement services (ranging from 9%-30%). Conversely, outreach provision
appears to engage an older client group than other access and engagement
provision.

On the whole access and engagement provision appears to engage younger
populations of users than structured treatment with only 13% of the structured
treatment population being under 25.

Drug Use

As expected the majority of clients in contact with access and engagement services
providing needle exchange are poly heroin and crack users. For those services not
providing needle exchange there are a large number of cannabis users accessing
alongside poly heroin and crack users with fewer stimulant (including cocaine and
crack) only users.

The fairly low numbers of stimulant only users in contact with access and
engagement provision is disappointing as two of the largest services are specifically
contracted to engage with the underserved stimulant using population.

However, the 2007/8 Needs Assessment again evidences that non-opiate users do
appear in higher numbers in access and engagement services than in structured
treatment. So while not reaching expected numbers of stimulant users this provision
is still proving to be more attractive and effective for the stimulant using client group
than structured treatment.

There are high numbers of cannabis only users in fairly long term contact with access
and engagement services and the appropriate placement of services for cannabis
users requires further consideration.

Note: Information available for access and engagement services is not of a
consistently high standard nor available in easily comparable data sets.



                                           41
3.9 RECOMMENDATIONS

Recommendations relevant to access and engagement provision:

   1. Outreach provision within the night-time economy should be available
      within the new treatment system model.

   2. Access to the drug and alcohol treatment system should be streamlined
      and simplified within the new treatment system model regardless of
      referral route.

   3. To utilise existing ‘generic’ assertive outreach provision within
      Nottingham City to identify, engage and refer problem drug and alcohol
      users into the treatment system.
      Further work is required to identify the full range of ‘generic’ assertive
      outreach provision (including the effectiveness of such provision) and
      understand commissioning/funding structures. ‘Generic’ assertive outreach
      provision would require appropriate support, training, pathways and
      investment to support this development.

   4. Brief interventions should continue to be provided at the access and
      engagement stage of the treatment journey within the new model, but
      are to be aligned with the NICE Guidance definition of brief
      interventions.

   5. Psychosocial interventions that are above the threshold of the NICE
      Guidance definition of brief interventions to be commissioned as
      structured psychosocial interventions within the new treatment system
      model.

   6. The treatment system should continue to work with local community
      groups and non-drug specific organisations to maximise referrals into
      the treatment system.

   7. An open access centre base should be considered within the new
      treatment system model that provides extended and flexible opening
      hours as required to meet identified client need.

   8. A single freephone number to be available 24/7 for all drug and alcohol
      users, including the criminal justice client group, acting as a first
      contact point and a crisis support provision.

   9. There should be improved pathways into structured treatment within the
      new treatment system model.

   10. There should be further consideration on the benefits of having a single
       provider or co-located service for an open access centre base, care co-
       ordination function and some structured treatment interventions, in
       order to improve the pathway between access and engagement and
       structured treatment. This would be similar to the Adult Offender
       Service model which has been identified as best practice within the
       criminal justice treatment system.




                                      42
Recommendations relevant to the general treatment system:

   11. The new treatment system model should include a single care co-
       ordination function to act as an anchor for all clients as they move
       through the drug treatment system.

   12. The new treatment system model should consider provision for
       culturally specific treatment options.

   13. Abstinence should be offered as a clear choice for clients throughout
       their treatment journey.

   14. Various self-help groups (including abstinence self-help groups) should
       be available as part of the new treatment system model.

   15. Referral to NA, AA and other established 12 step self-help groups
       should be offered by the new treatment system model as part of a clear
       menu of options.

   16. The new treatment system model should consider more appropriate
       ways of ‘re-engaging’ those clients who have dropped out or are at risk
       of dropping out of structured treatment. This may be more appropriately
       placed within a care co-ordination function.

   17. A full equality impact assessment of the new treatment system model to
       be undertaken in the next stage of the review.

   18. A full review of the cost effectiveness of the proposed model should be
       undertaken in the next stage of the review.

Recommendations relevant to aftercare, continuing care and wraparound provision:

   19. Continuing care provision should be explicitly commissioned within the
       new treatment system model at the appropriate stage in the client
       journey.

   20. Wraparound and diversionary activities should be explicitly available
       throughout the drug treatment journey, whether through specific
       activities/interventions as part of the drug treatment system or through
       referral into generic activities/interventions.




                                       43
4       Structured Treatment
This section looks at the structured treatment phase of the treatment journey. There
is a summary of national guidance, local delivery and consultation findings alongside
analysis of the strengths and weaknesses of this provision.

It should be noted that the review of Nottingham Alcohol and Drug Team was
intended to be a key focus of the overall treatment system review. Nottinghamshire
Healthcare Trust was to complete an internal review and prepare a detailed report to
the CDP for consideration; however, this has not been made available within the
required timescale.

4.1 National Guidance / Research

The following is a summary of national guidance in relation to the structured
treatment element of the drug treatment system.

Models of Care

Structured treatment provision is a core component of Models of Care. The
framework defines structured drug treatment as being a structured programme of
care centred on the client’s care plan, as agreed following a comprehensive
assessment of need. Structured treatment may include psychotherapeutic
interventions such as:
    • Psychosocial interventions including cognitive behavioural therapy and
       motivational interventions
    • Psychological interventions such as structured counselling
    • Methadone maintenance and detox programmes
    • Community detoxification
    • Structured day and after care

The care plan should contain clear goals based on the issues identified during the
assessment (and covering the four key domains of substance use; physical and
psychological health; social functioning; and criminal involvement) and be reviewed
regularly with the client. A structured treatment programme may comprise of a
number of concurrent or sequential treatment interventions. For clients whose needs
cross several domains, there should be a care co-ordinator, responsible for co-
ordination of that individuals care on behalf of all the agencies and services involved.

The guidance sets out that drug misusers in England must have access to the
following structured drug treatment services in their local partnership area:

    •   Specific community care assessment and care management
    •   Care co-ordination services for drug misusers with complex needs (provided
        by suitably trained practitioners)
    •   Specialist structured community-based detoxification service
    •   A range of specialist structured        community-based      stabilisation   and
        maintenance prescribing services
    •   Shared-care prescribing and support treatment via primary care
    •   A range of structured, care planned counselling and therapies
    •   Community-based drug treatment and testing order drug treatment



                                          44
   •   Structured day programmes (in urban and semi-urban areas)
   •   Other structured community-based drug misuse services targeting specific
       groups (e.g. stimulant misusers, young people in transition to adulthood,
       black and minority ethnic groups, women drug misusers, drug misusing
       offenders, those with HIV and AIDS, drug misusers with psychiatric problems)
   •   Liaison drug misuse services for acute medical and psychiatric sectors (e.g.
       pregnancy, mental health)
   •   Liaison drug misuse services for local social services and social care sectors
       (e.g. child protection, housing and homelessness, family services)
   •   Through-care and aftercare programmes or support.

Models of Care also sets out a requirement for treatment systems to deliver
integrated care pathways (ICPs) to ensure that care is provided to individuals in a co-
ordinated and integrated way and in response to their individual needs. ICPs should
have the following elements:

   •   A definition of the treatment modality provided
   •   Aims and objectives of the treatment modality
   •   Definition of the client group served
   •   Eligibility criteria (including priority groups)
   •   Exclusions criteria or contraindications
   •   Referral pathway
   •   Screening and assessment processes (see below)
   •   Development of agreed treatment goals
   •   Description of the treatment process or phases
   •   Care co-ordination
   •   Departure planning, aftercare and support
   •   Onward referral pathways
   •   Services with which the modality interfaces

National Drug Strategy: Effectiveness and Outcomes Agenda

The new National Drug Strategy has a renewed focus on the need for drug treatment
to be effective and to produce real outcomes for clients engaged in the drug
treatment system. There is a particular focus on clients moving through the system
and reintegrating with the community, and on family and carer support and
involvement.

The new Public Service Agreement (PSA) reflects the emphasis on effective
treatment, with the National Indicator 40 target being to increase the proportion of
clients in effective treatment year on year. This target has been adopted locally in the
LAA. The City therefore has to ensure that delivering effective treatment is a priority
and that greater proportions of clients are retained in treatment or have a planned
discharge if exiting prior to completing 12 weeks in treatment. The introduction of the
Treatment Outcome Profile (TOP) tool expands the expectation of effective treatment
to include the impact made by drug treatment on a client’s substance use, injecting
risk behaviour, criminal activity and health and social functioning.




                                             45
In order to deliver against this key LAA target, the city’s treatment system must
therefore deliver effective drug treatment that:

    •   Effectively addresses the needs of the city’s diverse drug using population
    •   Is effective in bringing about change in a client’s substance misusing
        behaviour, and across the further three care planning domains
    •   Retains individuals in drug treatment
    •   Results in a planned exit
    •   Supports clients to reintegrate successfully into the community.


Clinical Guidelines and Nice Guidelines

The 2007 Clinical Guidelines set out the parameters for safe and effective drug
treatment provision, including clinical governance requirements; the essential
elements of treatment provision; psychosocial and pharmacological interventions;
health considerations; and specific treatment situations and populations.

The NICE Guidelines provide considerable detail on the range of psychosocial
interventions that should be available at a local level and reflect the shift from
reliance on pharmacological interventions as the mainstay of drug treatment.

This guidance therefore must form part of the evaluation of our current treatment
system.

It should be noted that while contingency management forms a substantial part of the
NICE guidelines it is not considered in this review as local partnerships are awaiting
the results from national pilots prior to implementation.


4.2 The Local Situation: Structured Drug Treatment

Structured drug treatment (Tier 3) is currently provided by the following services in
Nottingham City:

   Chill Out Sound Support
    Chill Out Sound Support provide information, advice and support around mild to
    problematic, non-injecting drug use with the aim of eliminating or minimising the
    risks and damage associated with it. Much of this work is undertaken in night-
    time economy settings via outreach and is covered in section 3. The service also
    sees a significant number of individuals on an ongoing basis and provides
    structured psychosocial interventions to problematic non-injecting drug users.

   Dual Diagnosis Team
    The Dual Diagnosis team provides a consultancy, liaison and assessment/
    interventions service aimed at ensuring that those people with severe mental
    health problems get help with their substance misuse problems. The service
    offers direct interventions to clients with mental health problems and support to
    other services, mental health or substance misuse work in order to integrate the
    care of the client group and ensure that the client receives holistic integrated
    interventions. This service is hosted by the Nottinghamshire Mental Healthcare
    Trust as part of Nottingham Alcohol and Drug Team.




                                         46
   John Storer Clinic
    Hosted by the Nottinghamshire Mental Healthcare Trust, the John Storer Clinic is
    the City’s specialist prescribing service and forms part of the Nottingham Alcohol
    and Drug Team (NADT). The service comprises of nurses, social workers,
    occupational therapists, doctors and substance misuse specialists providing a
    wide range of treatments including detoxification, long-term prescribing, relapse
    prevention and harm reduction advice and information. NADT also hosts the
    Rapid Access prescribing service which serves those accessing treatment via the
    Criminal Justice System; Rapid Access is considered under the Criminal Justice
    element of the review (section 6).

   Probation Substance Misuse Team (SMT)

    This treatment team delivers structured treatment interventions to probation
    clients. The team’s work is considered under the Criminal Justice element of the
    review (section 6).

   New Pathwaves
    New Pathwaves is a therapeutic and specialist addictions counselling service for
    individuals and families who are directly or indirectly affected by drugs and
    alcohol issues and related psychological problems. New Path-Waves is open to
    all communities, specialising in the Black, Minority and Ethnic communities.

   Shared Care
    Shared Care is a prescribing based drug treatment intervention carried out within
    a Primary Care setting. Specialist drug treatment workers from NADT and
    appropriately trained GPs work together to deliver substance misuse treatment.
    Currently there are 15 Shared Care Clinics operating in various localities across
    the City. Shared Care Clinics are held both within GP practices and also outside
    of a practice setting in appropriate locations to support particular communities of
    interest.


4.3 Consultation Findings

The following key points have been collated from the consultation mechanisms
discussed in section 1.7:

1. There is a lack of integration, communication and joint working between services
   within the system.
   -   The fact that services could work better together was raised in the majority of
       questionnaires submitted for the review.
   -   Service users raised the point that they felt services did not communicate
       adequately together regarding shared clients.
   -   A key gap raised in questionnaires was a lack of a seamless treatment
       journey from first engagement to aftercare.

2. There is perceived to be a lack of choice in the treatment system
   -  Service users report that the treatment system is dominated by NADT / the
      John Storer Clinic and that there is limited alternative provision available for
      both opiate users and users of other drugs. This has been cited as a potential
      barrier for engagement.

3. There is a negative perception of some current structured treatment providers.


                                          47
    -   Service user feedback via the forum mechanisms and at consultation events
        indicates that some service users have a strong, negative perception of the
        current structured treatment system. This may be due to negative previous
        experience of a treatment service.
    -   The majority of groups at the Stakeholder Event placed significant emphasis
        on the need for an empathetic and compassionate workforce within a new
        treatment model, perhaps suggesting that this is lacking from the current
        model.

4. There is a lack of treatment options for crack cocaine users, stimulant users and
   other non-injecting drug users.
   -  Chill Out Sound Support engaged 27 individuals in structured treatment
      during 2007/8. This group of drug users remain under represented in drug
      treatment, however, and are more prevalent in access and engagement
      services and the treatment naïve population. This service is not accessible to
      injecting drug users.
   -  A significant proportion of keyworker questionnaires reported that keyworkers
      do not know where to refer these drug users for support for their drug use.
   -  The stakeholder event consultation raised this point as a key issue for our
      current treatment system.
   -  Needs Assessment data and feedback from 2007/8 made it apparent that
      both service users and keyworkers are unsure of the resources available to
      non-injecting and stimulant drug users and feel there is a gap in provision.

5. There is a gap around psychotherapy / psychological interventions to address
   underlying issues.
   -  A significant proportion of keyworker questionnaires reported that this was
      considered to be a gap in current treatment provision.
   -  The stakeholder event consultation raised this point as a key issue for our
      current treatment system.
   -  Both the carer and service user questionnaires identified a need for more
      psychological support for drug users.

6. There is a gap around structured activities / day care provision for service users.
   -  The CDP do not currently commission a structured day programme. The
      previous structured day care service was decommissioned due to low
      attendance (probably the result of overly intensive sign-up requirements).
   -  Service users have frequently voiced frustration at the lack of activities
      available to them to replace the patterns of behaviour and activities
      associated with former illicit drug use.
   -  Service users (at all stages of treatment journey and apparently regardless of
      substance of choice) report that boredom is a real barrier to successful
      engagement with treatment and may contribute to relapse / attrition.
   -  Keyworkers have reported difficulties in arranging or accessing suitable
      activities, and of not knowing how or where these activities may be taking
      place.
   -  Service managers have discussed an arrangement by which a menu of
      activities could be pulled together to address this issue.

7. The majority of services hold office open hours, which does not necessarily
   reflect the lifestyles / needs of the service users.
   -   This is consistently raised as a barrier to engagement by service users and
       keyworkers alike, and was reiterated at the stakeholder event and in
       questionnaires returned to the CDP.



                                         48
8. All services need to be culturally competent.
   -   Stakeholder event, questionnaires and service user feedback confirm that this
       is a priority that should be built into the city’s treatment model

9. Treatment choices and pathways should be clearly identifiable and well
   publicised.
   -  Stakeholder event, questionnaires and service user feedback confirm that this
      is a priority that should be built into the city’s treatment model.

10. There should be rapid access to treatment for all service users
    -  Stakeholder event, questionnaires and service user feedback confirm that this
       is a priority that should be built into the city’s treatment model.


4.4 Good Practice / System Strengths

The review of the current treatment system has highlighted a range of good practice
across structured treatment provision. This evidence of good practice is corroborated
by national guidance and / or an indication of particularly effective or innovative
provision.

As with the rest of the treatment system there are examples of some excellent work
happening with clients on an individual level across structured treatment provision.

Good practice within structured treatment includes:

Shared Care

The Shared Care system is well established in the city and well thought of both within
the locality and by neighbouring treatment providers.

There are currently 16 clinics operating across Nottingham to ensure that individuals
can access structured treatment within their locality and to support particular
communities of interest.

The clinic audit conducted as part of the review and questionnaires from shared care
workers indicated that there is a strong working relationship between the GPswSIs
and Primary Care Liaison workers involved in delivering shared care.

The clinic audit also showed evidence that individual’s wider wraparound needs were
being addressed by the GP providing treatment.

Retention of clients in shared care clinics is noticeably higher than across the city as
a whole – with 88% of shared care clients engaged for 12 weeks or more in 2007/8
against the city figure of 70%.

Harm Reduction

There is a strong emphasis on harm reduction and risk management in the specialist
prescribing service, linking to the strong harm reduction awareness and provision
network across the treatment system. However, centralised BBV intervention centre
outside of Tier 3 services means there is often attrition between referral and take up.
It should be noted that NADT do provide screening and vaccination within the
service, although this is primarily for the service’s own client group.



                                          49
Complex Cases

The consultant led specialist prescribing service is able to deal with complex medical
cases. The service has significant experience and expertise in assessing individuals
of this nature and identifying potential treatment options.


Dual Diagnosis

The Dual Diagnosis Team is an important resource for the system, providing
expertise on mental health issues for treatment providers and providing specialist
and intensive psychosocial interventions to clients with a dual diagnosis. The team
are currently developing a Dual Diagnosis Link Worker scheme across substance
misuse and mental health services in the city (with 40 link workers already identified).
This scheme aims to ‘mainstream’ Dual Diagnosis practice across mental health,
social care and third sector services throughout Nottinghamshire and ensure that
staff working in these fields can provide adequate support and understanding to their
clients.

Non-injecting Drug Users

There is specific structured psychosocial treatment provision for non-opiate and non-
injecting drug users through Chill Out Sound Support.

There is evidence that Chill Out Sound Support clients engaged in ongoing one-to-
one support report a reduction in drug use. It should be noted that this does not
necessarily translate into strong reduction and planned discharge performance, as
both currently fall below target. The service is working to address this.

Relocating the service to its own premises appears to have encouraged more
engagement with the service by the client group who were reluctant to access when
the service was co-located with a needle exchange service. There has been a
marked increase in the numbers accessing the service during 2008/9 to date (27
individuals were in treatment for the whole of 2007/8 and 78 in the first 6 months of
2008/9 – an increase of 188%).


4.5 Weaknesses

As we might expect, the majority of weaknesses identified during the review of
structured treatment overlap with the key consultations findings. There are some
significant challenges facing structured treatment which must be addressed in any
revised treatment system model if the system is able to meet the full range of local
need.

General

The current structured treatment configuration is not performing as necessary to
meet stretching LAA targets on effectiveness. Growth in numbers in treatment has
tapered off (with 4% growth seen in 2007/8 against 2006/7) and the system has
relatively low retention performance (70% of clients were retained in treatment for 12
weeks or more during 2007/8). While planned exits appear fairly high, there are
concerns that this will drop once the correct up-to-date guidance is being adhered to.




                                          50
There is a lack of out of hours access to structured drug treatment in the current
system, with the majority of services offering 9.00-5.00pm opening hours (or less)
during the week. There are only two evenings per week where there are
appointments available for prescribing based interventions (1 within NADT and 1
within Shared Care) and there is no weekend provision of structured treatment.
Consultation feedback confirms that more flexible opening hours would support more
individuals to access treatment.

Consultation feedback from the stakeholder event and the stakeholder
questionnaires suggest that the profile of structured treatment services in the city is
not particularly high and that the pathways for potential clients could be better
publicised.

Pathways / Integration / Co-ordination

Waiting times for access to the specialist prescribing service are currently on target.
However, the process from referral to treatment start across all structured treatment
interventions may benefit from review to ensure they are fully conducive to maximise
client retention at this vulnerable stage of engagement.

Tier 2 services have reported that they are unable to make referrals into structured
treatment services and that they sign post clients to self refer. This should be
reviewed further and addressed as soon as possible within the current system and
any new model.

The treatment pathways for non-opiate and non-injecting drug users in particular are
not clear, with a considerable proportion of this client group remaining in Tier 2
access and engagement treatment providers. This is probably due to the fact there
is no clearly defined / high profile structured treatment options for this client group (in
particular structured psychosocial interventions). This was reiterated throughout the
consultation exercises conducted as part of the review.

The lack of clear pathways appears to lead to inappropriate referrals within the
treatment system, particularly to Chill Out Sound Support. A number of clients are
referred to the service for complementary therapies (which are only provided as part
of an ongoing care planned package of treatment to Chill Out clients), and the
service receives some referrals from clients that fall outside of their service remit
(e.g. injecting drug users).

There appears to be a lack of integration between structured treatment providers and
access and engagement services, as the majority of referrals to structured treatment
are recorded as “self referrals”. Moreover, there appears to be a lack of integration
and referral pathways between structured treatment providers. For instance, the
2007/8 Needs Assessment identified that the majority of clients accessing the John
Storer Clinic are not being referred on (in 2007/8 90.2% of John Storer Clinic clients
remained in the service, and only 9.8%, 100 individuals, were referred on).

Structured treatment providers appear to work in isolation from each other and tend
not to joint work with or make referrals to other structured treatment providers
(according to case file review findings and consultation feedback). The lack of
movement of Standard Assessment Framework tools and the Treatment Outcome
Profile forms could be seen to corroborate this. However, it should be noted that
there are relatively well established relationships between the statutory services.
Consultation highlighted that clearer mechanisms for a care co-ordination function
would support improved integration and enhance clients treatment journeys.


                                            51
Delivery

The new 2007 Clinical Guidelines (and NICE Guidelines) are not fully implemented
across the system, for example:

   •   Prescribing rates can be perceived as below optimal for a proportion of
       clients. It should be noted that this may be due to clients not wishing to
       increase their doses or to minimise risk (when clients are drinking heavily for
       example). This is supported by findings from the review of access and
       engagement provision where there is evidence of a high proportion of clients
       in a prescribing based intervention that are also accessing needle exchanges.

   •   Prescribing packages of treatment tend to focus on the medical element and
       do not always address psychological or wider wraparound needs. This is
       evidenced in case file reviews and in feedback from service users in the City
       and is supported by findings that show access and engagement services
       providing enhanced and continuing care for clients in structured treatment
       programmes.

   •   Clinicians do not always optimise treatment interventions for clients who are
       not benefiting from treatment. For instance, clients who disengage may have
       their dosages reduced on a weekly basis or their script suspended until they
       re-attend the prescribing service. The 2007 Clinical Guidelines are clear that
       clinicians should take opportunities to maximise interventions for individuals
       at risk of disengagement or those who have disengaged from treatment.

The CDP does recognise that there is a careful balance to be held between risk
management and implementation of clinical guidelines, but also notes there is
perceived to be unwillingness to adopt the Clinical Guidelines fully within practice.

There is a need for a centralised system of clinical governance across the treatment
system. Several services within the City system have strong internal clinical
governance frameworks (such as the John Storer Clinic), but this is not consistent or
standardised across the treatment system.

Duplication

There is no direct duplication as such, which each service commissioned and
intended to provide distinct services to the structured treatment client group.

However, feedback on service manager questionnaires and NDTMS data available
on movement within the treatment system may suggest that a proportion of clients
seen within secondary care may be suitable for treatment in primary care. There
appears to be less onward movement from secondary to primary care than expected
according to NDTMS treatment data.

Despite work undertaken to address actively identify suitable clients in secondary
care and encourage referral into primary care periodically over the last two years this
remains low.

The shared care contract clearly defines a population of medically complex clients
that should not be seen within shared care:




                                          52
“Users with complex and co-morbid issues are seen within Specialist Prescribing.
Patients who are NOT seen within Shared Care include: pregnant women; young
people aged under 18; patients with significant psychiatric problems; patients with
significant physical complications of drug use; those who misuse stimulants only”

It may be that a similar definition is required for the specialist prescribing service on
clients suitable for primary care to support movement through the treatment system
and maximise the capacity within the treatment system.

Gaps

There is perceived to be a lack of choice in the treatment system. The greater
proportion of clients engaged with structured treatment are engaged with the John
Storer Clinic, with many clients starting their treatment journey with this service.
Consultation indicated that JSC was familiar to service users and stakeholders alike,
with other structured treatment providers being less well known. Service user
feedback confirms that many individuals equate structured treatment provisions with
the John Storer Clinic.

There is a lack of treatment options for crack cocaine users, stimulant users and
other non-injecting drug users. The Needs Assessment treatment mapping exercise
and consultation clearly shows that there is a gap with regards to treatment options
for crack, other stimulant and non-injecting drug users. As stated earlier,
psychosocial interventions are the mainstay of treatment for non-opiate users. Case
file reviews suggests that keyworkers do not provide psychological or psychosocial
interventions to crack users, or know where to refer them to.

There is a gap around psychotherapy / psychological interventions. NICE / Clinical
Guidelines state that these interventions should be available for all drug users,
particularly to address underlying issues, but they are not provided centrally in the
current treatment system. A psychologist attends the Health Shop specialist needle
exchange and New Pathwaves provides structured psychotherapy, but they are not
available across all service user groups and have limited capacity. Mapping of
treatment provision confirms that there are very few psychological interventions
available within treatment, and these are not available to all service users / referral
pathways do not seem to be clear.

There is a gap around structured activities / day care provision for service users.
Service users (at all stages of treatment journey and apparently regardless of
substance of choice) report that this is a real barrier to successful engagement with
treatment and may contribute to relapse / attrition. The vast majority of consultation
feedback picks up this issue as a key gap in Nottingham City.


4.6 Effectiveness

As stated in 4.1 above effective structured drug treatment as part of the wider drug
treatment system must:
   Address the needs of the city’s diverse drug using population
   Bring about change in a client’s substance misusing behaviour, and across the
    further three care planning domains
   Retain individuals in drug treatment
   Result in a planned exit
   Support clients to reintegrate successfully into the community.



                                           53
Retention and planned exits

Effectiveness performance in structured treatment systems was relatively strong, with
87% individuals in effective treatment (i.e.: being retained for 12 weeks or more in
treatment or leaving in a planned way if exiting prior to 12 weeks) during 2007/8.
Significant growth in numbers in treatment and improved retention and planned
discharges will be required to increase this level of effectiveness, however, and meet
the LAA targets. Early analysis of available data for 2008/9 suggests that
effectiveness performance is falling slightly although this is not conclusive due to
changes in national performance information.

Retention of clients is relatively low, with 70% of clients retained last year. A retention
focus group explored the reasons for this poor retention and found that a lack of care
co-ordination and integrated treatment provision contributed to lower retention. The
group also found that that crack users, homeless drug users, those from Black and
Minority Ethnic groups and those under 25 were less well retained in treatment. It is
to be noted that retention within Shared Care is much higher at around 88% for
2007/8.

Movement

As mentioned previously, movement between services is low according to NDTMS
data – with 90% of John Storer Clients remaining in the service during 2007/8. We
would expect to see movement between John Storer and Shared Care and also
generally referral from structured treatment into aftercare / continuing care.

Address clients holistic needs

Case file reviews and service user feedback suggests that the majority of structured
treatment provision focuses on the medical aspect of a client’s treatment needs.
There is a sense that individual’s wider psychological and social needs (including
housing, debt advice etc) tend not to be addressed by structured treatment providers.
With perhaps the exception of Shared Care, the wider needs of clients are often
addressed by a referral to another provider (often Tier 2 access and engagement
provision).


4.7 Care Pathways

As with access and engagement provision, the review of structured treatment
indicates that there are poor care pathways across the drug treatment system.

The majority of client’s access structured treatment provision via John Storer Clinic.
Waiting times performance for this service was below target during 2007/8, with 89%
of clients waiting under 3 weeks against the target of 100%. The current referral
process for John Storer Clinic clients is also relatively lengthy, with clients required to
present and complete a brief referral assessment, attend for a comprehensive
assessment and attend a medical appointment before starting a script. There was
some feedback from access and engagement services that supports this view.

The majority of referrals into structured treatment are recorded as self referrals by
treatment providers (47% of referrals into structured treatment during 2007/8 were
recorded as self referrals). The proportion of self referrals into structured treatment in
Nottingham City is also noticeably higher than regionally (31%) and nationally (38%).


                                            54
Although a high proportion of self referrals might suggest that problem drug users are
aware of treatment provision, it does suggest a lack of integrated working between
the services in the treatment system. This is particularly apparent when considering
the number of outreach services and open access services working in the city to
engage and refer clients into structured drug treatment. The low referrals from
access and engagement into structured treatment are considered in further detail in
section 3.5 and 3.6.


4.8 Client Group

During 2007/8, 2,178 clients were engaged in the structured treatment system.

Of these:

Gender

   73% were male; 27% were female.

This is consistent with previous years, and closely matches both regional figures and
the City census gender breakdown. The 2007/8 Needs Assessment found that
women engaged relatively well with treatment, while men were more prevalent in
terms of percentage breakdown in the groups less likely to be engaged in structured
treatment. This is higher than the estimated 19% of the problem drug using
population in Nottingham being female.

Ethnicity

   83% were White (80% White British; 1% White Irish; 2% White Other). 6% were
    Black (4% Caribbean; 2% Other Black ethnicity)
   5% were of mixed ethnicity (3% White & Black Caribbean; 1% White & Asian; 1%
    Other Mixed ethnicity)
   4% were Asian (1% Indian; 2% Pakistani; 1% Other Asian ethnicity)

When looking at ethnicity, Nottingham City has seen a gradual upward trend in the
proportion of clients from BME backgrounds in treatment (from approximately 15%
non-white in 2004, to approximately 17% non-white ethnicity in 2007). The
Nottingham City trend therefore reflects that of the other urban areas in the region,
Leicester and Derby, with a noticeably higher non-white prevalence than elsewhere
in the region. It is also important to note that the proportion of clients from ethnicity
other than White engaged in treatment is higher than the proportion of non-white
individuals residing in the City.

Nonetheless, the 2007/8 found that the prevalence of clients from BME groups in the
treatment naïve population remains higher than the proportion found in treatment,
suggesting that this client group are not accessing treatment to the extent expected.

Age

   13% were aged between 18 and 24
   48% were aged between 25 and 34
   29% were aged between 35 and 59




                                           55
The predominant in treatment group are aged between 25 and 34. The 2007/8 Needs
Assessment found that the proportion of under 25 year olds engaged in structured
treatment was dipping slightly, and that individuals between the ages of 18 and 25
were more prevalent in the population of problem drug users not engaging in
structured treatment. Analysis of access and engagement service data suggests that
these services tend to see higher proportions of under 25 year olds. Improved
pathways between these services might therefore improve the penetration of this
group into structured treatment.


Drug Use

   74% used opiates as their primary drug (70% Heroin; 3% Methadone – problem
    drug likely to be heroin rather than illicit methadone; 1% other opiates). 84% of
    the client group used opiates among their drugs of choice.
   4% used amphetamine as their primary drug. 8% used amphetamines among
    their drugs of choice.
   3% used cocaine as their primary drug. 9% used cocaine among their drugs of
    choice.
   4% used crack as their primary drug. 42% used crack among their drugs of
    choice
   13% used cannabis as their primary drug. 23% used cannabis among their drugs
    of choice.
   19% used alcohol alongside their drugs of choice.

The current structured treatment system appears to engage opiate users fairly well.
This would support the finding of this review that opiate prescribing treatment is well
provided in the current system. Crack primary drug users, and poly drug users who
use crack amongst their drugs of choice, are noticeably less well engaged in
structured treatment. This is a concern when Home Office prevalence data indicates
70% of the city’s problem drug users use crack cocaine. This would suggest that the
current structured treatment system does not include adequate treatment provision
(e.g.: psychosocial and psychological interventions) or is not effectively engaging this
problem drug using group.
Stimulant users engaged in structured treatment are also fewer in number than might
be expected based on what we know of the drug using population in Nottingham.
This may be due to the relatively low profile of treatment options for this client group.
For example, while Chill Out saw a significant number of stimulant users in
comparison to other services, the service is not well known to key stakeholder and
client groups. Improved referral pathways and publicity is likely to improve this.
There is a relatively high number of cannabis users engaged in our structured
treatment system when considering that the greatest provision of treatment in
Nottingham is prescribing treatment. While it is important that the needs of this drug
using group should be met in the city, it may be that these clients may benefit from a
specific service / programme of interventions rather than engaging with prescribing
and psychological services.




                                           56
4.9 RECOMMENDATIONS:

Recommendations relevant to structured treatment:

   1. Ensure that rapid access to treatment is available for all clients – with
      minimal delay between assessment of need and treatment start.

   2. That there is a care co-ordination function within the treatment system
      to facilitate a client’s journey through treatment and ensure that
      treatment interventions / wider support are maximised to meet
      individual needs.

   3. Contracts and contract monitoring arrangements with prescribing
      services should ensure requirements for prescribing services to provide
      optimal dosing in order to reduce the likelihood of clients ‘using on top’.

   4. Ensure all clients in structured treatment are provided with appropriate
      harm reduction advice on injecting, sharing, and increased risk of
      overdose when ‘using on top’.

   5. For the new model to include clear and integrated care pathways for all
      drug users – including expectations around movement from secondary
      and primary care.

   6. To develop clear definitions / expectations around the needs and
      treatment options for both complex medical cases and more stable
      client groups.

   7. That the capacity within Shared Care is maximised to support a greater
      number of clients, the expansion of the role of keyworkers and non-
      medical prescribers should be considered in the first instance.

   8. To ensure that the new treatment system provides real choice to clients
      regarding their treatment options, the new model should consider
      whether it is necessary to more clearly separate delivery of Shared Care
      from secondary care.


   9. To provide effective and suitable treatment interventions to non-opiate /
      non-injecting drug users in an appropriate / distinct environment.


   10. To ensure the treatment system has sufficient psychological and
       psychosocial therapies that are accessible to all drug users.


   11. To establish a menu of structured activities available to individuals
       engaged in treatment and ensure that clients are supported to access
       diversionary activities.

Recommendations relevant to the general treatment system:




                                       57
12. The new treatment model should be flexible in response to client need
    and provide some out of hours support / access to drug treatment.

13. Ensure that the new treatment model is well publicised throughout the
    community, with access routes made clear in all publicity material

14. For the new model to include clear and integrated care pathways (ICPs)
    for all drug users. This should make clear the entry criteria / exceptions
    for each service and highlight provision for non opiate and non injecting
    drug users.

15. That joint working between services needs to be an integral part of the
    treatment system, with a shared assessment, care planning and
    integrated working a specified requirement.

16. The Clinical Guidelines to be included in all SLAs / Delivery Agreements
    to ensure compliance with national guidelines and best practice and
    supported by contract monitoring mechanisms including audit.

17. The new treatment model will need to include a centralised Clinical
    Governance framework to ensure that delivery of treatment in the city is
    safe and effective.

18. The Clinical Governance framework must include an audit cycle to
    ensure compliance with guidelines and best practice (especially for
    medical treatment).

19. To ensure that all SLAs / Delivery Agreements include a clear service
    remit and set out the ICPs within the treatment system.

20. A full equality impact assessment of the new treatment system model to
    be undertaken in the next stage of the review.

21. A full review of the cost effectiveness of the proposed model should be
    undertaken in the next stage of the review.




                                    58
5. Aftercare/Continuing Care and Wraparound
This section of the review focuses on the aftercare and continuing care stage of the
treatment journey. It also considers wraparound provision as part of a client’s holistic
package of structured treatment and/or aftercare/continuing care provision.

Mentoring is considered in this section although it should be noted that support from
mentors is available regardless of where clients are in the treatment journey.


5.1 National Guidance / Research

The following is a summary of national guidance in relation to aftercare, continuing
care and wraparound.

NTA/Models of Care

Aftercare provision is defined within Models of Care as:

“…a package of support that that is planned with the client to support them when
they leave structured treatment.”

Such provision may include relapse prevention or harm reduction. It may also include
non drug related support such as housing, access to education and generic health
and social care.

It also states that at the point of aftercare and continuing care:

“Access to more specialised counselling services may be required following initial
assessment or review of service user needs. Such services may include
bereavement therapy or counselling therapy related to physical and / or sexual
abuse.”

Structured day programmes are an important part of the treatment system and
should be commissioned to contribute towards an improvement in social functioning,
life skills, vocational and educational goals, training, employment and housing
support.

Drug misuse and dependence UK guidelines on clinical management

The updated Clinical Guidelines describes the importance of utilising psychosocial
interventions within drug treatment, and in relation to aftercare, continuing care and
wraparound states that this includes providing:

“…Interventions to prevent relapse” and “help to address social problems, for
example, family problems, housing and employment.”

It also emphasises that Key workers may provide practical support or referral for
patients with social problems, which might include housing, childcare and child
protection, employment and education.

Relapse prevention work is identified as being of importance and the link is made
between typical relapse prevention strategies and using them to ultimately generate




                                            59
‘pleasurable sober activities and relationships, improving quality of life and attaining a
lifestyle balance’.

It notes that such activities can be useful both to ‘increase engagement in treatment
and to improve physical health and well being’.

NICE Clinical Guidelines

The NICE Clinical Guideline – Drug Misuse: Psychosocial Interventions – identifies
that evidence-based psychological treatments should be considered for those who
have achieved abstinence or are stabilised on opioid methadone treatment. Clearly
psychosocial and psychological interventions have a role to play in aftercare and
continuing care stage of the treatment journey.

The NICE Quick Reference Guide - Drug Misuse: Psychosocial Interventions and
Opioid Detoxification – states that following successful opioid detoxification in the
community or inpatient setting, all service users should be offered continued
treatment to support and help maintain abstinence, normally lasting for at least 6
months.

National Drug Strategy

The 2008 Drug Strategy places social reintegration of drug users through drug
treatment services as a central aim of the strategy.

A key strategy action is defined as to:

“Develop a package of support to help drug users, and particularly those causing the
most harm to access and complete treatment and to re-integrate into society.”

The strategy says it will reform the treatment system by ‘offering services such as
training and support in getting work, alongside drug treatment’. While the new focus
on reintegration will provide ‘support for people with drug problems to move towards
treatment, training and employment’.

Scottish Drug Strategy

The Scottish Drug Strategy quotes case studies that show examples of good working
practice that meet the wrap around and aftercare needs of clients.

It mentions the Lothian’s and Edinburgh Abstinence Programme that runs a three
month day programme which provides a package that includes:
“Vocational training and education providers to help equip clients with skills and
qualifications […] with two years aftercare planned and built into the programme […
and …] supported housing provided where required.”

The Glasgow Addiction Services is praised for placing getting people back to work, in
to educational opportunities or training as at the core of what they do. “Employment,
education, access to training and voluntary work are now not viewed as end point
goals for individuals, but as key intermediate goals.” The system is also praised
because if people relapse they can immediately be routed back into Community
Addiction Teams for a review of care and treatment.




                                           60
5.2 Consultation Findings

Through the treatment system review consultation process, several key issues were
identified in relation to aftercare/continuing care and wraparound provision.
Consistently highlighted issues included:

   1. Consultation questionnaires completed by service users, carers and workers
      within the field consistently highlighted aftercare, ETE and wraparound as
      being of vital importance within the treatment system. With stakeholders
      reporting a need for more aftercare for all drug and alcohol users.

   2. Wraparound provision for clients who are still using illicit drugs or on a script
      is a significant gap in the treatment system and was consistently identified as
      such through consultation. Whilst there is awareness of the aftercare
      provision of Double Impact there is a perception that there is no or not
      enough wraparound available for people within the treatment system. In
      particular service users spoke of boredom, loneliness and isolation and the
      need for a clear and accessible package of constructive diversionary
      activities, as well as practical issues such as benefits, debt etc.

   3. Consultation indicates a need for suitable and supported accommodation for
      recovering drug addicts. Access to emergency accommodation, second stage
      provision, including accessible abstinent housing and move on support should
      be available with clear referral pathways, remits and eligibility criteria.

   4. Consultation also highlighted the desire that opportunities be created for ex-
      service users to join the workforce to help both the ex-users themselves and
      provide support to those still using/within the treatment system. This is
      already proving successful for both the ex-service users and the client group
      served through existing mentoring provision.

   5. As with all other elements of the treatment journey it will be important to
      consider the consultation finding that opening times should be extended to
      provide more evening and weekend availability of aftercare and wraparound
      provision. This is particularly important in alleviating some of the boredom and
      isolation experienced by users and providing timely and responsive support to
      help prevent relapse.


5.3 Local aftercare and wraparound provision

There are 4 providers delivering some element of aftercare, wraparound and / or
mentoring provision to our client groups in Nottingham that have been considered in
detail as part of the treatment system review:

        Double Impact
       Double Impact is the main commissioned provider of aftercare services in the
       city. This consists of the Core Service that offers access to education, training,
       courses, life skills, support to access housing, relapse prevention groups, and
       group and structured activity (and is recorded as structured treatment to
       NDTMS), advice on a range of issues (treatment, voluntary work, employment,
       education and court support).




                                           61
       It also offers a debt advice service for clients that are within the treatment
       system and gate mentoring, to provide support to those in treatment from ex
       service users with help attending appointments.

       Double Impact recently changed the delivery of its structured day programme to
       allow for more flexibility of attendance. This means clients could pick and
       choose what they attended without signing up to minimum attendance
       agreements. They believe this improves attendance in the long run and allows
       clients to try new activities as and when they are ready.

       Double Impact provides services for both drug and alcohol users.

        Gate
       Gate Mentoring is part of Double Impact. It recruits and trains a pool of ex
       service users to provide mentoring support for people that are currently
       engaged within the treatment system. This takes the form of accompanying
       clients to a wide range of appointments, which could include appointments with
       various providers, including treatment, wrap around, health, legal, employment
       and housing services.

        Aspire
       Aspire is a mentoring project that aims to engage substance misusers that are
       not currently accessing drug and alcohol services to engage with and remain
       within treatment services. It uses a pool of volunteer mentors to provide
       outreach services in locations where there is no, or limited access to drug
       treatment. It focuses on providing outreach targeting drop-in for homeless
       people and women involved in prostitution.

       It is not a treatment provider but mentors provide holistic support and advice to
       clients to with the ultimate aim of helping them engage and remain in treatment
       throughout the treatment journey.

       FT2 ASH Housing Team
        Frameworks FT2 housing offers an excellent standard of Individual Support
        Planning and risk assessment in its provision of supported drug managed and
        abstinent housing, and the service is generally under pinned by high quality
        policies and procedures. The service is flexible and works to try and maintain
        residents within housing and treatment. There is evidence that systems are in
        place to share information with treatment providers e.g. sharing drug test
        results, keeping them informed of progress etc.

There are other providers of such wraparound interventions that are not directly
aimed at our client group and these have not been considered at length as part of the
review, however it is to be noted that they are still accessible to drug and alcohol
users. This is not an exhaustive list of all wraparound provision available to our client
group but reflects some of the best utilised services. There is clearly wraparound
provision available to clients, the challenge is ensuring that workers in the field are
aware of the provision and are able to appropriately refer clients into it:

       Progress 2 Work
        Part of the wider Working Links scheme, Progress 2 Work targets people with
        past drug or alcohol problems, ex-offenders and homeless people with the
        aim to help clients access training, employment and education at the clients
        own pace.



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      Framework Academy
       Framework Academy covers all of Frameworks learning services, providing
       an alternative to mainstream learning for homeless and vulnerable individuals
       including drug and alcohol users, delivering ‘learning and meaningful
       occupation’.

       People can judged to be vulnerable due to present or past issues such as
       substance misuse, mental health, low self esteem, homelessness, offending
       behaviour can access.

      AIR Project
       The AIR project is part of the Academy and provides an advice and guidance
       service, signposting people seeking to training, employment and educational
       advice to appropriate services.

      Probation ETE Services
       Probation provides opportunities for clients in contact with the Probation
       service (on orders, license etc) including some CJIT clients and level one and
       two POP clients. There is a wide range of available help with basic skills,
       educational and training courses, qualifications. Some funding is available for
       work related equipment.

      Castle College
       Castle College currently runs some basic skills sessions within direct access
       hostels. They could potentially be utilised to offer some services within any
       new provision.

      St Ann’s Advice Centre
       Welfare rights and debt advice is available from the St. Ann’s advice centre
       based on Robin Hood Chase. Areas of speciality are welfare benefits,
       employment law and debt advice. The specialist debt worker has strong links
       with the courts and City CJIT team. This is not currently receiving funding
       from the CDP but could be utilised within any future wraparound provision.

Housing

Supporting People have recently undertaken a review of housing provision available
to the drug and alcohol using client group (see section 1.6).


5.4 Good Practice

While    consultation feedback highlighted          significant gaps  within the
aftercare/continuing care and wraparound elements of the treatment system, there is
evidence of a range of good practice within existing provision:

Aftercare

Double Impact provides the main directly commissioned wrap around element
through its Aftercare service. Its recent decision to allow more flexible access to
structured activities and groups seems to mirror what was requested by service users
and forums. The service provides a good range of groups, relapse prevention,
courses, debt advice etc.




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However, as already stated this provision is limited to those who are abstinent or
‘clean and dry on the day’ and reflects a significant inequity of provision for those
who are stable or in maintenance prescribing.

Mentoring opportunities

The use of gate mentors made up of ex-service users is good practice in terms of
improving access into the field for this client group. It also meets consistent requests
from clients that they want more ex-users in the work force. There is evidence that
mentors are well trained, supported and supervised.

Mentoring services are able to focus attention on relationship building, which service
users have expressed is vital to supporting engagement and retention in the
treatment system.

Mentoring services provide enhanced support for clients within the treatment system.

Education, Training and Employment (ETE)

Frameworks Academy and Air project are highly successful at providing ETE
services for our client group, particularly people that are still using drugs and alcohol
or who might be in treatment. They offer small class sizes, one to one support,
flexible attendance, qualified teaching staff and the service is OFSTED inspected.
They are successful at completing care plans and have good outcomes in terms of
helping clients access further ETE, as well as offering some diversionary activities,
life skills and personal development.

Progress 2 Work also offers good ETE provision and is well placed through its
alignment with the employment service to deliver government driven agendas.

Supported housing

Framework FT2 Housing is providing a valuable pool of drug managed and
abstinence housing for vulnerably housed problem drug users. Both the drug
treatment workforce and service users identified that appropriate housing, including
for those still using and abstinent, would support better outcomes of treatment for our
client group.

Although Framework FT2 is only commissioned by the CDP to provide testing, brief
interventions and harm reduction advice to clients, and to help maintain clients within
the treatment system, it is clear they serve a much more valuable purpose than this.
They are a major provider of both drug managed and abstinent housing which is also
funded by Supporting People. Joint working by the CDP, Housing Policy and
Supporting People has identified the continuing provision of this housing as being of
major importance in the future.

Clients in Framework FT2 housing will have access to extra support from key
workers by the provision of brief interventions, harm minimisation and through close
links with treatment providers. They will also have good links to Frameworks ETE
services.

The Supporting People Review considers drug and alcohol supported housing in
more detail (see 1.6).




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Debt advice

The Double Impact debt advice worker provides guaranteed quick access to debt
advice for clients within the treatment system, without them having to compete with
clients outside the system. However, there are other providers of debt advice (most
notably St. Ann’s advice centre worker) that are effectively reaching some of our
client group. The St Ann’s advice centre worker has good links with the courts and
sees a high proportion of CJIT clients.

The Citizen’s Advice Bureau offer debt advice services but evidence suggests that
services are using either the debt worker at DI or the St. Ann’s advice worker.


5.5 Weaknesses

As anticipated the major weaknesses in relation to aftercare/continuing care and
wraparound provision are focused on key gaps in the treatment system and have
been picked both by the review of the current system and consultation mechanisms.
These gaps should be fully addressed within any revised model for the treatment
system.

Clients still using / scripted

The major weakness within the wraparound system is that there is a perceived lack
of wraparound provision for people that are still using or who are in treatment and
scripted. People that might be stable and scripted are excluded from the main drug
aftercare provider within the treatment system. The present system tends to view
“aftercare” and “wraparound” as inextricably linked similar entities i.e. that
wraparound needs are met when clients leave structured treatment and move into
abstinent aftercare.

There is also a perceived lack of structured activity for this client group, although
Framework Academy does provide a good service it is primarily focused around ETE
and only has capacity to support 600 individuals per year across the County for
people that are vulnerable for a variety of reasons, including substance misuse and
homeless (this could be past or present).

There is evidence that external providers do exist that could be utilised to provide
wraparound provision to drug and alcohol users. Although these clearly are used and
referred into by some treatment providers, there is a need to formalise pathways and
raise awareness of services across the whole treatment system to ensure equity of
access.

Abstinent versus ‘clean and dry’

Double Impact provides aftercare services, broadly based on the existing definition of
aftercare as contained within models of care, which points to a client group that is
exiting structured treatment and abstinent.

However, Double Impact also sees people as long as they are “clean and dry on the
day.” This means that people who are still actively using can access services if they
are deemed to have not used that day. This causes upset amongst some clients who
are abstinent and in recovery.




                                         65
There is evidently a need to establish a clearer definition of eligibility criteria for
aftercare and continuing care provision.

Relapse

The review shows evidence that people frequently dip in and out of Double Impact,
often returning when they have relapsed. They are seen and there was evidence of
workers discussing what groups they could access with them. However, there is
limited evidence that those relapsing and self-referring back to Double Impact were
referred back into treatment provision. There could be stronger plans and referral
pathways in place for clients in contact with aftercare service who relapse and need
to be referred back into treatment services.

At present, it appears that clients remain in contact with existing aftercare services
for support, and need to go through the process of self referral into prescribing
services / treatment services should they relapse.

Pathways

There was no evidence that all treatment providers routinely referred into aftercare
provision on completion of treatment, and the review demonstrated few examples of
treatment services passing on care plans to Double Impact to facilitate integrated
care pathways.

As already established there is a variety of ETE provision supplied by different
agencies. The major difficulty is that there is a lack of co-ordinated referral pathways
into such provision which disadvantages some clients and does not offer full client
choice. Referrers may have projects that they favour or may miss others due to a
lack of knowledge.

The wraparound care that a client may receive is therefore very much dependent on
the knowledge of an individual worker that is responsible for care co-ordination –
equality of wraparound provision is needed for all people within all areas of the
treatment system.


5.6 Effectiveness

Key objectives for the aftercare/continuing care element of the treatment journey as
set out in national guidance are to:

   •   Support successful outcomes of treatment
   •   Provide interventions to prevent relapse
   •   Support clients to reintegrate with the community

Each of these objectives must be successfully delivered for aftercare/continuing care
provision to be considered effective.

Support successful outcomes of treatment

Gate Mentors work with clients that have already entered the treatment system. Their
support to ensure that clients attend a variety of treatment and wrap around
appointments has been vital in keeping people within the treatment system. Their
work has therefore helped meet the needs identified on client care plans.



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In the year 07/08 Gate Mentors met 166 times with clients and accompanied them to
appointments. This included 47 appointments with treatment providers, 10 medical
appointments, 93 ETE and wraparound appointments.

Similarly, BETWEEN 07/08, Aspire Mentoring made 140 referrals for clients to
various providers in the City. Of these 28% of the total referrals were for drug
treatment, of which 54% were judged as successful outcomes.

Of the 140 total referrals, 66 were made to wrap around providers. 53% of these
referrals were attended and judged as successful.

FT2 during 2008 have demonstrated that they have also helped support successful
treatment outcomes. 153 of their residents this year have been in contact with
treatment providers.

They have conducted 268 drug tests. The results of these will have been shared with
prescribing treatment providers to help inform treatment.

There have been 14 successful planned discharges form the project so far this year.
This indicates a level of stability within these clients in that they are ready to move
on.

There have also been 28 onward referrals to other services, 21 of which were to
wrap around and ETE providers.

During 2007/08 there were 200 attendances of the Relapse Prevention Group alone,
and vast attendance at other related groups looking at topics such as Life without
drugs, assertiveness, stress and anger management, confidence building etc.

Those exiting treatment who are eligible to access Double Impact have access to a
range of interventions to sustain positive gains of treatment including access to
education, training, courses, life skills, relapse prevention groups, and group and
structured activity.

Interventions to prevent relapse

Double Impact as the sole provider of formal aftercare provision in the City works to
prevent relapse for its client group and includes relapse prevention groups and work
within its programmes of activity.

There may be a need to ensure that relapse prevention is part of the care planning
process at the start of an aftercare or continuing care programme and ensure that
there are improved referral pathways back to treatment for those who do relapse.

Support to reintegrate with the community

As already stated there are a wide range of wraparound interventions available in
Nottingham that would support our client group in successfully integrating with the
community. These are particularly strong in terms of ETE, debt advice and housing
provision. The major challenge is ensuring that the workforce is fully knowledgeable
of options and have established referral links with providers. More structure in the
system is needed so that referral in to ETE is expected as part of client’s treatment
through out their treatment journey – not just as part of Aftercare.



                                          67
Such provision is also available centrally within the drug treatment system through
Double Impact for those who are abstinent or ‘clean and dry on the day’. There are a
wide range of courses and activities available that are well attended. Clients have
flexibility to access structured activities rather than having to sign up and commit in
advance, which, the service believes, improves participation. At present Double
Impact seems to provide a mixture of wraparound and aftercare services.

The treatment system does not effectively support all clients to reintegrate with the
community as the pathways to external wraparound interventions are not routine or
well established and aftercare provision is not available to those who are still using or
still in treatment (particularly those on a script).

It is important to reiterate the finding that a great deal of ‘continuing care’ work
actually happens within access and engagement services but that this is not the
appropriate placement of this provision nor is it aligned with commissioned remits.

Double Impact

A more detailed analysis of provision at Double Impact indicates that the service has
effective assessment processes in place and is quick to access with all clients with a
valid waiting time waiting less than 3 weeks. The service is effective in engaging new
clients and maintaining existing ones.

Over half (61%) of the discharges from the service are planned in comparison with a
City wide total of 70%. The service claims that it attempts to make follow up contact
with every one with whom they do not have contact for a period of thirty days
(although there was little evidence of this seen within the file audit).

Around 58% of clients are retained in treatment with Double Impact for 12 weeks or
more which is poor against a local target of 85% and overall performance of 70%
across the City.

Retention and planned discharge performance suggests that the service is not as
effective as structured treatment providers which is surprising considering that the
client group is likely to be largely stable and that the service appears to be offering
interventions and activities that are desirable to the client group. Further work to
understand why this is the case is required.

Mentoring

Mentoring provision clearly has a role to play across the treatment journey with the
review highlighting that mentor provision identifies and engages with problem drug
users making wide ranging and appropriate referrals into the treatment system.
Mentoring services will then continue to support clients while they build relationships
with treatment providers.

Mentoring provision within the City also provides effective retention of clients within
the drug treatment system by providing follow up and ongoing contact with clients
who are disengaging from their service and/or the treatment system. Aspire have
evidence of excellent client retention.




                                           68
Framework Academy

In 2007 The Academy was inspected by Ofsted and its overall effectiveness was
rated as ‘Good’. The service was successfully reaccredited as a Matrix standard
organisation and Job Centre Approved Provider.


5.7 Care Pathways

Clients enter Double Impact through established care pathways, but these are
dependent on good relationships being formed with treatment providers who will refer
into the service. There is therefore a chance that referrals may not be made if a
service is not aware of Double Impact.

However, Double Impact is widely known as the main aftercare provider in the City
and does receive referrals from treatment services although there is a high rate of
self referral which is not indicative of an effective treatment journey into aftercare
provision.

The referral process at Double Impact seems effective at getting clients seen within
targeted waiting times.

As already highlighted there is evidence that some clients tend to come back to
Double Impact when they have relapsed for support, rather than following a planned
route back into contact with a treatment provider.

Both Gate and Aspire mentoring services are widely used and mentors accompany
clients to a vast range of appointments with different services and providers. There is
evidence of mentor services appearing in the care plans of a range of treatment
services and of joint working.

The debt advice worker works with clients from a range of treatment services and
provides some outreach provision in order to maximise accessibility.


5.8 Client Group

Aftercare/continuing care and wraparound provision is largely available to those who
are abstinent or ‘clean and dry on the day’. Some provision outside of the treatment
system (e.g. Progress 2 Work, Framework Academy, debt advice worker) is available
to clients who might still be using or scripted.

This means that the service as a whole offers support to some sections of the client
group whilst excluding others. This is confusing and inequitable.

Aspire mentoring service specialise in meeting the needs of underserved groups
(including women in prostitution and homeless) not engaged with treatment.
Framework FT2 also focuses on some of the most vulnerable groups, including
homeless and vulnerably housed problem drug and alcohol users.

The demographic breakdown shows the gender, age and race of people accessing
Double Impact correspond very closely to the figures produced by previous needs
assessments on the profile of problem drug users.




                                          69
Gender

07/08 stats show for the core Double Impact service:
78% clients male
22% female
This is a lower proportion of women accessing the service than seen in access and
engagement services and structured treatment but is slightly higher than the overall
estimate for the proportion of women who make up the problem drug using
population in Nottingham.

Double Impact provide women’s specific group, but most other groups at the service
appear to be quite general in terms of demographics.

Aspire appear particularly good at reaching female clients with 52% of clients on the
caseload at the time of the review being women which is more than double the
proportion of women through to make up the overall problem drug using population.

Ethnicity

77% of the Double Impact client group were of white British ethnicity demonstrating
the service is engaging a higher proportion of Black and Minority Ethnic clients than
elsewhere in the treatment system and 10% higher than the estimated proportion of
users from Black and Minority Ethnic communities in the overall problem drug using
population.

Age

The biggest age groups accessing Double Impact are 25 – 34 year olds (41%) and
35 – 44 year olds (35%).

Drug Use

The main primary problem drug for clients in contact with Double Impact is cannabis
(37.50%) followed by heroin (27%), with fewer reporting crack (15%), cocaine (8%)
and amphetamine (10%) as their primary problem drug.

The Academy works particularly well with some of the most disadvantaged groups of
people and recent statistical analysis showed that 81% of people accessing the
service had a drug and / or alcohol problem. Their work is particularly valuable for
getting these people (many of whom will be treatment naive) into mainstream
services.




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5.9 RECOMMENDATIONS

Recommendations relevant to aftercare, continuing care and wraparound provision:

   1. Plans to support clients who relapse should be established as part of a
      clients care plan when they initially move into aftercare.

   2. There needs to be a clearly defined referral route into wraparound
      services as a part of all care plans. This should be co-ordinated by a
      worker within the drug treatment system, possibly a care co-ordinator.

   3. A wide range of wraparound and diversionary activities should be
      available through the treatment system to all drug users. These may be
      provided within the treatment system or may be provided externally with
      strong referral pathways and integrated into care plans and care co-
      ordination.

   4. The aftercare model should be opened up to continuing care and so be
      available to drug users who are stable including those who are stable on
      maintenance.

   5. Joint work should be undertaken with housing and Supporting People
      to ensure the appropriate range of supported accommodation is
      available to meet the needs of our client group.

Recommendations relevant to the general treatment system:

   6. A full equality impact assessment of the new treatment system model to
      be undertaken in the next stage of the review.

   7. A full review of the cost effectiveness of the proposed model should be
      undertaken in the next stage of the review.

   8. Mentoring provision should continue to be commissioned as part of the
      new treatment system model.




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6      Criminal Justice Treatment System
This section of the review concentrates on drug treatment for drug using offenders
through the criminal justice system. National policy has led to the implementation of
‘end to end’ management for the treatment of drug using offenders and so this
section covers the whole criminal justice treatment journey from access and
engagement through to exit.


6.1 National Guidance / Research

The following is a summary of national guidance in relation to the criminal justice
treatment system.

The Drug Interventions Programme

The Drug Interventions Programme (DIP) is a key part of the Government’s strategy
for tackling drugs and reducing crime. And it’s working: drug-related crime has fallen
by a fifth since DIP started and record numbers of people are being helped with their
drug misuse.
Introduced in 2003, with new elements having been phased in each year since, DIP
aims to get adult drug-misusing offenders out of crime and into treatment and other
support. Some interventions operate right across England and Wales, while
additional “intensive” elements operate in those areas with the highest acquisitive
crime (as in Nottingham).

DIP provides new ways of working as well as linking existing ones across the
criminal justice system, healthcare and drug treatment services and a range of
other supporting services.

DIP has introduced a case-management approach to offer offenders treatment
and support from the point of arrest to beyond sentencing. Sharing information
on the treatment needs of individual offenders allows professional multi-skilled
teams to provide tailored solutions.

Models of Care

The NTA define the Drug Interventions Programme within Models of Care as:

     “Criminal justice and treatment providers working together with other
    services to provide a tailored solution to adults who commit crime to fund
    their drug use. The Drug Interventions Programme aims to break the cycle of
    drug misuse and offending behaviour by intervening at every stage of the
    criminal justice system to engage offenders into drug treatment.”

They put Criminal Justice Integrated Teams (CJIT’s) at the heart of DIP, as
providing a case management approach to offer access and support. This
support starts at the point of first contact with the criminal justice system and
continues through the criminal justice journey (through custody, court, sentencing
and beyond, into resettlement).




                                         72
National Drug Strategy

Treatment for drug using offenders is a key policy within the updated National Drug
Strategy which aims to:

   “Target […] the drug-misusing offenders causing the highest level of crime,
   improving prison treatment programmes and increasing the use of community
   sentences with a drug rehabilitation requirement”

The Strategy aims to target those most at risk and aims to prioritise access to
treatment for those drug using offenders who enter through DIP and those leaving
prison or completing the Drug Rehabilitation Requirement (DRR) of a community
sentence of period on licence.

Drug Rehabilitation Requirements

A Drug Rehabilitation Requirement (DRR) provides fast access to a drug treatment
programme with the goal of reducing drug related offending.

Offenders agree their treatment plan with the probation and treatment services
(locally the treatment is also provided by the Probation Service). The plan will set out
the level of treatment and testing and what is required at each stage of the order.

Lasting between six months and three years, the DRR aims to:

   •   help offenders produce a personal action plan so that they can identify what
       they must do to reduce offending and stop their use of drugs;
   •   explain the links between drug use and offending and how drugs affect
       health;
   •   Help offenders identify realistic ways of changing their lives for the better.

Treatment is carried out at a specified place, either as an in-patient or out-patient and
includes regular drug testing and court reviews. It may also provide clinical treatment;
a day care programme; health education; activities to improve social skills, education
and career prospects and participation on an offending behaviour programme.

A Community Order with a DRR can be reviewed by the court. Failure to stick to the
treatment plan will mean a return to court for breach of the order. This could result in
re-sentencing which may result in a prison sentence.

Prolific and Priority Offenders

It is estimated that approximately 10% of the active offender population are
responsible for half of all crime and that a very small proportion of offenders
(0.5%) are responsible for one in ten offences. The Prolific and other Priority
Offender (PPO) strategy was announced by the Prime Minister in 2004 to provide
end-to-end management of this group of offenders.

In Nottingham City the PPO scheme draws on best practice guidance nationally in
relation to targeting and management of persistent drug misusing offenders.




                                           73
Integrated Drug Treatment System

The Integrated Drug Treatment System [IDTS] aims to increase the volume and
quality of treatment available to prisoners, with particular emphasis on early custody,
and will start to address better integration between clinical and CARAT Services.

Many of the benefits of drug treatment tend only to materialise after several weeks of
ongoing intervention.

The management of continuity of treatment is therefore vital, and the Integrated Drug
Treatment System for prisons is designed to facilitate continuity at both points of a
period of custody: reception of individuals who are in current receipt of treatment, and
release of IDTS clients with continuity of treatment needs. This is central to the role
of CARAT workers and is outlined in NOMS Drug Strategy Unit DIP Prisons
Guidance 1.

The roles and responsibilities of the National Treatment Agency, HMP Nottingham
and the CDP have been unsure. As of July 2008 the CDP assumed commissioning
responsibility for the IDTS programme. Therefore, any areas of development will be
identified during Stage Two of the Treatment System Review.


6.2 Consultation Findings

New and pre-existing consultation findings utilised for the treatment system review
presented some key issues for consideration under the criminal justice element of the
treatment system.

In summary these consultation findings included:

    1. The co-location of offender managers and drugs workers is beneficial for the
       client as it facilitates integrated working, as is being able to access a wide
       range of interventions from one place.

    2. Service user consultation identified that access to the Fit 4 Work programme
       was very beneficial as it addressed several areas of needs for clients. The Fit
       4 Work programme addressed the life skills of offenders through nutrition,
       exercise and education.

    3. A range of positive feedback on the effectiveness of CJIT from services users
       and other professionals involved with CJIT.

    4. There is some duplication between the CJIT role and the role of some access
       and engagement provision, in particular where a pre-existing or disengaged
       CJIT client is picked up by another drug treatment access and engagement
       service.

    5. Consultation from the first stakeholder event indicated that the treatment
       system should cater for many substance misuse needs not just opiates and
       crack cocaine use. As DIP primarily focuses on opiate and crack cocaine


1
  National Offender Management Service (2006) Drug Strategy Unit DIP Prisons Guidance Delivery of
the Drug Intervention Programme in Prisons – Guidance for Prisons




                                                74
       users. This could be seen as a gap for drug using offenders who do not use
       these substances.

    6. As stated in other sections, consultation consistently highlighted the need for
       suitable out of hours provision and ideally some 24/7 access for clients in
       times of crisis. Building on the 0800 number that CJIT currently provide.

    7. Rapid access to structured treatment is desirable across the treatment
       system not just limited to those clients coming through the criminal justice
       route.

    8. The criminal justice system needs to recognise alcohol as part of offending
       behaviour and provide appropriate interventions to address this particular
       type of offending behaviour through appropriate support and interventions.


6.3 Criminal Justice Drug Treatment Provision in Nottingham

Drug treatment through the criminal justice system is currently provided by the
following services in Nottingham

   Criminal Justice Intervention Team (CJIT)
    CJIT hosted by Nottinghamshire Probation Service provide ‘end to end’
    management of drug using offenders coming through the criminal justice system,
    including through custody suites, courts and prison release. The service provides
    assessment and brief interventions at Test on Arrest, care co-ordination and
    unstructured interventions as well as support and referral into treatment. CJIT
    also provides a throughcare and aftercare provision for clients who are
    completing treatment or orders. CJIT also work with prison releases as part of
    the Integrated Drug Treatment System (IDTS) to support them to re-engage with
    treatment. The conurbation element is commissioned by Nottinghamshire County
    DAAT.

   Rapid Access
    Hosted by the Nottinghamshire Mental Healthcare Trust as part of the
    Nottingham Alcohol and Drug Team, Rapid Access provide the first phase of
    structured drug treatment for drug using offenders coming through the criminal
    justice route.

   Probation Substance Misuse Team (SMT)
    A jointly funded service between Nottingham CDP and Nottinghamshire
    Probation Service with the conurbation element commissioned by
    Nottinghamshire County DAAT. This treatment team delivers structured
    treatment interventions to probation clients with offender management as integral
    to the service’s delivery model. SMT provide case management, offender
    management and, psychosocial and prescribing based interventions.


6.4 Good Practice

The review of the drug treatment system has highlighted a range of good practice
across the criminal justice element. Some of the good practice identified around
integration and care co-ordination provides a useful framework for the wider drug
treatment journey where there is limited similar provision.



                                         75
Good practice within the criminal justice drug treatment system includes:

Integration

The Adult Offender Team is the co-location of local services involved in delivering
offender management and treatment for drug using offenders at Castlegate House.
The co-location of teams within the Adult Offender Team model is having positive
gains in enabling more integrated working between services and workers providing
discreet elements of a client’s holistic package of care.

Such integration is also improving care pathways for clients, in particular in transition
from engagement via CJIT into treatment with Rapid Access.

Feedback from consultation indicates that the co-location of offender managers and
drug workers is beneficial, as is being able to have a wide range of interventions
accessible from one place.

SMT make effective use of mentor services, particularly when clients are difficult to
engage, demonstrating further integration with the wider drug treatment system.

Care co-ordination

There is strong evidence of good care co-ordination across the criminal justice
system through CJIT and SMT workers who co-ordinate treatment, offender
management and wraparound/continuing care for clients in a holistic package of
care. Such care co-ordination acts as an anchor for the client as they move through
their treatment and offender management journey.

However, there is also evidence that there could be increased care co-ordination to
enable those drug using offenders already successfully engaged in a treatment
programme to remain in that treatment programme if placed on a DRR or order. This
would require improved care co-ordination across the criminal justice system and
offender management through to mainstream drug treatment.

The CJIT model of care co-ordination is noted as good practice with a single care co-
ordinator allocated for while the client is engaged in treatment and care co-ordination
handing over to the aftercare element of the service one the client is no longer in
treatment.

Consultation feedback suggested that improved care co-ordination functions
throughout the treatment system would support clients to access appropriate
treatment interventions, as well as providing clearer and easier to navigate care
pathways and facilitating more integrated care.

Rapid access

National guidance on DIP stipulates that clients accessing through the criminal
justice route should have rapid access to structured drug treatment provision. As
stated above this is provided by the NADT Rapid Access team based within the Adult
Offender Team at Castlegate House, where clients are seen for assessment and
start of treatment within 48 hours.

At present the majority of the work provided by the Rapid Access team is focused
primarily on prescribing based interventions although there is some psychosocial
structured treatment also available.




                                           76
At present there is no equivalent level of rapid access provision for non-criminal
justice clients. As stated earlier, consultation identified that all drug users should
have rapid access to structured treatment inline with that provided to clients coming
through the criminal justice route by Rapid Access at the Adult Offender Team.

Wraparound

Analysis within the criminal justice drug treatment system indicates that there is
availability of strong wraparound provision with both CJIT and SMT addressing
client’s holistic needs. SMT in particular provide education, training and employment
opportunities and the Fit 4 Work programme referenced in the consultation findings
above.

Out of hours support

CJIT provide a 24/7 service to support clients and provide crisis support. Such
provision was identified as needed across the treatment system through consultation
mechanisms.

CJIT also cover the custody suites for extended hours from 8am to 10pm enabling
those drug using offenders identified through Test on Arrest to be engaged and
referred to treatment.

Needle Exchange in Custody Suite

In early 2008/9, a new scheme for provision of needle exchange within custody
suites was launched to reduce the health risk created when injecting drug users have
clean injecting equipment disposed of at custody suites.

This fits with the Nottingham Harm Reduction Strategy aim to implement a range of
interventions to keep drug users as healthy as possible while they choose to continue
using drugs.
The ‘Safe Works Scheme’ sees the Police and CJIT work together to ensure injecting
drug users are identified within custody suites and clean injecting equipment
provided upon release wherever possible.
The scheme is due for evaluation later in the year.


6.5 Weaknesses

While there is a range of good practice within the criminal justice drug treatment
system, analysis and consultation has also identified some challenges facing
effective delivery.

Pathways

There is evidence that some care pathways for criminal justice clients would benefit
from strengthening, in particular:

   •     Pathways between the criminal justice system (CJS) and treatment
         providers

   •     Pathways from CJS into continuous care

   •     Pathways and the exchange of information between prison and the
         community



                                         77
   •     Pathways into alcohol specific services

Although there have been a considerable amount of developments around care
pathways into access and engagement there is minimal evidence that this is
consistent.

Structured versus brief interventions

As with access and engagement provision (section 3), much of the work done by
CJIT once a client is allocated to the CJIT caseload should be considered structured
treatment. CJIT clients are often provided with a fairly high level of support which is
care planned, often structured and provided by a single keyworker/case co-ordinator.

This is supported through self assessment by CJIT who felt they delivered ‘other
structured interventions’ in line with the National Treatment Agency definition while
this work is not included in the Service Level Agreement.

Such work is not being counted as structured treatment in reports to the Home Office
and NTA which provides the information for monitoring performance against targets
for the partnership.

As with the main drug treatment system, it is possible that CJIT are plugging the gap
of structured psychosocial interventions within the criminal justice system, particularly
for those clients who are not suitable for prescribing based interventions. This is
supported by the fact that there are a high proportion of crack and cocaine users
being case managed by CJIT.

Duplication

There appears to be some duplication across services within the criminal justice
system with duplication noted between SMT and Rapid Access evidenced within
pathways and audits.

There also appears to be duplication between criminal justice services and the wider
drug treatment system. In particular CJIT duplicates at some level with structured
treatment provision, access and engagement services and mentoring provision.

The duplication with access and engagement services is strengthened by the review
of access and engagement provision. Analysis shows that it can evidently be difficult
to identify who should work with disengaged CJIT clients identified by wider access
and engagement services. This still appears to be problematic despite joint working
protocols being established across these services.

This is supported by the fact that CJIT have experienced difficulty in understanding
their remit, often moving into other areas of work. This is not unique to CJIT and is
evidenced throughout the treatment system adding to the likelihood of duplication.

Referral into structured treatment and DRR’s

A fairly consistent area of concern that has been identified over recent years is the
number of individuals referred via CJIT through into structured treatment. All systems
are currently being reviewed to improve the referral process from CJIT to Rapid
Access and through into NADT.

While it is hoped that co-location of CJIT and treatment elements through the Adult
Offender Team will improve referrals into structured treatment, it is also possible that
some CJIT clients (particularly non-opiate users) are having their needs met by CJIT
as there is a common perception that there is no structured treatment provision


                                           78
available other than prescribing (see above). This is a gap consistently highlighted
through consultation and analysis of both the wider drug and alcohol treatment
systems. In part this is likely to be due to the fact that CJIT is providing structured
interventions and so onward referral may not required.
It has also been identified that there are no systems in place for the early
identification of individuals appropriate for a Drug Rehabilitation Requirement through
CJIT.


6.6 Effectiveness

As explained in Models of Care the main aim of DIP is to break the cycle of drug
misuse and offending behaviour by intervening at every stage of the criminal justice
system to engage offenders into drug treatment.

In order to be considered effective, the criminal justice treatment system must:

   •    Identify and engage drug using offenders

   •    Refer drug using offenders into structured drug treatment

   •    Provide effective offender management



Identify and engage drug using offenders

CJIT work within the custody suites is the main route to identify and engage drug
using offenders into the treatment system.

The access and engagement element of CJIT provision through Test on Arrest has
improved dramatically over the last six months highlighting the services ability to
adapt to change.


                              Nottingham CIty KPI 2007/8


 100%

  90%
  80%

  70%

  60%

  50%
                                                                             KPI 1
  40%
                                                                             KPI 2
  30%                                                                        KPI 3
  20%                                                                        KPI 4
  10%

   0%
         Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May-
          07   07   07  07    07   07   07   07 07     08   08   08   08   08




                                           79
The establishment of the DIP/PPO Performance Meeting has enabled detailed
performance monitoring of the DIP process. The monthly meetings has provided a
forum on which to problem solve issues in partnership with all the agencies involved.

There is however considerable amount of improvement required in engaging those
drug using offenders leaving prison which could benefit from improvement through
the Integrated Drug Treatment System.

Refer drug using offenders into structured drug treatment
As covered in more detail above, referral into structured drug treatment via CJIT has
its areas for improvement. Work underway to review systems will go someway to
improve this as will the recommendations to review and expand the availability of
structured psychosocial interventions and to consider whether the work provided by
CJIT is ‘other structured interventions’.


6.7 Care Pathways
As well as pathways into treatment through the custody suites via CJIT drug using
offenders are also referred into SMT through the courts, as well as general offender
managers being able to identify someone with a drug problem who may be suitable
for a DRR.

However, the pathways out of SMT into the wider drug treatment system and general
offender management appear to be more effective than the pathways into the
service. Routes into SMT and onto DRR’s would benefit from improvement and
further embedding within practice.
Information taken from the 2006/7 and 2007/8 DIP Compact performance reports
suggests that many clients in contact with CJIT are receiving Tier 2 interventions with
them. National performance data and local information suggests that the proportion
accessing structured drug treatment is relatively low in comparison. A waiting times
audit undertaken in 2006/7, which sought to establish the number of clients
accessing structured treatment within 3 weeks of contact with DIP, suggested very
low numbers moving into structured drug treatment. Likewise, local performance and
monitoring reports produced for the partnership’s DIP Operational group suggest that
onward movement is low. On average, the attrition rate for clients attending their
treatment appointment following an assessment and referral by CJIT was 50%.

22% of referrals into structured treatment were via DIP or Criminal Justice System
(CJS). This is consistent with last year, but is less than in the region (30%) and
nationally (25%).

The interventions put in place to date 2007/8 have included a focus on Follow Up
Assessments, which were introduced to the DIP system in April 2007. This second
appointment is a legal requirement, and was implemented to combat the attrition of
clients moving into treatment following their initial CJIT appointment. From April 07,
clients were legally required to begin their assessment in the custody suite and
complete the remainder at another appointment. In Nottingham, this second
appointment takes place within a treatment centre, to provide opportunity for clients
to complete a Comprehensive Treatment Assessment or arrange a treatment
appointment at the same locality. In the first 6 months of 2007/8, the attrition rate for
treatment appointments at Rapid Access has reduced to approximately 30% on
average, with 70% of clients attending their appointment.




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The number of referrals is currently averaging at 39 a month. This remains relatively
low in comparison to the number of treatment naïve clients estimated to be in contact
with CJIT, and suggests further work is required.

Alcohol Arrest Referral

The Nottinghamshire Healthcare Trust’s review of alcohol treatment services
comments that the Alcohol Arrest Referral Scheme in the Nottingham police custody
suites is transferred into CJIT. This is supported in principle but is dependant on
appropriate funding.


Alcohol Treatment Requirements (ATRs)

The Nottinghamshire Probation Service have been pro-active in establishing ATRs
within the offender management. It is recommended that there are further
developments in determining the referral pathways into alcohol treatment services in
line with the new proposed treatment system model.


6.8 Client Group

It may be that the Tier 2 interventions provided to the clients in contact with CJIT are
adequate to meet their treatment needs. Nonetheless, the proportion of DIP referrals
into structured drug treatment is less than expected looking at the 2006/7 data. This
is particularly pertinent as the problem drug users in contact with CJIT are more likely
to be under 25, male, using cocaine or crack and / or of BME ethnicity than seen in
the in treatment population. This clearly reflects the treatment naïve population, and
suggests there are blockages to this group accessing treatment via DIP.

Considerable work has been undertaken in the previous treatment year (2006/7) and
is ongoing in 2007/8 around improving the pathway into treatment for clients in the
criminal justice system. The Rapid Access service, a structured treatment provider
specifically in place to meet the needs of problem drug users coming through the
criminal justice route, has expanded to provide stimulant interventions alongside
rapid prescribing. The period a client is held in Rapid Access has also been extended
to support them in stabilizing in treatment before moving into mainstream services.

Pathway process maps have also been developed to maximise the impact of DIP on
supporting problem drug users coming through the Criminal Justice System into
treatment. (See Process Map in appendices). The flow of clients into structured
treatment from DIP has continued to be a focus for 2007/8, with low compact
performance prompting further in depth investigation into the DIP pathway (see
Performance Exception Paper in appendices).

Looking at the profile of DIP referrals into structured treatment against the profile of
clients referred from other sources, it is evident that clients referred by DIP are more
likely to be:

   •   Males – by a significant margin (87% are males)

   •   White (81%)

   •   More likely to be aged between 25 and 34 (56%)



                                          81
   •   Much more likely to be opiate users (94%)
   •   Current (35%) injectors – or never have injected (30%)


6.9 RECOMMENDATIONS

Recommendations relevant to the criminal justice treatment system:

   1. That SMT and Rapid Access become one service working across the
      Adult Offender Team.

   2. Should structured interventions be identified within CJIT work should
      be done to capture this formally in contracting arrangements and
      reporting.

   3. Dependent on positive evaluation of the needle exchange scheme in
      custody suites this provision should be continued.

   4. Further work should be undertaken to identify the level of structured
      interventions being provided by CJIT.

   5. Further work to clarify roles and responsibilities with clear eligibility
      criteria requirements should be developed within the new model in
      order to reduce duplication between criminal justice treatment and drug
      treatment providers.
   6. Clearer care pathways and eligibility criteria for clients engaged via CJIT
      into both treatment and Drug Rehabilitation Requirements should be
      developed.

   7. Explore the potential of alcohol treatment being delivered through the
      Drug Intervention Programme.



Recommendations relevant to the general drug treatment system:

   8. The new model for the wider drug treatment system should consider the
      benefits and practicalities of adopting a similar model of a virtual or co-
      located service for those clients not coming through the criminal justice
      route.

   9. The new model for the wider drug treatment system should consider the
      benefits and practicalities of having a clear care co-ordination function
      as an anchor to the client’s treatment journey for those clients not
      coming through the criminal justice route.

   10. The wider drug treatment system should adopt a similar rapid access
       model so that all clients can begin structured drug treatment within 48
       hours and ensure equality of access.

   11. The lack of clearly identifiable psychosocial and psychological
       structured treatment across the drug treatment system should be
       addressed within the new model.




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12. The new model should consider whether a 24/7 freephone number could
    be implemented across the drug and alcohol treatment system
    incorporating or building upon the existing provision through CJIT.


13. A full equality impact assessment of the new treatment system model to
    be undertaken in the next stage of the review.

14. A full review of the cost effectiveness of the proposed model should be
    undertaken in the next stage of the review.




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7.       Families and Carers

This section looks at the cross cutting issue of support for families and carers of drug
users, as well as how families are involved in the treatment of drug users.


7.1 National Guidance / Research

The following is a summary of national guidance relevant to families and carers of
drug users within the treatment system.

The latest statutory definition of carers (as presented in the National Carers Strategy:
Carers at the heart of 21st-century families and communities) is as follows:
     “A carer spends a significant proportion of their life providing unpaid support to
     family or potentially friends. This could be caring for a relative, partner or friend
     who is ill, frail, disabled or has mental health or substance misuse problems.”
It is important to note that this government definition includes caring for individuals
with substance misuse problems for the first time.

Section 11 of the Health and Social Care Act 2001 places a duty on NHS
organisations to involve and consult with patients in the planning and delivery of
services. This can apply to a commissioning partnership where the NHS is one of the
partners. There are also statutory responsibilities towards carers in the Carers Acts
1995, 2000 and 2004. It is the responsibility of Adult Services to address these
statutory responsibilities.

The Adult Services Housing and Health (ASHH) are currently undertaking a review of
the city’s response to the statutory rights of carers in Nottingham. The statutory
response to carers will therefore not be covered in detail in this review.

Nonetheless, there is a clear requirement for commissioning partnerships and drug
treatment services to consult with and support carers of drug users. The 2007
Clinical Guidelines and National Drug Strategy both place considerable emphasis on
the fact that carers should be involved in the care of drug users (within the remit of
client consent) and that they may require considerable support themselves. This
responsibility is further documented and contained in guidance such as:

        Models of care for the treatment of adult drug misusers: Update 2005 (MoC)
        NTA policy on involvement of user and family members 2008
        Quality in Alcohol and Drug Services – Organisational Standards for Alcohol
         and Drug Treatment Services. QuADS

This guidance goes beyond the statutory definition of carers to include those
individuals who are affected by another’s drug user. When considering what the
Nottingham Treatment System response to these individuals should be, the following
definition of carer has therefore been used:
     “A ‘carer’ is defined as someone affected by another’s problematic
     drug/alcohol use, regardless of their relationship or whether they are still in
     contact with the user in question. This may include family members, partners,
     friends or significant others (including children of users) who require specific
     and/or specialist support”



                                              84
(Definition established by Nottingham City Carers Strategy Group - Drugs and
Alcohol)

Clinical Guidelines

The updated clinical guidelines recognise both the needs of families and carers due
to the drug use of someone else and also their important role in the treatment of the
drug users. They state that:

“Drug misuse can place an enormous strain on the families of drug misusers
including the children of drug-using parents, and can have a serious negative impact
on the long-term health and wellbeing of family members. Drug treatment can also
have a positive impact in improving the quality of life for families and carers.”

“The families and other carers of drug-misusing patients are a valuable resource in
drug treatment and can be involved wherever possible and agreed by the patient.
Consideration should be given to family or couples-based interventions. However,
they are often in need of information and support for themselves, and their needs
should not be overlooked.”

“If families and carers have been offered but not benefited from guided self-help
and/or support groups and continue to have significant family problems,
consideration should be given to providing formal psychosocial interventions.”

NICE Guidelines

The NICE Guidelines on psychosocial interventions in drug misuse make clear that:

           “Staff should discuss with people who use misuse drugs whether
           to involve their families and carers in their assessment and
           treatment plans.”

Staff should also identify the needs of families and carers of people who misuse
drugs (including children) and where needs are identified should:

   •   Offer guided self-help (typically one session)
   •   Provide information on and facilities contact with support groups
   •   Where additional support is required staff should consider offering individual
       family meetings.

Hidden Harm

The Hidden Harm report by the Advisory Council on the Misuse of Drugs (ACMD,
2003) estimated there were between 250,000 and 350,000 children of problem drug
misusers in the UK.

The report stated that parental problem drug use can and does cause serious harm
to children at every age, and that reducing harm to children from parental problem
drug misuse should become a main objective of policy and practice.

Adult drug treatment services have a vital role to play in identifying the needs of
children of adult drug users and any potential or actual risk to that child.




                                         85
Hidden Harm has not been considered in detail in the treatment system review;
however, useful information has been gathered through the process in order to
inform detailed analysis as part of the annual needs assessment process.


7.2 The Local Situation: Carer Provision

      Regents House
       Nottingham City has a specific carer support service in place, Regents
       House, to address the needs of those affected by another’s drug use.
       Regents House provides support and advice for carers, family members and
       other individuals affected by another’s drug use. Examples of interventions
       the service provides include structured packages of support for those affected
       by another’s drug use, alternative therapies and pamper days, drop in, advice
       and information, confidential helpline, and group support.

      Carer Referral Form
       The Nottingham City Treatment Standard Assessment Framework includes a
       carer referral form to ensure that opportunities to address carers’ needs and
       refer them to appropriate support are taken wherever possible.

      Carers’ Forum
       The City Carers’ Forum was established by Regents House in August 2007.
       The forum is well attended, with approximately 45 individuals signed up to
       membership. The forum provides opportunity to give up to date information to
       carers of substance misusers in the city and ensure they are able to discuss
       and influence issues relevant to drug treatment and carer provision within
       Nottingham.

      Service Support
       The guidance relating to supporting carers of drug users, as listed above,
       places an emphasis on individual services ensuring that they consider the
       needs of carers and take steps to address these needs. Services should also
       have consultation mechanisms in place to provide advice and information to
       carers and ensure they are consulted regarding treatment developments.

       There was some evidence of services providing family and couples based
       support within the current treatment system however this was limited and
       there is a history of splitting up partners accessing for treatment.


7.3 Consultation Findings

The following key points have been collated from the consultation mechanisms
discussed in section 1.7:

1. Treatment services are not proactive in providing support to carers of drug users
   in treatment, or referring them to Regents House’s carer provision. Of the 16
   questionnaires that stated the respondent had a significant other in treatment,
   only 3 (19%) were asked if they needed support.

2. Referrals to Regents House for carer’s often come late into the associated drug
   user’s journey and are often not made at assessment or early stages of
   treatment.



                                         86
3. Feedback from carers who submitted questionnaires was very positive regarding
   the support provided by Regents House. The availability of a helpline at evenings
   and weekends was noted as especially helpful in supporting carers when they
   need it most.

4. There is felt to be a need for greater respite care for carers to provide them with a
   break from caring responsibilities. (Please note, this would generally fall under
   the statutory element of carer provision.)

5. Carers perceive there is a lack of communication between treatment services,
   which may hinder the support provided to carer and / or drug users.

6. Carers reported that there is a need for individual and tailored packages of care
   for carers from BME ethnic groups or with diverse needs.

7. Carers fed back that there is a need for greater education and information on
   drug use and its consequences for those affected by another’s drug use.

Please note: carers views on the structured treatment system and current provision
for problem drug users is included in the relevant sections throughout this report. The
above consultation points relate solely to the way in which carers’ needs are
addressed in the current system.


7.4 Good Practice / System Strengths

   The city has a specific support service for carers and those affected by another’s
    drug use. Regents House carer service has been recognised as a model of good
    practice in the National Carer Strategy.

   The pamper days at Regents House generated positive feedback from carers,
    who reported that being able to relax and take time out to invest in self care was
    particularly beneficial to them.

   The Regents House Carer’s Forum is well attended and ensures that carers’
    voices are heard on key issues relating to drug treatment and carer provision.

   Regents House has established links with GPs and primary care services to
    support GPs in recognising carer needs and clarifying the support available to
    meet these needs (e.g.: through referral to Regents House). This has involved
    attending GP training days and practice meets. The service has since seen
    increased referrals from primary care.

   The carer’s service has seen a greater number of clients from BME groups over
    the previous year. It should be noted that the caseload remains predominantly of
    White ethnicity.


7.5 Weaknesses

    •   The extent to which carers’ needs are assessed and / or addressed by
        treatment services across the treatment system seems inconsistent. The
        carer referral form, for example, does not seem to be completed in services



                                          87
       as standard practice at assessment. Nor does there appear to be a consistent
       understanding of the approach to addressing carer needs across the system.

   •   There is a potential lack of understanding around carer issues within
       treatment services. This is suggested by the inconsistent approach taken to
       addressing carer needs and from feedback from carers to Regents House
       and as part of the CDP consultation exercise. Regents House are able to
       provide advice and information but there is currently relatively low take up
       from treatment services.

   •   The carer support service in the city is underused by the wider treatment
       system. There are limited direct referrals made by treatment services to
       Regents House, despite the carer referral form, with the majority of referrals
       coming via the helpline (advertised with leaflets and posters) and GPs.

   •   Regents House report that they are currently working to capacity, particularly
       around evening and weekend provision.

   •   There is no clearly commissioned provision for family or couples based
       therapy within the drug treatment system although there is some limited
       evidence of this happening at an individual keyworker level in order to meet
       need.


7.6 Care Pathways

   •   Regents House received 158 referrals during 2007/8 with the majority being
       self referrals (20%).
   •   The key pathway to engaging with Regents House is via the helpline, which is
       advertised by leaflets, posters and in treatment services.
   •   The service receives some direct referrals from GPs – these have increased
       over the previous year.
   •   The service receives less direct referrals from treatment providers than
       expected.

A breakdown of the referral sources for 2007/8 is given below:


7.7 Client Group

   •   The caseload is predominantly of White ethnicity, with only 13.5% of clients
       from BME groups. The service has reported an increase in clients other than
       white, but the current ethnic breakdown does not reflect that of the in
       treatment population. It should be noted that 10% of clients did not have an
       ethnicity recorded which affects the validity of the analysis.

   •   The dominant service user type in Mother of a drug user. It should be noted
       that the service’s staff are currently all female. A more diverse staff group
       may support the further engagement of male clients.




                                         88
7.8 RECOMMENDATIONS

Recommendations relevant to carer’s provision:
   1. The new treatment system model should make clear the steps services
      are required take to assess and address carer needs, including
      consultation and referral mechanisms.
   2. Education and training should be provided to treatment services /
      others in contact with carers to ensure that the support available to
      carers is highlighted and keyworkers feel equipped to deal with these
      issues.
   3. Regents House and other carer support services should make efforts to
      ensure they can address the diverse needs of clients in the city,
      including proactive publicity and recruitment messages to males and
      those from BME groups.
   4. The referral pathways to Regents House should be clarified and the
      profile of the service raised by promotion in appropriate settings.
   5. The CDP / ASHH to consider the requirements for carer provision in the
      city following the completion of the carer needs assessment to ensure
      there is adequate capacity in the treatment system.

Recommendations relevant to the general treatment system:

   6. The new treatment system model should ensure that family and couples
      based interventions are an explicitly commissioned and available option
      for structured treatment.

   7. A more detailed review of hidden harm provision in relation to the adult
      drug treatment system to be considered as part of the adult drug
      treatment needs assessment and young people’s drug treatment needs
      assessment.




                                       89
8.     Equality and Diversity Practice and Policy
Equality and diversity policy and practice was explored through self assessment
questionnaires for service managers. The responses received by the deadline for
drug treatment services have been analysed by the CDP Equality & Diversity
Manager.

The responses received by alcohol treatment services will be considered as part of
stage 2 of the treatment system review in the wider Equality Impact Assessment.

A total of 10 questionnaires were received from drug treatment services managers in
time for consideration in the final report. This gives a good representation of local
provision.


8.1 General

Overall the ED practice is good or acceptable. There is varied practice across the
treatment system, which is not surprising considering that many different services are
commissioned. Working through the NTA’s Diversity Assessment Package is likely
to improve practice across the service and this should be a requirement for all
services.

There are a number of areas that give rise for concern. In particular, a minority of
services appear to have a limited understanding of equality and diversity that focuses
mainly on race/ethnicity to the exclusion of other categories. Some do nothing to
target groups that may not be aware of their service demonstrating a poor
understanding of barriers. Two organisations do not recognise that faith can
sometimes be a barrier to accessing services. There is therefore a need for further
training and support to raise staff and managers’ awareness.

The quality of data recording and analysis is inconsistent across the treatment
system. Although all services are collecting information on race/ethnicity, we should
ensure that they also record across gender, disability, sexual orientation, and faith as
a minimum. The majority of services do not appear to analyse or evaluate their data
in a constructive way that addresses identified inequalities and the validity of some of
the information is questionable. However there were some very good examples of
good practice and there could be scope for experience sharing across the service.

Most services are undertaking positive work in publicising their services to diverse
communities; however there appear to be significant gaps around targeting disabled
and lesbian gay, bisexual and transexual communities. Only three websites are in
accessible formats. Half of the services operate from inaccessible buildings – though
they do offer outreach to disabled clients. We need to be sure that this is adequately
promoted to disabled people who need the services. Services make use of
interpreters/translators where required.

Three services operate under the misconception that because of the size of their
organisation or the targeted nature of their work they are exempt from some aspects
of good practice; clearly this should be addressed by offering those organisations
further support and guidance. A further positive measure would be to undertake a
more in-depth review of those organisations whose ED practice gives rise for
concern with a view to offering additional support and guidance.



                                          90
8.2 Corporate Commitment

Overall corporate commitment appears to be good. All services have an equality and
diversity or equal opportunities policy and nearly all have a designated person with
overall responsibility. Policies are reviewed regularly and reference equality and
diversity in terms of service provision and recruitment/employment. Most services
have a diversity strategy or action plan.

Although 50% of the services have a good or reasonable understanding about
barriers to accessing services and jobs, the other 50% showed a lack of, or minimal,
understanding.

Four of the services are public sector and therefore subject to the Public Duty
embedded in equalities legislation. Although all 4 services have equality schemes
that cover race, gender and disability, none were able to say how many disabled
clients they have. Two of the services have completed equality impact assessments,
with a third due to be completed in 2008. However there are questions around the
quality of the assessments in relation to disability information and the consultation
and publication aspects of the assessments.


8.3 Data Collection and Analysis

Although services have systems in place to gather diversity data, there are service-
wide inconsistencies around the categories that information is gathered on. Also, not
all services analyse all categories of data they collect. In particular there are gaps
relating to disability, sexual orientation and faith. The main reasons given for this are
that BOMIC does not allow it, it is not required by commissioners or the Standard
Assessment Tool does not include it. The poor and inconsistent nature of data
tracking, collection and analysis will exacerbate any difficulties in understanding the
treatment journey for diverse clients.

There was minimal evidence of services making use of ED data to respond to service
gaps or inform changes, with only 3 services giving clear examples.          Mostly,
services used the information to submit returns to commissioners. Furthermore, the
validity of some of the information gathered may be questionable e.g. one service
with 77 clients said they were all heterosexual and that none were disabled.


8.4 Access to Services

All services have information in plain language which emphasises confidentiality.
However, only 3 have accessible websites. Several services promote themselves to
a wide range of organisations, agencies and community groups but some rely on
“word of mouth” to promote themselves to diverse communities. It may be helpful to
provide services with an up to date list of community organisations and make use of
the CDP's IAG to promote services within their communities. A small number of
services felt there was no need to promote themselves as they felt there were no
barriers and some had a limited understanding of the need to target diverse groups
other than, say, race/ethnicity.

Services know how to make use of interpreters/translators where required for both
community languages and British Sign Language.



                                           91
50% of services operate from accessible premises – those whose buildings are not
accessible (including 2 needle exchanges) –operate an outreach facility if clients
request it.

In terms of accommodating clients of different faiths, most services appear to be
culturally sensitive; however two services do not see the relevance to them of
responding to different faiths and feel there are no barriers – this may indicate a need
for some faith awareness training to improve the cultural competence of staff and
managers.

Service user representation appears to be unrepresentative in the majority of
services.


8.5 Workforce and Recruitment

Most services appear to have fair recruitment and selection practice but little is done
to promote vacancies within minority communities and more emphasis could be put
on improving ED recruitment practice further. However, 90% of services do not have
any targets to work towards a more diverse workforce. Two services are of the
opinion that they need not be concerned about working towards a representative
workforce, either because they are small in size or because of the targeted nature of
their service. Services need to be encouraged to see ED as relating to all equality
strands and not only gender or race/ethnicity. They should also be more fully aware
of their responsibilities in relation to equalities legislation and employment.

On the whole, cultural competence is measured at application and interview stages
of recruitment and induction training is provided. Most of the workforce has
undergone ED training and 90% of services appear to have good measures in place
to support staff with ED and cultural competence.


8.6 RECOMMENDATIONS

1. Services to be required to work through NTA’s Diversity Assessment
   package

2. CDP Drug Treatment Workforce Strategy to consider appropriate
   recruitment practices in relation to equality and diversity in further detail

3. The Standard Assessment Framework tools and guidance to be updated
   with all equality and diversity categories in the January 2009 refresh

4. The promotion of the new treatment system model to include appropriate
   promotion of accessibility and ensure the freephone number and treatment
   system is promoted to a full range of groups in the correct formats.

5. All public sector providers to be made aware of their responsibility to
   ensure meaningful Equality Impact Assessments are completed in their
   services

6. Provider’s information and case management systems to enable recording
   of all equality and diversity categories



                                          92
7. Guidance on establishing appropriate representation of service users to be
   included in the Nottingham Service User Involvement Strategy.




                                     93
9.         Alcohol Treatment System

9.1 Purpose of the review

There is a lack of clarity and clear understanding about the city’s alcohol treatment
system that does not exist in relation to the drug treatment system. There is no
current and complete map of alcohol services in the city and misunderstandings and
confusion about the range of treatment options and services available are common.
The purpose of the alcohol treatment system review is to regain a strategic overview
of alcohol services in Nottingham City and compare the existing structure against
national guidance, local need and stakeholder feedback.


9.2 National guidance

This section provides a comprehensive review of what research tells us about
effective alcohol treatment systems. The following paragraphs summarise the
available evidence on what constitutes effective, integrated solutions for alcohol
treatment.

Models of Care for Alcohol Misusers

Models of care for alcohol misusers (MoCAM) is the definitive best practice guidance
for developing local alcohol treatment systems. MoCAM integrates the evidence base
for effective treatment interventions for alcohol misusers and provides a tiered
framework and key quality criteria for commissioning local systems. It is important to
recognise that while MoCAM provides a conceptual framework to aid commissioning,
implementation and delivery must be determined by local need.

Categories of alcohol misuse

MoCAM identifies four main categories of alcohol misusers based on the World
Health Organisation’s categorisation: hazardous drinkers, harmful drinkers,
moderately dependent drinkers and severely dependent drinkers. These categories
provide a conceptual framework for commissioners to enable broad mapping of
drinkers to appropriate treatment interventions.

Hazardous drinkers
Hazardous drinking is defined as regular excessive weekly consumption (over 21-50
units for men; over 14-35 units for women). Hazardous drinking ‘refers to patterns of
use that are of public health significance despite the absence of any current disorder
in the individual user’. 2

Harmful drinkers
Harmful drinking is defined as consumption over 50 units per week for males and 35
units per week for females. Harmful drinking is a ‘pattern of use which is already
causing damage to health. The damage may be physical or mental’. 3




2
    Models of care for alcohol misusers, National Treatment Agency 2006
3
    Ibid


                                                  94
The Local Alcohol Profiles for England estimates that there are 42,147 adults over
the age of 16 that engage in hazardous drinking and 14,516 harmful drinkers in
Nottingham 4.

Dependent drinkers
Dependent drinkers characteristically have a ‘psychological dependence’ on alcohol.
MoCAM distinguishes between moderately and severely dependent drinkers. The
key differentiation between moderately and severely dependent drinkers is the
intensity of treatment required. Moderately dependent drinkers may recognise that
they have a problem and have not yet reached the stage of needing to drink to
relieve withdrawal symptoms; severely dependent drinkers may have formed a habit
of relief drinking and have long-standing problems with alcohol. Drinkers within these
categories are expected to benefit from structured specialised treatment.

Thus, it is recommended that a local alcohol system should consist of two main
components:

      -    Targeted and opportunistic screening and simple brief interventions for
           hazardous and harmful drinkers
      -    Care-planned treatment for moderately and severely dependent drinkers in
           specialist substance misuse settings

Four-tiered framework of provision
MoCAM advises that a four-tiered framework of provision for alcohol treatment
should be adopted to act as a conceptual framework to guide commissioning.
Commissioners should ensure that all four tiers of interventions are commissioned in
a local alcohol treatment system. Based on this requirement, the chart overleaf
depicts the recommended model for a local alcohol treatment system.


9.3 Interventions explained

Hazardous and harmful drinkers
Targeted screening should be conducted in non-specialist settings, such as primary
care services, A&E departments, homelessness services, probation and prison
services, to identify those individuals drinking at hazardous and harmful levels.
Brief structured advice should be offered to encourage a reduction in alcohol intake.
If further support is required, additional advice sessions or extended brief
interventions could be offered to increase chance of success.

Dependent drinkers
Moderately or severely dependent drinkers require specialised, care planned,
structured treatment. This treatment should be provided in specialist alcohol settings
within the community. A small proportion of severely dependent drinkers may also
require inpatient care for more intensive treatment.




4
    North West Public Health Observatory (2007)


                                                  95
                Hazardous & harmful drinkers      Moderately dependent drinkers     Severely dependent drinkers


Tier 1                               Tier 2                           Tier 3                         Tier 4

Screening; identification of         Open access services that        Community-based, care-         Residential rehabilitation
hazardous, harmful and               provide non-care-planned,        planned, structured            and alcohol specialist
dependent drinkers; brief            alcohol-specific                 treatment                      inpatient treatment
interventions; information /         interventions; extended
advice on sensible drinking          brief interventions;
& how to reduce                      assessment & referral into
consumption                          structured treatment
                                                                                                     Interventions should
Interventions should include:        Interventions should include:    Interventions should           include:
                                                                      include:
-   Targeted screening via           -   Alcohol-specific advice                                     -   Care-planned
    AUDIT tool                           and support                  -   Comprehensive                  structured treatment
-   Provision of brief               -   Outreach provision               assessment                 -   Psychosocial
    interventions                    -   Extended brief               -   Regular key working            interventions
-   Shared care interventions            interventions                    sessions with service      -   Prescribing
-   Referral into specialised        -   Assessment & referral into       users                          interventions and
    alcohol treatment for those          specialised treatment        -   Prescribing                    medically-assisted
    identified as dependent          -   Shared care                      interventions &                withdrawal
    drinkers                         -   Mutual aid groups                medically-assisted
                                                                          withdrawal                 Delivered in inpatient
Delivered in a wide range of         Delivered in a number of         -   Psychosocial               alcohol units
agencies, which may include:         agencies, including:                 interventions
- Primary healthcare                 - Primary healthcare             -   Structured day
- A&E                                - A&E                                programmes & care-
- Psychiatric services               - Liver units                        planned day care
- Social services                    - Social services
    departments                          departments                  Delivered in specialist
- Homelessness services              - Psychiatric services           alcohol treatment services
- Hospital wards                     - Homelessness services          within the community or
- Custody cells                      - Domestic violence              shared care facilities
- Probation services                     agencies                     within primary care
- Prison services                    - Antenatal clinics              settings
- Education services                 - Probation services
- Occupational health                - Prison services
    services                         - Occupational health
- Antenatal services                                           96
9.4 Effective interventions

The following interventions have been proven to be both effective and cost-effective
treatment modalities for alcohol misusers and should be delivered as best practice in
local alcohol treatment systems.

Alcohol screening & brief interventions

Screening in non-specialist settings improves the early identification of people
drinking at hazardous and harmful levels, with a view to preventing the onset of
chronic health harms associated with excessive alcohol consumption. Targeted,
opportunistic screening, rather than universal screening, is proven to be most
effective.

There is extensive research support for brief interventions as an effective treatment
modality for this client group. Review of the effectiveness of treatment for alcohol
problems (2006) concludes that “brief interventions … delivered in a variety of
settings, are effective in reducing alcohol consumption among hazardous and
harmful drinkers to low-risk levels.”

Brief interventions consisting of advice and information should be provided to this
client group following screening. Simple brief interventions, usually consisting of a
session of 5 minutes in which structured advice is given to the individual, should be
offered initially. Extended brief interventions of 20 – 30 minutes and often involving
repeat sessions may be necessary if this initial session is unsuccessful. Extended
brief interventions usually consist of “a condensed form of cognitive behavioural
therapy.” Motivational enhancement therapy has been identified as the most effective
extended brief intervention.

Further guidance on the delivery of screening and brief interventions is available
from:

   -   Primary care framework: Alcohol services in primary care, NHS, May 2008
   -   The World Health Organisation
   -   British Medical Journal
   -   Preston Alcohol Brief Intervention Training Pack: Evaluation Report, John
       Moores University, 2006

Treatment for dependent drinkers

The following interventions are shown to deliver the best outcomes for dependent
drinkers:

   -   Comprehensive assessment to determine the exact nature of an individual’s
       alcohol problem
   -   Regular key working sessions
   -   Care-planned treatment
   -   Structured psychosocial treatments (“Cognitive behavioural approaches to
       specialist treatment offer the best chances of success”, Review of
       effectiveness of treatment for alcohol problems”)
   -   Structured day care programmes
   -   Pharmacological therapies (use of prescribed medication) to treat physical
       dependence




                                         97
   -   Inpatient treatment (this may be required by severely dependent drinkers.
       However, “only a minority of people will be so vulnerable as to require patient
       hospital treatment” (MoCAM)

Treatment for dependent drinkers should be delivered in specialist services by
competent staff within community settings or via shared care to ensure easy access.

Stepped care model

MoCAM recommends that a stepped care approach to treatment is adopted, where
the least intensive form of treatment is offered to clients initially, progressing to more
intensive forms if these are unsuccessful.

Review of the effectiveness of treatment for alcohol problems demonstrates that less
intensive forms of treatment are no less effective than more intensive forms of
treatment amongst moderately dependent drinkers. These should be delivered within
specialist settings as the first treatment in a stepped care approach. This principle
should be borne in mind when constructing care pathways for an improved treatment
system, e.g. care pathways should offer service users access to treatment within
community settings before offering the option of inpatient care.


9.5 Key principles for commissioning local alcohol treatment systems

MoCAM offers the following key principles for commissioning local alcohol treatment
systems. These principles should underpin the improved alcohol treatment system in
Nottingham City.

   •   Alcohol treatment systems must be flexible enough to cater for patient choice.
       A range of interventions should be provided to meet client need and a choice
       of treatment goals

   •   Alcohol services should provide approaches that                are   sensitive   to
       cultural/religious attitudes to alcohol for BME groups

   •   Drug users in treatment should have their alcohol use and treatment needs
       routinely and continually assessed and their alcohol & drug problems treated
       in the same setting, where possible. Referrals into specialist alcohol treatment
       should be a routine feature in treatment of PDUs

   •   Joint commissioning of homelessness services for alcohol misusers is best
       practice to ensure that local systems meet the needs of homeless alcohol
       misusers

   •   Service users should be able to access alcohol treatment on multiple
       occasions and from different services concurrently, e.g. AA or other mutual
       aid groups

   •   Each alcohol treatment intervention should have a clear role within the
       treatment journey, clear aims and objectives, eligibility criteria, a defined client
       group, agreed treatment goals, and onward referral pathways. This
       information should be built into service specifications and service level
       agreements.




                                           98
9.6 Commissioning standards

The following are key quality criteria for the commissioning of local alcohol services.
Local commissioners should ensure that the following standards are met as best
practice:

   •   Implementation of a commissioning cycle consisting of an annual needs
       assessment, planning, commissioning, monitoring and review

   •   Regular monitoring alcohol treatment services to monitor performance against
       key performance indicators, service user outcomes and uptake of treatment
       options

   •   Clear and standardised screening procedures across all relevant agencies

   •   Clear and standardised assessment processes and recording procedures

   •   Adequate sharing of information between services to aid care pathways and
       minimise duplication

   •   Clear criteria for referral and eligibility for entry into each point of the alcohol
       treatment system and clear and effective care pathways

   •   Protocols for joint and collaborative working between alcohol treatment
       services and other agencies

   •   Adequate training of staff and the development of skills and knowledge in line
       with DANOS competences

9.7 Learning from other areas

Both the Derby Community Safety Partnership and the Derbyshire Primary Care
Trust are currently reviewing their treatment systems against MoCAM and with
reference to local need to inform a proposed reconfiguration of local alcohol
treatment services.




                                           99
                  9.8 Summary of consultation findings

The following is a summary of feedback received from stakeholders through the
methods of consultation described in the Introduction. This includes stakeholder
recommendations for an improved alcohol treatment model.


 1. The local alcohol treatment system should be fully integrated with effective
    care pathways and communication between alcohol services, between the
    alcohol and drug treatment systems and between alcohol treatment
    providers and mental health, wraparound and family / carer services

 2. Alcohol and drug treatment should remain separate with effective care
    pathways between the two systems to ensure that the needs of clients with
    both alcohol and drug problems are effectively addressed

 3. Consistency was identified as imperative to a service user’s treatment
    journey. A single, primary key worker should remain with the service user
    throughout their treatment journey and effectively coordinate their treatment
    and the involvement of several different service providers

 4. Improved access to psychological support / counselling to address non-
    alcohol specific issues and possible root causes to service users’ alcohol
    misuse, such as bereavement, history of abuse, domestic violence etc

 5. Widespread advertising of alcohol services is needed so that service users
    are able to clearly identify the range of services and treatment options
    available

 6. Standardised assessment and care planning tools are required to ensure
    consistent and equitable standards of care

 7. A single point of access into the treatment system to manage all
    assessments and referrals into specialist treatment. Referrals would be in
    line with clear, commissioned care pathways




                                      100
9.9 Current Provision

Alcohol treatment services available in Nottingham City

A complete mapping of existing services was conducted as part of the review to
establish the full range of treatment services available for alcohol misusers in
Nottingham City.

The following alcohol treatment services are currently available in Nottingham City.

    •   QMC alcohol liaison service
    •   APAS
    •   Mary Magdalene Foundation (The Sanctuary)
    •   Newcastle House *
    •   Porchester Ward *
    •   Porchester Day Unit *
    •   Alcohol arrest referral team *
    •   The Priory

* There are proposals to reconfigure these services following an internal review carried out by
the Nottinghamshire Healthcare NHS Trust.

A further two services have recently been commissioned by the PCT. The first will
oversee and monitor the provision of alcohol screening and brief interventions at
A&E; the second will oversee and monitor the provision of screening and brief
interventions in primary care settings. Delivery of both services is expected to
commence in Autumn 2008.

In addition, the PCT also commissions a support service for carers and families
affected by someone’s drug and alcohol misuse through Regent’s House and two
access and engagement services through Framework specifically targeted at rough
sleepers with substance misuse problems (the Street Outreach Team and HASP).
Aftercare support is available for clients with co-existing drug and alcohol problems
via Double Impact.

There are two services in the city that provide support and treatment for young
people under the age of 18 with alcohol problems: Base 51 and Compass Young
People’s Service.

As far as possible, the following information has been collated on all of these
services to provide a comprehensive overview for commissioners and stakeholders,
and to enable strategic analysis.


9.10 Current system overview

Alcohol helpline

A local-rate help line provides generic information on alcohol and alcohol services.
The Alcoline service (provided by APAS) is utilised by individuals concerned about
their own alcohol use, by those concerned about another person’s alcohol use, or by
professionals seeking advice on alcohol disorders. Callers requiring further advice or
treatment are signposted on to other services.



                                             101
Open access service

An open access walk-in service is available at APAS Direct where members of the
public are able to access immediate alcohol-specific advice on a one-to-one basis.
The following interventions are available through APAS Direct depending on the level
and urgency of a client’s needs: alcohol screening and assessment, drink diaries,
crisis/triage response, written material and fact sheets, signposting to appropriate
treatment and wraparound services, and harm reduction strategies. A care plan is
devised for each client to facilitate follow-up sessions.

These interventions can be classed as brief interventions and extended brief
interventions, although several aspects of the service are reminiscent of tier 3
interventions, including the use of trained key workers, comprehensive assessment
and care plans. In addition, the majority of clients can be described as dependent
drinkers, not hazardous and harmful drinkers. The above services rely on self-
referral, whereas MoCAM focuses on the early identification of individuals that are
unaware they are drinking at hazardous or harmful levels.

The forthcoming provision of alcohol screening and brief interventions in A&E and
primary care settings will specifically target this client group.

Structured treatment

The majority of treatment provision in Nottingham City can be described as
structured tier 3 treatment, catering specifically for dependent drinkers. There are
four main providers of structured alcohol treatment in the city, each providing
different treatment modalities.

   1. Weekly alcohol-specific, care-planned, one-to-one support is available
      through APAS. Treatment options include: rational emotive behaviour
      therapy, cognitive behavioural therapy and motivational enhancement therapy
      (please note that this is not a comprehensive list). Both abstinence and
      controlled drinking treatment goals are available.

   2. The 12-step programme is offered by the Mary Magdalene Foundation at the
      Sanctuary via care planned, one-to-one support sessions over a 26 week
      period. Group counselling and family / carer support is also available. This
      service is entirely abstinence-based.

   3. Three services are provided through the Nottingham Alcohol and Drugs
      Team:

   •   Newcastle House offers an outpatient and day therapy unit, which provides
       cognitive behavioural therapy on a one-to-one basis and in group settings
   •   Porchester Day Unit offers cognitive behavioural therapy and community
       detoxification for severely dependent drinkers with chronic alcohol-related
       physiological damage
   •   Porchester Ward offers inpatient detoxification

These services cater for both abstinence and controlled drinking treatment goals.




                                        102
   4. Inpatient care is also available at the Priory, which provides a range of
      abstinence-based, care planned structured treatment and medically assisted
      withdrawal in inpatient alcohol units.

The QMC alcohol liaison service provides a link for hospital patients with alcohol
disorders (usually in conjunction with physiological damage) into community
detoxification and structured treatment at the Nottingham Alcohol and Drugs Team.
The service also provides an outpatient liver damage clinic and extended brief
interventions for this client group.

The alcohol arrest referral scheme provides assessment and access into treatment
for individuals arrested under the influence of alcohol. It was recommended by the
Nottinghamshire Healthcare NHS Trust’s review of alcohol services that this service
be disestablished to refocus resources on “core business”.

Supported accommodation for alcohol misusers

There is a wide range of supported accommodation for people with alcohol problems
in Nottingham, funded through Supporting People. These services play a valuable
role in enabling access to alcohol treatment services and wraparound support
amongst the homeless or vulnerably housed. The following services provide
abstinence-based accommodation to support detoxification and facilitate move-on to
independent housing (further information can be found in annex b):

   •   Michael Varnam House (service users can opt to follow a controlled drinking
       programme after a 28-day period of abstinence)
   •   YMCA “dry floor”
   •   Ken Wilde House
   •   Woodborough Road
   •   Studio House

Service users are screened/ assessed by these services to determine the
seriousness of their alcohol problem and are referred into the alcohol treatment
system. These services also provide weekly, care planned one-to-one support to
address clients’ wraparound support needs (including help with finances; access to
education, training and employment opportunities; and housing advice) and round
the clock access to crisis support to assist service users during the detoxification
process.

Other temporary housing services available for those with substance/alcohol misuse
problems include:

   •   London Road
   •   36/57 Bentinck Road
   •   Aidan Tenancy Support Team
   •   Aidan House
   •   Colville House
   •   Somerville House
   •   Noelle House
   •   Park House & Lake Street

MoCAM recommends that “housing and hostel provision may need to be considered
in tandem with developing local systems for alcohol treatment … Best practice



                                        103
examples involved joint commissioning mechanisms, to ensure local systems meet
alcohol misusers’ healthcare and housing needs”.

Day care

There are currently two day centres for people with alcohol problems that are
homeless / at risk of homelessness: Handel Street (a “wet centre”) and Emmanuel
House (a “dry” day centre). Both services provide day-time activities for this client
group, facilitate engagement with treatment and accommodation services and
provide wraparound support. Both services are commissioned through Supporting
People and the Housing Directorate.

Day centre provision as a whole has recently been reviewed by the Housing
Directorate, Supporting People, and Adult Services and the need to refocus provision
onto meaningful activity and life-skills training has been identified. A proposal has
also been made to merge the two centres into a single open access day centre.
Anecdotally, we know that a significant number of street drinkers access the Handel
Street day centre, although the exact numbers are unknown. It is therefore
recommended that alcohol treatment commissioners are involved in these
discussions to ensure that the needs of street drinkers are met by any new or
reconfigured service and to maximise the opportunity to engage this chaotic client
group into treatment.

Identified gaps in the current treatment system

The following gaps have been identified by mapping existing services against the
treatment model recommended in MoCAM:

   •   Targeted screening, brief and extended brief interventions for hazardous and
       harmful drinkers. In addition to provision in primary care and A&E settings it is
       recommended that these interventions are delivered in a wider range of
       generic services including Probation, homelessness services, custody cells,
       prison services, education services, occupational health services, antenatal
       clinics and hospital wards
   •   Outreach provision for street drinkers that are not rough sleeping
   •   Community-based structured treatment (This is currently only delivered
       through one service)
   •   Shared care services
   •   Structured day programmes and care planned day care
   •   Provision of alcohol treatment in custody suites in line with drug treatment
       provision

Gaps identified by stakeholders

The majority of stakeholders believed that there are gaps in the current alcohol
treatment system (4 out of 6 service managers, 61% workers, and 43% service
users).

The following gaps were identified:

   •   Non-alcohol specific psychological support
   •   Primary care interventions
   •   Locality based services
   •   Community alcohol team


                                         104
   •   More capacity in inpatient detoxification services
   •   Shared care
   •   Non-AA self-help groups
   •   Follow-on / aftercare
   •   A&E interventions
   •   Structured day care provision


9.11 Effectiveness of the current treatment system

The following section provides an assessment of how effectively the current alcohol
treatment system is working based on feedback from service managers, staff, service
users, community members and other stakeholders; the findings of the
Nottinghamshire Healthcare NHS Trust’s review of alcohol treatment services; and
an assessment of client files at APAS.

A lack of information prevents a full evaluation of the effectiveness of alcohol
services. The following information, which is routinely collated in relation to drug
treatment services, is not available in relation to alcohol services:

   •   Annual needs assessments
   •   A record of service reviews
   •   A record of contract reviews
   •   Analysis of monitoring data
   •   Care plan audits
   •   Retention data
   •   Throughput data
   •   Regular financial returns

This prevents analysis of service performance against key indicators, system
effectiveness in meeting local needs, service user outcomes, client throughput,
waiting times, cost effectiveness, and the financial management of individual services
and the system as a whole. It is recommended that commissioning arrangements are
considered as part of the implementation stage of the review, in line with the World
Class Commissioning model.

Good practice

There is widespread agreement amongst service managers and workers that the
current alcohol treatment system offers a variety of choice and that there is a wide
range of services offering different treatment approaches to treatment. The majority
of service users that partook in our consultation reported having a positive
experience of treatment.

The review confirmed that alcohol treatment services have developed organically,
without a lead from commissioners, with service providers taking the initiative to
develop service provision and referral pathways to meet local need.

Care pathways

There is a common perception that there are poor care pathways within the current
system, poor communication and referral links between services, and therefore, an
inflexibility of choice offered to service users between different treatment options.
This was attributed to:


                                         105
   •   A lack of formal care pathways
   •   A lack of awareness and understanding of other services

Clear alcohol treatment pathways as described in MoCAM do not exist within the
current system. There are no clear, commissioned care pathways denoting an
alcohol treatment journey. Movement through the treatment system currently relies
on referral arrangements negotiated between individual services. Referrals between
treatment agencies are limited. The Nottinghamshire Healthcare Trust’s review of
alcohol services refers to introspective services, where the majority of referrals to
NADT are received via the Consultant Psychiatrist or from within NADT. Until
recently, there were no formal referral arrangements between APAS and NADT,
resulting on minimal movement between these services. Movement between
services is further restricted by inconsistent assessment processes, resulting in some
services not accepting assessments from other services.

A lack of awareness of other services was widely reported, with some confusion
about the role and remit of other services amongst service managers, staff and
service users.

The lack of established care pathways is impacting significantly on service users’
experience of treatment. The Alcohol Service User Forum has consistently reported
that there is restricted movement between services and between treatment options,
preventing service users from accessing the most appropriate treatment to meet their
needs and restricting patient choice.

The stepped care model recommended by MoCAM is not followed in the current
system, with no clear progression from less intensive treatment to more intensive
treatment. According to the Nottinghamshire Healthcare NHS Trust’s review of
alcohol provision, service users can currently self-refer directly into structured
treatment at Newcastle House or the Porchester Day Unit or inpatient detoxification
at Porchester Ward.

It is recommended that clear alcohol treatment pathways are established to ensure
equitable and consistent systems of access to treatment for service users. Each
service must have a clear and unique remit, which is defined in service level
agreements and communicated to all stakeholders. Clear criteria for referral and
eligibility for entry into each point of the alcohol treatment system should be created
in line with MoCAM guidance. It is also recommended that pathways are established
for service users requiring non-treatment specific support, including supported
accommodation, mental health treatment and assistance with employment or
training.

Patient choice

Stakeholder consultation indicates that the variety of treatment options available is a
strength of the current alcohol treatment system. Analysis of current provision
highlights four distinct options for structured treatment and the availability of both
abstinence and controlled drinking treatment options. A choice of treatment goals is
offered by two service providers (NADT and APAS). However, restricted movement
between services prevents service users from accessing the full range of treatment
options available. Poor communication and referral links between services was
identified as a barrier to accessing treatment by service users.




                                         106
The establishment of clear care pathways will maximise access to the full range of
available treatment options and improve patient choice.

Ease of access

Waiting times for treatment was a recurring concern raised by stakeholders during
consultation and was identified as a weakness of the current system and barrier to
treatment. A third of service users reported waiting more than 3 weeks to access
treatment, although a similar proportion reported no waiting time for treatment. This is
likely to be indicative of insufficient capacity within the current treatment system to
meet demand.

A lack of awareness of services and treatment options available to service users was
identified as a significant barrier to accessing treatment and patient choice, with over
90% of current service users hearing about services from other people (either
healthcare professionals or by word of mouth). Consultation confirmed that there is
widespread confusion about the city’s alcohol services and a lack of clarity about the
treatment options available in the system as a whole and within each service. Almost
half of service users agreed that “it can be confusing knowing which service to go to
for help”.

The review revealed a strong demand for better advertising of services within
community settings to maximise access to treatment and client choice. Suggestions
include advertising in pubs, off-licenses, schools, educational institutions, frontline
services, healthcare settings, the local media and wraparound services.

There is concern with current opening times and a call for out-of-hours services. It is
recommended that the benefits and cost effectiveness of extended opening hours is
considered and implemented in the new model for alcohol treatment.

Client base

The vast majority of service users can be described as dependent drinkers. This is
true for clients accessing extended brief interventions via APAS Direct’s open access
service as well as structured treatment. Hazardous and harmful drinkers are absent
from the current treatment system. This reinforces the need to prioritise treatment
provision for this client group within the new treatment system model.

Equality and diversity

Data on the diversity of clients accessing alcohol treatment is rudimentary and
inconclusive. Whereas ongoing analysis of diversity data is routine for the drug
treatment system through annual needs assessments, NDTMS and quarterly
contract monitoring, diversity data in relation to alcohol service users is inconsistent
and incomplete.

The data below has been collated from contract monitoring returns in relation to the
four major alcohol treatment providers in Nottingham City.




                                          107
Ethnicity

                White       Mixed       Asian or Black of Chinese             Unknown
                                        British  Black    or other
                                        Asian    British  ethnic
                                                          group
Provider 90%                2.4%        3%       2.7%     0                   1.4%
1
Provider 96%                0           1.8%         1.8%        0            0
2
*Information
available for
new clients
only

Provider        93%         1%          4.5%         1.8%        0            0
3 **Drugs
and alcohol
clients
Provider                                   Data not reported
4

Age

                19-29       30-39       40-49        50-59        60-69       Unknown
Provider        33%         32%         21%          9%           3%          0.02%
1
Provider        Not         Not        Not         Not            Not         Not
2*              available   available  available   available      available   available
Provider                            The average age of clients is 39
3 **
Provider                                   Data not reported
4

Disability

No data available

Gender

                Male        Female
Provider        Not         Not
1               available   available
Provider        56%         44%
2*
Provider        60%         40%
3 **
Provider          Data not reported
4

Sexuality

No data available




                                            108
The analysis above reveals significant gaps in diversity data, preventing a conclusive
assessment of the uptake of alcohol treatment across categories of ethnicity,
disability, gender, age and sexuality. Available data does, however, provide
indications of severe under-representation of BME groups in treatment. Further work
is needed to collect diversity data from all services across the five diversity
categories and to analyse this data against profiled need as further explored in
annual alcohol needs assessments.

A range of unmet needs were identified through consultation, primarily relating to
equality and diversity and dual diagnosis. Two thirds of service managers reported
that the current system is not equipped to meet the full range of client needs; 19
service users identified equality and diversity needs that are not being addressed
(specific needs identified were better access to service providers’ buildings for
disabled service users, and BME workers). There was consistent feedback through
consultation that alcohol services, as with drug services, must be culturally
competent and that there should also be option for culturally specific provision.

There was recurring feedback that clients with dual diagnosis needs should have
better access to psychiatric / mental health care.

Assessment and care planning

The lack of standardised screening, assessment and care planning processes was
identified as a gap in the alcohol treatment system by service managers. As identified
above, the absence of standard assessment tools restricts referrals between
services. An audit of client files conducted at a major treatment provider revealed that
the lack of a standard process for assessment and care planning has led to mixed
quality assessments and inadequate care plans.

All files audited evidenced screening and comprehensive assessment of all clients
(including those accessing the open access service), in a way that appears to be
structured to meet MoCAM guidance. However, a minority of assessments were
incomplete.

Care plans fell well short of MoCAM standards. Care plans were often missing from
client files and care plan reviews were only documented in a minority of cases. Those
care plans that were present consistently did not meet MoCAM guidance:

   •   Treatment goals were not set
   •   Planned interventions were not outlined
   •   No reference to risk management plans
   •   Review dates were not identified
   •   Care plans did not reflect cultural/ethnic backgrounds, gender or sexuality
   •   Care plans did not reference the involvement of other professionals /
       agencies

Interviews with staff revealed a significant gap between what is recorded in care
plans and actual practice, suggesting that the care planning process and not the
quality of treatment is inadequate.

The care plan is a tool to guide the expected course of treatment for a service user. A
care plan should be used to record and monitor a client’s needs, any changes to the
client’s situation and any interventions that have been provided. The care plan is




                                          109
therefore central to coordinating care and facilitating a client’s movement between
services.

It recommended that standardised processes for screening, assessment and care
planning are established based on national guidance.



9.12 RECOMMENDATIONS

   1. Ensure formal, effective care pathways between supported
      accommodation services and treatment services within the new
      treatment model

   2. Participate in the reconfiguration of day care services to ensure that the
      needs of street drinkers are met and to maximise the opportunity to
      engage this client group in treatment

   3. All gaps in treatment provision should be addressed.

   In particular:

   4. Targeted alcohol screening and the provision of brief and extended brief
      interventions for hazardous and harmful drinkers should be rolled out
      as a priority across primary care settings, A&E departments and a wide
      range of generic services

   5. Expansion of structured alcohol treatment within community settings to
      meet demand

   6. Investigate whether alcohol treatment should be incorporated into the
      Drug Intervention Programme

   7. Commissioning arrangements are considered as part of the
      implementation stage of the review, in line with the World Class
      Commissioning model

   8. Clear alcohol treatment pathways are established to ensure equitable
      and consistent systems of access to treatment for service users

   9. Implementation of the stepped care model

   10. A clear and unique remit should be established for each service and
       built into service level agreements to avoid confusion and guide service
       users and service providers through care pathways

   11. Widespread advertising of alcohol services in community settings and
       awareness raising amongst staff and service managers

   12. Standardised processes for screening, assessment and care planning
       should be created to facilitate referral between services and ensure high
       standards in line with national guidelines

   13. Consider the benefits and cost effectiveness of extended opening hours
       of alcohol services


                                       110
14. Collect diversity data from all services across the five diversity
    categories. Analyse this data against profiled need

15. Ensure all services are culturally competent and equipped to meet the
    needs of BME clients




                                 111
Annex a
Annex a contains information on each provider commissioned as part of the drug and
alcohol treatment systems.

It should be noted that varying levels of information are available for each service
and may not be in a comparable format.

Provider: The Health Shop

The service provides a specialist needle exchange and harm reduction service to
Nottingham City and Conurbation clients.

Interventions / Services Provided

The Health Shop is expected to provide the following interventions:

   Advice and information
   Needle exchange (outreach and fixed site) in line with Band C of Nottingham
    Needle Exchange Strategy
   Harm reduction interventions
   Health promotion
   Full range of BBV screening, vaccination and support
   Immediate healthcare including wound care
   Nursing and health care advice to other drug treatment professionals
   Motivational interventions and short term key working focused on preparing for
    change
   Services for anabolic steroid users
   Advice and information on sexual health
   Auricular acupuncture and other complimentary therapies
   Group work sessions
   Gateway and referral point to wider drug treatment system
   Relapse prevention
   Overdose prevention training

Client Group

   The service is available to problem drug user’s resident within Nottingham City
    (and conurbation) and those with no fixed abode.

   The service focuses on injecting drug users in particular and other risk taking
    chaotic problem drug users experiencing drug related health concerns including
    crack smokers.

   Through needle exchange and harm reduction provision will engage homeless
    and roofless substance misusers in conjunction with the Homeless Healthcare
    Team.



                                          112
   In 2007/8, The Health Shop had 788 clients accessing for needle exchange.

Funding

2007/8 Spend
Amount                                              Funding source
£204,256                                            PTB

2008/9 Allocation
Amount                                             Funding source
Not yet established                                PTB

   It is not possible to calculate a unit cost for this service

Access & Pathways

   The majority of referrals into The Health Shop are self referrals.

   Onward referrals from the service were made to a range of providers with the
    most common being:
    -  22% GP
    -  20% GUM
    -  16% Victoria Health Centre

Performance

   No. of individuals accessing the service
    Target: 550
    Actual: 788
    Performance: 143% of target achieved.

   Number of new referrals
    Target: 150
    Actual: 380
    Performance: 253% of target achieved.

   No. of service users receiving hep B tests
    Target: 226
    Actual: 28
    Performance: 12% of target achieved.

   No. of service users receiving hep C tests
    Target: 226
    Actual: 35
    Performance: 15% of target achieved.

   Number of onward referrals to structured treatment
    Target: TBA
    Actual: No information provided
    Performance:

    N.B. performance for 2008/9 shows signs of improvement and there is evidence
    of under-reporting in 2007/8.


                                            113
Provider: HLG

The service provides access and engagement provision and care co-ordination for
the homeless and vulnerably housed client group.

Interventions / Services Provided

HLG is expected to provide the following interventions:

   Psychosocial interventions (contingency contracting, motivational interventions)
   Advice and information
   Harm reduction interventions
   Rapid access to prescribing
   Other interventions focused on engagement
   Interventions to help the client prepare for change
   Interventions to address specific needs that may impact on a client remaining in
    treatment


Client Group

   The service is available to homeless people within Nottingham City who are not
    currently engaged with treatment services and who are ineligible for support
    through DIP.

   Initial priority to be given to hostel residents housed in direct access or Black and
    Minority Ethnic specific hostel provision.

   To respond to emerging need in underserved groups (including Black and
    Minority Ethnic Populations, commercial sex workers, crack users, drug using
    parents, people with disabilities, women, families/significant others of people with
    drug misuse problems.

   In 2007/8, HLG had 550 individuals in contact with the service including a total of
    207 new individuals.

   A snapshot breakdown of the new client group is given below:




                                          114
    Gender
    Male                   76        79%          Female        20      21%

    Ethnicity
    White British          120       61%          Bangladeshi    -        -
    White Irish            37        19%          Other Asian    -        -
    Other White             3        1.5%         Caribbean      4       2%
    White & Black           8         4%          African        -        -
    Caribbean
    White & Black           -          -          Other Black    -        -
    African
    White & Asian           1        0.5%         Chinese        -       -
    Other Mixed             -          -          Other          -       -
    Indian                  -          -          Not Stated    4       2%
    Pakistani               -          -          Missing       20      10%
                                                  ethnicity
                                                  code
    Age
    18-24                  34        17%
    25-35                  86        42%
    36-45                  52        26%
    46-55                  11        5%
    46-65                  0          -
    Not recorded           20        10%

Funding

2007/8 Spend
Amount                                              Funding source
£142,915                                            PTB & NRF

2008/9 Allocation
Amount                                              Funding source
£147,029                                            PTB

Access & Pathways

     The majority of referrals into HLG are self referral and drop in (42%) Other key
      referral sources include:
      -    10% London Road
      -    8% The Health Shop
      -    6% Outreach Team

      Onward referrals from the service were made to a wide range of providers with
       the most common being:
       -   17% John Storer Clinic
       -   3% Double Impact
       -   6% GPs
       -   8% The Health Shop




                                            115
Provider: Homeless Healthcare Team

The service delivers healthcare interventions to the homeless population in
Nottingham, not limited to drug users.

Interventions / Services Provided

The Homeless Healthcare Team is expected to deliver the following interventions:
   Accessible healthcare
   Support homeless people to access mainstream and secondary services
   Training and education
   Support for other professionals working with the client group


Client Group

   The service is available to homeless people (including those in temporary or
    unstable accommodation) within Nottingham City.

Funding
Included in Health Shop budget.


Provider: Phoenix Futures

The service provides assertive outreach in key localities of need in the City and
delivers brief psychosocial interventions for their client group.

Interventions / Services Provided

Phoenix Futures is expected to provide the following interventions:

   Outreach
   Advice and information
   Harm reduction and health promotion advice and information
   Psychosocial interventions (including motivational interviewing, brief solution
    focused therapy, cognitive behavioural therapy)
   Complimentary therapies
   Relapse prevention advice and information

Client Group

   The service is available to problem drug users resident (or accessing) within the
    areas 4 and 6 of Nottingham City.

   The service focuses in particular on individuals that have never accessed or have
    disengaged from structured treatment services, are unable to access site-based
    services due to disability/illness, Black and Minority Ethnic Populations, stimulant
    users, sex workers.



                                          116
   In 2007/8, Phoenix Futures had 324 clients receiving brief psychosocial
    interventions.

Funding

2007/8 Spend
Amount                                              Funding source
£163,091                                            PTB & NRF

2008/9 Allocation
Amount                                             Funding source
£278,604                                           PTB

   It is not possible to calculate a unit cost for this service

Access & Pathways

   The majority of referrals into Phoenix Futures are generated by assertive
    outreach. Remaining referral sources include:
    -   15 other drug treatment service
    -   7 community source
    -   6 self referral
    -   11 generic service
    -   4 link worker

   Onward referrals from the service were made to a range of providers with the
    most common being:
    -  58 housing services / support
    -  27 other tier 2
    -  26 NADT (Including Shared Care and Waverly)
    -  7 Chill Out Sound Support
    -  3 Double Impact
    -  14 Other

Performance

   No. of outreach contacts
    Target: 367
    Actual: 494
    Performance: 135% of target achieved.

   No. receiving brief interventions
    Target: 357
    Actual: 324
    Performance: 91% of target achieved.




                                            117
Provider: BAC-IN

The service provides brief interventions to users from Black, South Asian and Dual
Heritage Communities.

Interventions / Services Provided

BAC-IN provides:
      Brief interventions
      Care co-ordination
      Self-help groups
      Mentoring and advocacy

Client Group

      The service is available to Nottingham City and conurbation clients of Black,
       South Asian and Dual Heritage Communities.

      A snapshot breakdown of the client group is given below:
    Gender
    Male                     72       77%         Female          21   23%

    Ethnicity
    Black African            7                    Black           8
    Caribbean                         18%         Caribbean            21%
    Black British            6                    Dual            6
                                                  Heritage
                                      16%         Black/White          16%
    Dual Heritage            4                    British         1
    Asian/White                       11%         Indian               3%
    Indian                   1        3%          British         2    5%
                                                  Pakistani
    Pakistani                1         3%         Kashmiri        2    5%


    Age
    18-20                    2        5%
    20-25                    9        24%
    26-30                    3        8%
    31-35                    5        13%
    36-40                    10        -
    41-45                    6        16%
    46-50                    2        5%
    50+                      1        3%

Funding

2007/8 Spend
Amount                                              Funding source
£85,352                                             PTB



                                            118
2008/9 Allocation
Amount                                            Funding source
£87,913                                           PTB


Access & Pathways

   The majority of referrals into BAC-IN are primarily self referrals:
    -   Prison
    -   Apas
    -   NADT
    -   Young Diverse Minds
    -   Regents House
    -   QMC
    -   GPs
    -   PPO
    -   CJIT
    -   Probation
    -   Priory Clinic

   Onward referrals from the service were made to a wide range of providers with
    the most common being:
    -   17% John Storer Clinic
    -   3% Double Impact
    -   6% GPs
    -   8% The Health Shop


Provider: Compass The Point

The service provides tier 2 interventions to problem drug users residing in
Nottingham City through an open access centre base, a needle exchange, and
assertive outreach.

Interventions / Services Provided

Compass The Point is expected to provide the following interventions:

   Assertive outreach and engagement (areas 1, 2, 3, 8 & 9 of the City)
   Psychosocial interventions (including motivational interviewing, brief solution
    focused therapy, and cognitive behavioural therapy)
   Needle exchange (outreach and fixed site) in line with Band B of the Needle
    Exchange Strategy
   Advice and information
   Harm reduction interventions
   Health promotion
   Complimentary therapies
   Relapse prevention
    A gateway and referral point to the wider drug treatment system




                                           119
Client Group

       The service client group is: problem drug using adults residing in Nottingham
       City, with a primary focus on underserved groups identified through local needs
       assessments as not engaging in treatment (including but not limited to Black and
       Minority Ethnic populations and stimulant users).

      In 2007/8, Compass The Point had 523 clients receiving psychosocial
       interventions, 102 clients receiving psychosocial interventions in outreach
       locations, and 292 clients accessing needle exchange (note some clients will
       appear in 2 or 3 categories).

      A breakdown of the client group seen during 2007/8 is given below:
    Gender
    Male                      417        67.5%         Female         201   32.5%

    Ethnicity
    White British             490         79%          Bangladeshi
    White Irish                8           1%          Other Asian    4     0.5%
    Other White               18           3%          Caribbean      13     2%
    White & Black              1          0.2%         African        3     0.5%
    Caribbean
    White & Black                                      Other Black    7      1%
    African
    White & Asian              2          0.3%         Chinese
    Other Mixed                21          3%          Other          2     0.3%
    Indian                     1          0.2%         Not Stated     27     4%
    Pakistani                                          Missing        21     3%
                                                       ethnicity
                                                       code
    Age
    16-18                      5          1%
    19-24                     117         19%
    25-34                     273         44%
    35-44                     161         26%
    45-54                     52          8%
    55-65                      3          0%
    65+                        0           -

Funding

2007/8 Spend
Amount                                                   Funding source
£315,246                                                 PTB

2008/9 Allocation
Amount                                                   Funding source
£324,428                                                 PTB

      It is not possible to calculate a unit cost for this service



                                                 120
Access & Pathways

   For 2007/8 referrals into the service were made up as follows:
    -   50% of referrals were referrals from a ‘concerned other’
    -   13% were from health services (the majority of these being from The Health
        Shop)
    -   12% were self referrals
    -   6% were from structured treatment
    -   5% were young people’s services
    -   4% were from probation
    -   4% were from housing

   Onward referrals from the service were made to:
    -  40% to structured treatment
    -  40% to health services (including The Health Shop)
    -  7% to housing
    -  7% to education and employment
    -  4% to other tier 2
    -  1% to probation
    -  1% to young people’s services

Performance

   No. receiving brief psychosocial interventions
    Target: 475
    Actual: 523
    Performance: 110% of target achieved.

   Number accessing needle exchange
    Target: 240
    Actual: 292
    Performance: 122% of target achieved.

   Number of outreach contacts
    Target: 800
    Actual: 1010
    Performance: 126% of target achieved.

   Number receiving brief psychosocial interventions in outreach location
    Target: 120
    Actual: 102
    Performance: 85% of target achieved.

   Number of onward referrals to structured treatment
    Target: 100
    Actual: 108
    Performance: 108% of target achieved.

   Number of triage assessments
    Target: 575
    Actual: 401
    Performance: 70% of target achieved.




                                       121
   Number of care plans
    Target: 575
    Actual: 403
    Performance: 70% of target achieved.

Provider: John Storer Clinic

The service provides structured treatment in the community to adult problem drug
users residing in Nottingham City. The service primarily provides specialist
prescribing treatment to complex case drug users who, due to their complex needs,
are not suitable to be treated in primary care. The service is also intended to provide
structured psychosocial interventions to address the needs of opiate and stimulant
users.

Interventions / Services Provided

The John Storer Clinic is expected to provide the following interventions:

   Comprehensive Assessment
   Prescribing interventions
   Psychosocial interventions
   Keyworking
   Harm Reduction
   Relapse Prevention
   Appropriate onward referral

Client Group

   The service client group is: problem drug using adults residing in Nottingham
    City, whose needs are too complex to be treated effectively in primary care.

   In 2007/8, the John Storer Clinic treated 927 individuals.

   A breakdown of the client group seen during 2007/8 is given below:




                                          122
    Gender
    Male                     676        73%         Female        251      27%

    Ethnicity
    White British            760        82%         Bangladeshi   0        0%
    White Irish               8         1%          Other Asian   4        0%
    Other White              14         2%          Caribbean     25       3%
    White & Black            18         2%          African       2        0%
    Caribbean
    White & Black             2         0%          Other Black   19       2%
    African
    White & Asian            3          0%          Chinese       0        0%
    Other Mixed              12         1%          Other         20       2%
    Indian                   4          0%          Not Stated    16       2%
    Pakistani                20         2%          Missing       0        0%
                                                    ethnicity
                                                    code
    Age group at mid point of the year (30/09/2007)
    9                         0          0%      17                2       0%
    10                        0          0%      18                1       0%
    11                        0          0%      19 -24           80       9%
    12                        0          0%      25 - 34          466      50%
    13                        0          0%      35 - 44          283      31%
    14                        0          0%      45 - 54          74       8%
    15                        0          0%      55 - 64          20       2%
    16                        0          0%      65+               1       0%

Funding

2007/8 Spend
Amount                                                Funding source
£900,000 – PTB Block Sum for NHCT                     PTB

2008/9 Allocation
Amount                                          Funding source
£373,035.20                                     PTB

      The John Storer Clinic saw 927 individuals. Including management costs, this is
       a unit cost of £402.41 (based on 2008/9 allocation).

Access & Pathways

      During 2007/8, John Storer Clinic saw approximately 400 new presentations.

      Referral source data for 2007/8 is not yet available. For 2006/7:
       -   55% of referrals were self referrals;
       -   39% were from the Criminal Justice System;
       -   3% were from GPs
       -   3% were from other sources.




                                              123
   89% of clients accessing the service during 2007/8 waited under 3 weeks. This
    falls below the target for 100% of clients to wait less than 3 weeks.

   With regard to onward referrals, movement outside of John Storer Clinic into
    other treatment services is relatively low. In 2006/7, 28 clients were referred on.
    Referrals were made to Porchester Ward; Double Impact; the Windmill Clinic;
    and Probation.

Performance

Please note that the targets below are the structured treatment KPI targets rather
than contract targets – the contract held last year was a PCT Block Contract, with
less detailed targets than required here.

   No. in Treatment
    Target: 1200
    Actual: 927
    Performance: 77% of target achieved.

   Avg. New Presentations Per Month
    Target: 49
    Actual: 41
    Performance: 84% of target achieved.

   % of Waits to be Under 3 Weeks
    Target: 100%
    Actual: 89%
    Performance: 89% of target achieved.

   % of new presentations to have a care plan
    Target: 100%
    Actual: 96%
    Performance: 96% of target achieved.

   % of clients to be retained for a minimum of 12 weeks
    Target: 75%
    Actual: 68%
    Performance: 87% of target achieved.

   % of clients discharged to have a planned exit
    Target: 95%
    Actual: 70%
    Performance: 74% of target achieved.


Provider: Dual Diagnosis

The Dual Diagnosis team functions as a consultancy, liaison and assessment /
interventions service aimed at ensuring that those people with a dual diagnosis of
mental health issues and problem drug use are supported to address their substance
misuse. The Dual Diagnosis team offers both direct interventions to clients with
mental health problems as part of a structured care plan and also support to other
services, mental health or substance misuse work in order to integrate the care of the
client group and ensure that the client receives holistic integrated interventions.



                                         124
Interventions / Services Provided

The Dual Diagnosis Team is expected to provide the following interventions:
      Advice and Information
      Comprehensive Assessment
      Psychosocial interventions
      Keyworking
      Harm Reduction
      Training to mental health and substance misuse teams

Client Group

      The Dual Diagnosis client group is: problem drug using adults residing in
       Nottingham City with a dual diagnosis (ie: co-existing mental health issues).

      In 2007/8, the team provided structured treatment interventions to 133
       individuals.

      A breakdown of the client group seen during 2007/8 is given below:

    Gender
    Male                     108         81         Female        25        19%
    Ethnicity
    White British            93         70%         Bangladeshi   0         0%
    White Irish               1          1%         Other Asian   2         2%
    Other White               4          3%         Caribbean     6         5%
    White & Black             7                     African       1         1%
    Caribbean                           5%
    White & Black             2                     Other Black   2         2%
    African                             2%
    White & Asian             5         4%          Chinese       0         0%
    Other Mixed               1         1%          Other         1         1%
    Indian                    1         1%          Not Stated    4         3%
    Pakistani                 3         2%          Missing       0         0%
                                                    ethnicity
                                                    code
    Age group at mid point of the year (30/09/2007)
    9                         0          0%      17                0         0%
    10                        0          0%      18                0         0%
    11                        0          0%      19 -24           32        24%
    12                        0          0%      25 - 34          50        38%
    13                        0          0%      35 - 44          32        24%
    14                        0          0%      45 - 54          15        11%
    15                        0          0%      55 - 64           3         2%
    16                        0          0%      65+               1         1%




                                              125
Funding
2007/8 Spend
Amount                                        Funding source
£900,000 – PTB Block Sum for NHCT             PTB

2008/9 Allocation
Amount                                     Funding source
£214,602                                   PTB

   Dual Diagnosis provided treatment to 133 individuals, with a unit cost of
    £2529.13. It should be noted that this cost does not reflect the consultancy or
    training work undertaken by the service.

Access & Pathways

   During 2007/8, the Dual Diagnosis Team saw approximately 76 new
    presentations.

   Referral source data for Dual Diagnosis is not clear in NDTMS provided reports.
    The team does not tend to accept self referrals and reports that the majority of
    referrals come from GPs, mental health services/wards and other treatment
    services.

   76% of clients accessing the service during 2007/8 waited under 3 weeks. This
    falls below the target for 100% of clients to wait less than 3 weeks.

   NDTMS data suggests that onward referrals from the Dual Diagnosis team are
    rare.

Performance

Please note that the targets below are the structured treatment KPI targets rather
than contract targets – the contract held last year was a PCT Block Contract, with
less detailed targets than required here.


   No. in Treatment
    Target: 230
    Actual: 133
    Performance: 58% of target achieved.
    It should be noted that 2007/8 target was based on what we know to be
    inaccurate previous performance.

   Avg. New Presentations Per Month
    Target: 7
    Actual: 7
    Performance: Target achieved.

   % of Waits to be Under 3 Weeks
    Target: 100%
    Actual: 76%
    Performance: 76% of target achieved.




                                        126
   % of new presentations to have a care plan
    Target: 100%
    Actual: 95%
    Performance: 95% of target achieved.

   % of clients to be retained for a minimum of 12 weeks
    Target: 68%
    Actual: 48%
    Performance: 71% of target achieved.

   % of clients discharged to have a planned exit
    Target: 75%
    Actual: 87%
    Performance: Target achieved and exceeded - 116% of target achieved.


Provider: Chill Out Sound Support

Chill Out Sound Support provide information, advice and support around mild to
problematic, non-injecting drug use with the aim of eliminating or minimising the risks
and damage associated with it. Much of this work is undertaken in night-time
economy settings via outreach. The service also sees a significant number of
individuals on an ongoing basis and provides structured psychosocial interventions to
problematic non-injecting drug users.

Interventions / Services Provided

Chill Out Sound Support is expected to provide the following interventions:
   Comprehensive Assessment
   Harm reduction advice and information
   Holistic therapies
   One-to-one brief interventions
   One-to-one structured interventions
   Outreach sessions in night-time venues
   A gateway and referral point to the wider drug treatment system

Client Group

   The Chill Out client group is: adults residing in Nottingham City using drugs on a
    recreational to problematic basis (not including injecting drug users). Through the
    outreach provision, the service will engage with substance users accessing
    Nottingham city centre bars, nightclubs and other events and venues.

   In 2007/8, the team provided structured treatment interventions to 27 individuals.

   A breakdown of the client group seen during 2007/8 is given below:




                                          127
    Gender
    Male                     19         70%         Female         8        30%

    Ethnicity
    White British            23         85%         Bangladeshi    0        0%
    White Irish              0          0%          Other Asian    0        0%
    Other White              0          0%          Caribbean      2        7%
    White & Black            1                      African        0        0%
    Caribbean                           4%
    White & Black             0                     Other Black    0        0%
    African                             0%
    White & Asian             0         0%          Chinese        0        0%
    Other Mixed               0         0%          Other          0        0%
    Indian                    1         4%          Not Stated     0        0%
    Pakistani                 0         0%          Missing        0        0%
                                                    ethnicity
                                                    code

    Age group at mid point of the year (30/09/2007)
    9                         0          0%             17        0         0%
    10                        0          0%             18        0         0%
    11                        0          0%           19 -24      8         30%
    12                        0          0%           25 - 34     15        56%
    13                        0          0%           35 - 44     3         11%
    14                        0          0%           45 - 54     1         4%
    15                        0          0%           55 - 64     0         0%
    16                        0          0%            65+        0         0%

Funding
2007/8 Spend
Amount                                                Funding source
£97,214.00                                            PTB

2008/9 Allocation
Amount                                                Funding source
NYK                                                   PTB

      It is not possible to produce a unit cost for Chill Out’s structured treatment
       provision as the estimated allocation includes a considerable amount outreach
       activity. Further work will therefore be required to establish more precise
       estimates of cost for this service.

Access & Pathways

      During 2007/8, Chill Out Team saw approximately 25 new presentations.

      Referral source data for Chill Out Sound Support is not yet available. The service
       receives self referrals / presentations following outreach work, and referrals from
       other treatment services.

      100% of clients accessing the service during 2007/8 waited under 3 weeks.



                                              128
2007/8 Performance

Please note that the targets below are the structured treatment KPI targets rather
than contract targets.

   No. in Treatment
    Target: 40
    Actual: 27
    Performance: 68% of target achieved.

   Avg. New Presentations Per Month
    Target: 3
    Actual: 2
    Performance: 67% of target achieved.

   % of Waits to be Under 3 Weeks
    Target: 100%
    Actual: 100%
    Performance: Target achieved.

   % of new presentations to have a care plan
    Target: 100%
    Actual: 60%
    Performance: 60% of target achieved.

   % of clients to be retained for a minimum of 12 weeks
    Target: 75%
    Actual: 100%
    Performance: Target achieved and exceeded.

   % of clients discharged to have a planned exit
    Target: 60%
    Actual: 43%
    Performance: 72% of target achieved.


Provider: Shared Care
Shared Care is a prescribing based drug treatment intervention carried out within a
Primary Care setting. Specialist drug treatment workers and appropriately trained
GPs work together to deliver substance misuse treatment. Currently there are 15
Shared Care Clinics operating in various localities across the city. Shared Care
Clinics are held both within GP practices and also outside of a practice setting in
appropriate locations to support particular communities of interest

There are currently 16 Shared Care Clinics in Nottingham City:
   The Arboretum
   The Arches Shared Care Clinic
   Beechdale Surgery
   Bilborough Medical Centre
   Churchfields Medical Practice
   Clifton Cornerstone Shared Care Clinic
   The Family Medical Centre
   The Forest Practice



                                        129
      Handel Street Clinic
      The Health Point Clinic
      The Meadows Shared Care Clinic
      NDU
      POW! Prescribing Clinic
      The Windmill Practice
      Wells Spring Surgery
      Women’s Shared Care Clinic

Interventions / Services Provided

      Comprehensive Assessment
      Prescribing interventions
      Harm Reduction
      Relapse Prevention
      Appropriate onward referral

Client Group

      Approximately 452 individuals were seen in Shared Care during 2007/8.

      The client group for Shared Care is adult problem drug users in Nottingham City
       who require prescribing treatment and are non complex medical cases.

      A breakdown of client demographics for 2007/8 is given below:

    Gender                         No.       %                                      No.        %
    Male                             265     61%      Female                          166      39%

    Ethnicity                      No.       %                                      No.        %
    White British                    371     86%      Bangladeshi                          0    0%
    White Irish                         2      0%     Other Asian                          0    0%
    Other White                         4      1%     Caribbean                           18    4%
    White & Black Caribbean            12      3%     African                              0    0%
    White & Black African               2      0%     Other Black                          3    1%
    White & Asian                       0      0%     Chinese                              1    0%
    Other Mixed                         2      0%     Other                                4    1%
    Indian                              1      0%     Not Stated                           1    0%
    Pakistani                           4      1%     Missing ethnicity code               6    1%

    Age group at mid point
    of the year (30/09/2007)       No.       %                                      No.        %
    9                                    0       0%                            17       0       0%
    10                                   0       0%                            18       2       0%
    11                                   0       0%   19 -24                           28       6%
    12                                   0       0%   25 - 34                         226      52%
    13                                   0       0%   35 - 44                         132      31%
    14                                   0       0%   45 - 54                          40       9%
    15                                   0       0%   55 - 64                           3       1%
    16                                   0       0%   65+                               0       0%




                                             130
Funding
2007/8 Spend
Amount                                      Funding source
£242,410.00                                 Excluding Primary Care Liaison Team
Est. £401,878.00                            Including Primary Care Liaison Team

2008/9 Allocation
Amount                                      Funding source
£304,008.00                                 Excluding Primary Care Liaison Team
£463.476.00                                 Including Primary Care Liaison Team

Access & Pathways

   Approximately 230 individuals presented to treatment with Shared Care clinics
    during 2007/8.

   The majority of referrals to Shared Care are from the John Storer Clinic.

   100% of clients accessing Shared Care treatment during 2007/8 waited under 3
    weeks.

   With regard to onward referrals, movement from Shared Care clinics into other
    treatment services is low

Performance

Please note that the targets below are the structured treatment KPI targets rather
than contract targets.

   No. in Treatment
    Target: 450
    Actual: 452
    Performance: Target achieved.

   Avg. New Presentations Per Month
    Target: 26
    Actual: 15
    Performance: 58% of target achieved.

   % of Waits to be Under 3 Weeks
    Target: 100%
    Actual: 100%
    Performance: Target achieved.

   % of new presentations to have a care plan
    Target: 100%
    Actual: 97% (system wide achievement – not possible to establish shared care)
    Performance: 97% of target achieved.

   % of clients to be retained for a minimum of 12 weeks
    Target: 75%
    Actual: 87%
    Performance: Target met and exceeded.




                                         131
   % of clients discharged to have a planned exit
    Target: 65%
    Actual: 64%
    Performance: 98% of target achieved.

Provider: New Pathwaves

New Pathwaves is a therapeutic and specialist addictions counselling service for
individuals and families who are directly or indirectly affected by drugs and alcohol
issues and related psychological problems. New Path-Waves is open to all
communities, specialising in the Black, Minority and Ethnic communities.

Interventions / Services Provided

New Pathwaves is expected to provide the following interventions:
   Comprehensive Assessment
   Psychological interventions (e.g. structured counselling)
   BME specific support
   Group therapy
   Appropriate onward referral

Client Group

   The service client group is: problem drug using adults residing in Nottingham City
    who require psychological interventions. The service has a specific remit to
    support clients from BME communities.

   In 2007/8, the New Pathwaves treated 23 individuals.

   A breakdown of the client group seen during 2007/8 is given below:




                                         132
    Gender
    Male                     16        70%         Female         7        30%
    Ethnicity
    White British             0         0%         Bangladeshi    1         4%
    White Irish               0         0%         Other Asian    2        9%
    Other White               1         4%         Caribbean      5        22%
    White & Black             1         4%         African        3        13%
    Caribbean
    White & Black             1         4%         Other Black    0         0%
    African
    White & Asian             1         4%         Chinese        0         0%
    Other Mixed               1         4%         Other          0         0%
    Indian                    2         9%         Not Stated     0         0%
    Pakistani                 5        22%         Missing        0         0%
                                                   ethnicity
                                                   code
    Age group at mid point of the year (30/09/2007)
    9                         0          0%      17               0         0%
    10                        0          0%      18               0         0%
    11                        0          0%      19 -24           3        13%
    12                        0          0%      25 - 34          8        35%
    13                        0          0%      35 - 44          8        35%
    14                        0          0%      45 - 54          3        13%
    15                        0          0%      55 - 64          1         4%
    16                        0          0%      65+              0         0%

Funding
2007/8 Spend
Amount                                               Funding source
£30,000                                              PTB

2008/9 Allocation
Amount                                         Funding source
£30,900.00                                     PTB

-      New Pathwaves saw 23 individuals, meaning an estimated unit cost of
       £1,343.48.

Access & Pathways

      During 2007/8, New Pathwaves saw approximately 12 new presentations.

      Referral source data for 2007/8 is not yet available. In 2006/7, 100% of referrals
       to New Pathwaves were self referrals.

      100% of clients accessing the service during 2007/8 waited under 3 weeks.

      With regard to onward referrals, movement from New Pathwaves into other
       treatment services is low



                                             133
2007/8 Performance

Please note that the targets below are the structured treatment KPI targets rather
than contract targets.

   No. in Treatment
    Target: 25
    Actual: 23
    Performance: 92% of target achieved.

   Avg. New Presentations Per Month
    Target: 1.5
    Actual: 1
    Performance: 67% of target achieved.

   % of Waits to be Under 3 Weeks
    Target: 100%
    Actual: 100%
    Performance: Target achieved.

   % of new presentations to have a care plan
    Target: 100%
    Actual: 100%
    Performance: Target achieved.

   % of clients to be retained for a minimum of 12 weeks
    Target: 75%
    Actual: 69%
    Performance: 92% of target achieved.

   % of clients discharged to have a planned exit
    Target: 70%
    Actual: 43%
    Performance: 61% of target achieved.


Provider: Double Impact

Provide aftercare services in the City including access to education, training,
courses, life skills, relapse prevention groups, debt advice and group and structured
activity.

Interventions / Services Provided
The Double Impact core service provides the following interventions:

       Engage clients in structured aftercare programmes to build up their skill base
        and confidence

       Encourage access to training and employment

       Enable people to overcome substance misuse problems and lead healthy and
        safe lives.

       Reduce relapse into criminal activity


                                          134
      Improve health and social functioning

      Move people through cycle of change towards abstinence, support drug free
       lifestyle and reduce relapse.

      Provide services for stimulant users

      Involve service users in planning and delivery of care

      Assist with community reintegration via work experience and work
       placements

      Flexibly provides structured activity and a vast number of groups and
       programmes. It also uses outside providers to deliver ETE and wraparound
       services. There is a good focus on providing accredited training for service
       users. The courses ran well meet the aims set out in the SLA.

Client Group

      Double Impact provides services for recovering drug or alcohol users that are
       abstinent following exiting clinical treatment, or attempting recovery and who
       present as clean and dry on the day.

      During 2007/8 Double Impact had 296 clients.

Gender
Male                     232        78%         Female          64     22%

Ethnicity
White British            225        76%         Bangladeshi     1       0%
White Irish               3         1%          Other Asian     7       2%
Other White              10         3%          Caribbean       15      5%
White & Black             8                     African         0       0%
Caribbean                           3%
White & Black             0                     Other Black     7       2%
African                             0%
White & Asian             3         1%          Chinese         0       0%
Other Mixed               4         1%          Other           0       0%
Indian                    6         2%          Not Stated      3       1%
Pakistani                 0         0%          Missing         0       0%
                                                ethnicity
                                                code

Age group
16-18                     2         1%
19-24                    42         14%
25-33                    120        41%
35-44                    104        35%
45-54                    22         7%
55-64                     6         2%




                                          135
Access & Pathways

      The main referrals for the Double Impact core service were self during 2007/8:

            Referral Source
    Self                      55%
    Priory Clinic             9%
    Refuge/housing            12%
    Statutory drug
                              5%
    service
    Non-statutory drug
                              3%
    service
    Criminal Justice
                              6%
    Agency

2007/8 Performance


      No. in Treatment
       Target: 200
       Actual: 296
       Performance: 148% of target achieved.

      New Presentations
       Target: 98
       Actual: 202
       Performance: 206% of target achieved.

      % of Waits to be Under 3 Weeks
       Target: 100%
       Actual: 100%
       Performance: Target achieved.

      % of new presentations to have a care plan
       Target: 100%
       Actual: 100%
       Performance: Target achieved.

      % of clients to be retained for a minimum of 12 weeks
       Target: 85%
       Actual: 58%
       Performance: 68% of target achieved.

      % of clients discharged to have a planned exit
       Target: 60%
       Actual: 61%
       Performance: 102% of target achieved.




                                           136
Provider: Gate Mentoring

Part of Double Impact.

Interventions / Services Provided
To develop a pool of trained volunteer mentors from ex service users to provide
support and guidance for current users in the treatment system, and to help them
attend appointments relevant to their care plan goals.

Service is successful in doing this. Interviews with staff have cited examples where
Mentors have been able to persuade clients not to miss legal appointments and not
to use drugs on the way.

Client Group

      The only data available on clients mentored is on gender

Gender
Male                     65        71%         Female        27       29%

Funding
2007/8 Spend
Amount                                           Funding source
£56,550                                          PTB

2008/9 Allocation
Amount                                           Funding source



Provider: Aspire

Interventions / Services Provided
Mentoring support for drug users not currently engaged in the treatment system.
Aims to refer people in to treatment and help retain them there, through general
support that compliments, but does not duplicate the work of care plan providers.

Particularly focuses on two drop in’s that offer services for homeless people and
women involved in prostitution.

Client Group

      236 clients over 2007/8

      The only useable data available is on gender

Gender
Male                     116       49%         Female        120      51%




                                         137
Funding
2007/8 Spend
Amount                                            Funding source
£75,450                                           PTB


Access & Pathways

      The main referral route into Aspire is through Jericho Road Project (44%) and
       Rally project (53%)

      133 of the total 236 clients in contact with the service over 2007/8 were new
       clients.

2007/8 Performance

      Number of active mentors – 38 against target of 50

      Number of individuals receiving mentoring support 141 against target of 80

      All of these were referred into holistic services or structured treatment.

      Number of assessments completed – 72 against target of 40.


Provider: Framework FT2

Interventions / Services Provided

Clients housed within Framework drug managed and abstinent housing. Service
provides drug testing, brief interventions, harm reduction, relapse prevention advice
and training for staff to deliver interventions.

To refer residents into treatment as appropriate.

Client Group

Useable data not available for a full financial year picture.


Funding
2007/8 Spend
Amount                                            Funding source
£20,000                                           PTB
£20,000                                           DIP

2008/9 Allocation
Amount                                            Funding source




                                           138
Access & Pathways

       Access to accommodation is always via the Homelessness Gateway. Spaces
        will therefore be filled as they arise and when suitable residents become
        available.

       Referrals do take place to other agencies for extra support. However, as all
        residents have treatment providers, these needs should be met by the care
        plan provider and this may indicate duplication.

       30 service users were resettled during 07/08. This might include people that
        went on to their own tenancies or to other more suitable hostels.

       22 were evicted for giving positive drug tests.

2007/8 Performance

       Delivered brief interventions, relapse advice and harm reduction info to 100%
        of residents in 07/08.

       84% of drug tests on people in abstinence accommodation were negative,
        against a target of 95%


Provider: Regents House

Regents House provides support and advice for carers, family members and other
individuals affected by another’s drug use. Examples of interventions the service
provides include structured packages of support for those affected by another’s drug
use; alternative therapies and pamper days; drop in; advice and information;
confidential helpline; and group support.

Interventions / Services Provided

Regents House provides the following interventions:
   Advice and Information
   Carer Assessment
   Keyworking
   Group Work
   Carer Event s (day respite / pamper days)
   Training
   Confidential Helpline

Client Group

   The Regents House client group is those adults residing in Nottingham City who
    are affected by another’s drug use. (Please note, the service also provides
    support to those residing in the county and conurbations and to young people –
    this activity is not included in this review).




                                          139
The service client breakdown for all contacts (including helpline and one-to-
ones) is given below:

Ethnicity: White UK                                                           1367 76.7%
Ethnicity: Not stated                                                          176 9.9%
Ethnicity: White/Asian                                                           4 0.2%
Ethnicity: White Other                                                          96 5.4%
Ethnicity: White Irish                                                          37 2.1%
Ethnicity: Pakistani                                                            32 1.8%
Ethnicity: Indian                                                               11 0.6%
Ethnicity: East European                                                         2 0.1%
Ethnicity: Black Other                                                           2 0.1%
Ethnicity: Asian Other                                                           0 0.0%
Ethnicity: Black Caribbean                                                      23 1.3%
Ethnicity: White/Black Caribbean                                                15 0.8%
Ethnicity: Black African                                                         0 0.0%
Ethnicity: Bangladeshi                                                           3 0.2%
Ethnicity: Black British                                                         4 0.2%
Ethnicity: Mixed other                                                          11 0.6%

One to One support: Aunt                                                         1 0.2%
One to One support: Parents                                                      3 0.5%
One to One support: Types of service user: Brother                               2 0.4%
One to One support: Types of service user: Daughter                             12 2.1%
One to One support: Types of service user: Ex-Partner                           17 3.0%
One to One support: Types of service user: Father                                4 0.7%
One to One support: Types of service user: Friend                               21 3.7%
One to One support: Types of service user: Grandparent                          34 6.0%
One to One support: Types of service user: Mother                              289 50.8%
One to One support: Types of service user: Partner                             155 27.2%
One to One support: Types of service user: Sister                               27 4.7%
One to One support: Types of service user: Son                                   4 0.7%

     The caseload is predominantly of White ethnicity, with only 13.5% of clients
      from BME groups. The service has reported an increase in clients other than
      white, but the current ethnic breakdown does not reflect that of the in treatment
      population.

     The dominant service user type in Mother of a drug user. It should be noted
      that the service’s staff are currently all female. A more diverse staff group may
      support the further engagement of male clients.
Funding
2007/8 Spend
Amount                                             Funding source
£232,498                                           PTB

2008/9 Allocation
Amount                                        Funding source
£249,003.00                                   PTB

N.B. please note, this is full service costs rather than city only spend


                                           140
Access & Pathways

      During 2007/8, Regents House received approximately 187 new presentations.

      A breakdown of referral sources is given in the table below:

                        REFERRAL SOURCE                                %
    Referral from: YOT                                                2.1%
    Referral from: Hospital                                           1.1%
    Referral from: Friend                                             5.3%
    Referral from: BAC-IN                                             3.2%
    Referral from: APAS                                               2.1%
    Referral from: Hetty's                                            3.2%
    Referral from: Nottingham Deaf Services                           1.6%
    Referral from: Self                                               16.6%
    Referral from: Outreach Team                                      1.1%
    Referral from: Porchester Road Clinic                             0.5%
    Referral from: Womens Aid                                         1.1%
    Referral from: The Sanctuary                                      1.1%
    Referral from: Parentline                                         1.6%
    Referral from: JSC                                                10.7%
    Referral from: Double Impact                                      3.2%
    Referral from: Face It                                            1.1%
    Referral from: Compass Young Persons                              2.1%
    Referral from: Thorneywood                                        1.1%
    Referral from: NADT                                               0.5%
    Referral from: Drinkine                                           0.5%
    Referral from: Rapid Prescribing Team                             0.5%
    Referral from: Ken Wilde House                                    0.5%
    Referral from: EIP / Psychosis CPN                                2.1%
    Referral from: Police                                             0.5%
    Referral from: Phoenix Futures                                    0.5%
    Referral from: Health Shop                                        0.5%
    Referral from: Website                                            5.9%
    Referral from: Step Forward                                       0.5%
    Referral from: FRANK                                              1.6%
    Referral from: Head2Head                                          0.5%
    Referral from: Direct Access                                      0.5%
    Referral from: Building Bridges                                   0.5%
    Referral from: BBC Radio Nottm                                    0.5%
    Referral from: New Castle House                                   2.7%
    Referral from: SORTED                                             0.5%
    Referral from: HLG                                                2.1%
    Referral from: Tree Tops                                          0.5%
    Referral from: CJIT                                               5.9%
    Referral from: CDP                                                0.5%
    Referral from: Advertising                                        3.2%




                                              141
Referral from: Compass Adult Friends                                1.6%
Referral from: GP                                                   4.8%
Referral from: Hetty's Life Education Centre                        0.5%
Referral from: School                                               1.1%
Referral from: Social Services                                      1.6%

2007/8 Performance


       Measure                                        Target      Actual

       Number of calls received by the helpline        200       270 Avg.
       each month
       Percentage of messages received by the          95%        Not yet
       helpline responded to by 12 noon the                      available
       following day
       Number of One-to-One Support Sessions            50       60 Avg.
       per month
       Percentage of support plans in place for        95%        >95%
       Service Users receiving 1-2-1 support
       (excluding those on their first or second
       session)
       Percentage of support plan goals achieved       40%        Not yet
       per quarter                                               available
       Minimum number of Service User                   4           4
       consultation events per year


Provider: Criminal Justice Interventions Team

Interventions / Services Provided

The CJIT will support an end-to-end integrated approach to the case management
and care co-ordination of drug users who are engaged within the criminal justice
system and will address drug related offending behaviour.

The overall aim of CJIT is to reduce drug related offending. This will be achieved
through the delivery of the following objectives:

   •   Manage service users drug use and co-ordinate the management of their
       offending by the relevant criminal justice agency
   •   Engage and motivate service users to maximise the number of entrants into
       treatment and other support services.
   •   Provide an end to end care co-ordination method of working as outlined in
       Models of Care which will allow the identification and tracking of individual
       service users across police stations, courts and the community.
   •   Assertively engage and motivate service users to ensure the maximum
       number of successful treatment, court bail and offender programme
       completions.




                                               142
Client Group

Client group as specified in SLA:
        Substance misusing offenders/ex-offenders aged 18 years or over who reside
        within the Nottingham Petty Sessional Area (PSA), which consists of
        Nottingham City, Broxtowe, Rushcliffe and Gedling boroughs, including those
        who are currently engaged with treatment services.

Funding

2007/8 Spend
Amount                                   Funding source
£1,126,287*                              Drug Interventions Programme
*This includes service and accommodation costs

2008/9 Allocation
Amount                                    Funding source
£1,172,195*                               Drug Interventions Programme
*Accommodation costs are not included as they have transferred to the AOS.

Access & Pathways

Access and referral pathways to the Service will be available through the following
mechanisms (These are identified as a minimum requirement and should not be
seen as restrictive to prevent successful engagement with the identified service user
group):

      •   Testing on Arrest.
      •   Court referrals at pre-sentence stage (Restriction on Bail (ROB))
      •   Prisons’ Counselling, Assessment, Referral, Advice and Throughcare
          (CARAT) teams.
      •   Other DIP areas.
      •   Probation Approved Premises – regular drop in / satellite presence.
      •   Self referral via the 24/7 Freephone Helpline.
      •   Probation referral towards the end of a DRR sentence
      •   Referrals from the Sherwood Project

Performance

Summary of Compact Targets:

                Measure
KPI                                                                                   Target
1               95% of adults arrested for a trigger offence to be drug tested                 95%


2               95% of adults who test positive and have an initial required                   95%
                assessment imposed, to attend and remain at the initial required
                assessment
3               85% of adults assessed as needing a further intervention, to have a            85%
                care plan drawn up and agreed
4               95% of adults taken onto the caseload to engage in treatment                   95%




                                              143
Summary of Performance Indicators


Measure                                                                                 Target
% of those adults that have tested positive and have a required assessment                       95%
imposed, that attend and remain at the required assessment (Schedule A2)
% of required assessments to be undertaken at the custody suite during the              95% (not including
offenders period of detention (Schedule A2)                                                exclusions)
% of those adults that have not tested positive, with whom initial contact is made               90%
and who are not already on the caseload, that are assessed by the CJIT (Schedule
A2)
% of calls made to the Testing on Arrest Point of Contact that are answered or that              100%
receive a response within 30 minutes (if a message has been left) within operational
hours (Schedule A2)

% of positive test results that are communicated to the court (Schedule A3)                      100%
% of those individuals that have not had a Required Assessment and are bailed with                95%
ROB, that receive a Relevant Assessment at court (Schedule A3)

% of cases that are referred to the appropriate DIP team within 24 hours, in relation            95%
to individuals that are granted bail with attached ROB conditions and that are not
residents of Nottingham PSAs (Schedule A3)

% of referrals contacted within 48 hours by CJIT                                                 100%



Provider: Substance Misuse Team

Interventions / Services Provided

The SMT provide a care and case management of clinical interventions in
liaison with the Rapid Prescribing team, in addition, the SMT shall manage the
individual’s order. Interventions will tackle:
     • Homelessness
     • Basic skills deficits
     • Employability
     • Fit for Work Programme
     • Provide structured use of leisure activity

Client Group

The SMT manage all individuals subject to a DRR who are residents of
Nottingham City.

Funding

2007/8 Spend
Amount                                             Funding source
£351,374                                           Pooled Treatment Budget




                                              144
2008/9 Allocation
Amount                                  Funding source
£415,690                                Pooled Treatment Budget

Performance

No contract or agreement in place for 2007/08.


Provider: Rapid Prescribing

Interventions / Services Provided

The SMT provide a care and case management of clinical interventions in
liaison with the Rapid Prescribing team, in addition, the SMT shall manage the
individual’s order. Interventions will tackle:
     • Homelessness
     • Basic skills deficits
     • Employability
     • Fit for Work Programme
     • Provide structured use of leisure activity

Client Group

The SMT shall manage all individuals subject to a DRR and are residents of
Nottingham City.

Funding

2007/8 Spend
Amount                                  Funding source
£351,374                                Pooled Treatment Budget

2008/9 Allocation
Amount                                  Funding source
£415,690                                Pooled Treatment Budget

Performance

No contract or agreement in place for 2007/08.




                                     145
Annex b – Alcohol services in Nottingham

Provider: Alcohol interventions in primary care (Framework Housing
Association) (Due to commence September 2008)

Interventions/ services provided

   •   Development of targeted alcohol screening and brief interventions in primary
       care settings as part of a two-year pilot scheme
   •   Delivery of training programmes for GPs and practice nurses on how to use
       alcohol screening tools and deliver brief interventions
   •   Promotion and monitoring of the delivery of brief interventions in primary care

Client group

   •   Hazardous & harmful drinkers

Provider: APAS

Interventions/services provided

   •   Alcoline

           -   Local rate helpline providing generic information on alcohol and
               alcohol services
           -   09:00 – 19:00 Monday – Friday
           -   09:00 – 13:00 Saturday

   •   APAS Direct

           -   Open access drop-in service offering alcohol-specific advice, alcohol
               screening and assessment
           -   Harm reduction advice & psychosocial interventions
           -   Signposting to other services
           -   Care plans are devised for each client to facilitate follow-up sessions
           -   Brief interventions / extended brief interventions
           -   Abstinence and controlled drinking goals
           -   Open until 18:30 Monday – Thursday, 16:30 Friday, 12:30 Saturday

   •   Core service

           -   Weekly alcohol-specific one-to-one support
           -   Care planned interventions
           -   Structured evidence based psychosocial therapies
           -   Abstinence and controlled drinking goals

   •   Awareness raising and training

           -   Training programmes delivered to professionals, private companies
               and community organisations on alcohol awareness
           -   Advises on the development of alcohol workforce policies




                                         146
Client group

   •   Service is open to anyone with alcohol problems. Primary client base is
       individuals with alcohol dependency


Provider: Double Impact

Interventions/services provided

   •   Aftercare services
   •   Complementary therapies
   •   Access to personal development, housing, training, education, employment
       opportunities
   •   Open access to relapse prevention and/or harm reduction activities
   •   Referral to treatment agencies/services if service user needs access back to
       treatment
   •   Group sessions and mentoring activities on a daily basis
   •   Structured aftercare programmes such as structured day programmes
   •   Advice and harm reduction support
   •   Structured personal development programmes such as taster courses/short
       courses to develop special skills
   •   Referral to agencies/services who provide drug/alcohol free accommodation
   •   Housing and benefits advice
   •   Preparation for education courses
   •   Access to education, training and employment opportunities

Client group

   •   Recovering and stabilising substance misusers
   •   People who have experienced problematic drug or combined drug and
       alcohol use


Provider: Mary Magdalene Foundation (The Sanctuary)

Interventions/services provided

   •   One-to-one care-planned interventions
   •   Structured evidence based psychosocial therapies
   •   12-step programme based on AA ‘big book’
   •   12-week course of workshops on: parenting skills, loss & bereavement,
       relapse prevention, assertiveness techniques, anger management
   •   Group counselling
   •   Weekly family support group
   •   Training for professionals
   •   2 x AA meetings and 1 x EA meeting held each week
   •   Open Monday to Friday 9:00 – 16:30
   •   Telephone support Monday to Friday 9 – 4.30




                                        147
Client group

   •   Alcohol dependents over 18 years of age pursuing an abstinence treatment
       goal
   •   A 24 hour period of sobriety is required before assessment
   •   This service is exclusively abstinence-based


Provider: Nottingham Alcohol and Drugs Team

Newcastle House (NADT)

Interventions/ services provided

   •   Outpatient and day therapy unit offering 30 day places over the 7 day period
   •   One-to-one interventions linked to a 12 week group counselling programme
   •   Structured evidence based psychosocial therapies
   •   Consultant-led service
   •   Treatment options range from abstinence to controlled drinking

Client group
    • Severely dependent drinkers

Porchester Day Unit

   •   30 day places, seven days a week
   •   Medically supported detoxification
   •   Consultant-led service
   •   One-to-one care-planned interventions
   •   Structured evidence based psychosocial therapies
   •   Group counselling
   •   Treatment options range from abstinence to controlled drinking

Client group

   •   Severely dependent drinkers with chronic psychological and physiological
       dependence
   •   Clients who have had multiple treatment episodes for alcohol dependence
   •   Clients with complex / multiple needs

Porchester Ward

   •   Inpatient facility offering 4 specialist alcohol detoxification beds
   •   Medical detoxification
   •   Treatment options range from abstinence to controlled drinking

Client group

   •   Severely dependent drinkers with significant alcohol-related physiological or
       psychological damage, or clients unable to detoxify in a community setting
   •   Consultant led service




                                           148
QMC alcohol liaison team

Interventions/services

   •   Screening and assessment
   •   Alcohol liver disease clinic
   •   Extended brief intervention clinic
   •   Referral to specialist treatment services (NADT services)
   •   Enable patients that began their detoxification process on hospital wards, to
       continue their treatment within the community through the outpatient clinic
   •   Physiological assessment
   •   Teaching/training – alcohol awareness and alcohol withdrawal training
       sessions to staff in Nottingham

Client group

   •   Dependent drinkers admitted to the Queens Medical Centre with alcohol-
       related physiological damage

From autumn 2008 the QMC alcohol liaison team will be expanded to oversee the
delivery of alcohol screening and brief interventions in the A&E department. This
service will be targeted at hazardous and harmful drinkers.


Provider: Priory

Interventions/services provided

1. Inpatient detoxification programme
   • Physical stabilisation and detoxification under medical supervision
   • Prescribing
   • Medically assisted alcohol withdrawal

2. Inpatient treatment programme
   • Group counselling
   • Individual counselling – care-planned one-to-one interventions
   • Links with external support groups (12-step)
   • Structured evidence-based psychosocial therapies
   • Aftercare support

3. Day programme
   • Monday – Friday, 9 – 5pm
   • Group counselling
   • One-to-one interventions
   • External support groups
   • Structured evidence-based psychosocial therapies
   • Weekly aftercare support

7 inpatient beds and 3 day programme places are commissioned by the PCT
covering both alcohol and drug treatment




                                         149
Client group served

   • Adults with drug and/or alcohol dependency
This service is exclusively abstinence-based

Provider: Regent’s House

Interventions/services provided

   •   Family / carer support
   •   Free telephone support
   •   In-house one-to-one support
   •   Outreach support
   •   Group support sessions

Client group

   •   Families and carers affected by someone else’s drug or alcohol misuse


OUTREACH SERVICES

HASP (Framework Housing Association)

Interventions/services provided

   •   As above
   •   Plus long-term resettlement packages for former rough sleepers

Client group

   •   Rough sleepers with substance misuse and/or mental health problems


Street Outreach Team (Framework Housing Association)

Interventions/services provided

   •   Housing related support & access into treatment
   •   An outreach service for rough sleepers
   •   Assess rough sleepers for health status
   •   Provides access to treatment services
   •   Provides specialist housing for rough sleepers with substance misuse and/or
       mental health problems
   •   Provides access to day centre facilities and support services based in local
       day centres for rough sleepers
   •   Provides risk assessment and housing focussed assessment to
       accommodation providers
   •   Life skills and ETE training
   •   Provides link with other agencies to meet all holistic support needs for rough
       sleepers




                                         150
Client group

   •   Rough sleepers with substance misuse and/or mental health problems



DAY CENTRES

Emmanuel House

Interventions/services

   •   Dry day centre
   •   Deliver programmes of training and activity-based sessions for the client
       groups

Client group

   •   Vulnerable people (particularly older people) who are or at risk of rough
       sleeping or who are or are at risk of homelessness
   •   Primary need of clients is drug use
   •   17% require support for alcohol misuse

Commissioning/funding source

   •   Housing Directorate, Adult Services, Supporting People, Nottinghamshire
       PCT


Handel Street (Framework)

Interventions/services provided

   •   Open access wet day centre
   •   Identify and engage people who are rough sleeping / at risk of rough sleeping
       or those who are homeless / at risk of homelessness because of drug and
       alcohol problems
   •   Facilitate engagement with accommodation and other appropriate services
   •   Provide practical help and advice for this client group to enable them to move
       into accommodation
   •   Encourage clients into ETE
   •   Plan, develop and deliver programmes of training and activity-based sessions
       (‘meaningful occupation’) for the client group at day centres
   •   Life and social skills training, literacy, numeracy, ICT
   •   Since 2006, the centre has developed ‘meaningful occupation’ sessions,
       requiring service users to abstain from drinking alcohol whilst attending

Client group

   •   People at risk of homelessness because of drug and alcohol problems
   •   Rough sleepers, street drinkers and people who cannot access other services




                                         151
Commissioning/funding source

   •   Housing Directorate and Adult Services


SUPPORTED ACCOMMODATION SERVICES FOR ALCOHOL MISUSERS

For further information please refer to the ‘Strategic review of Supporting People
funded drug and alcohol related accommodation in Nottingham’


Ken Wilde House (Stonham Housing Association)

Interventions/services provided

   •   Abstinence-based accommodation
   •   8 bedrooms with shared facilities
   •   20 hours weekly support per person
   •   Sleep-in cover from midnight to 7am in case of emergency
   •   Staffed 24 hours a day/ 7 days a week
   •   Supports service users to access local specialist treatment agencies
   •   Provides service users with skills for independent living
   •   Help in managing finances and benefit claims
   •   Help finding long-term accommodation
   •   Facilitate access to employment/training/education opportunities

Client group

   •   Men and women who have long term problems with alcohol and/or drug use
   •   Clients must be at least 4 days clean and sober or have a desire to remain
       abstinent
   •   Clients must be willing to engage in 1-1 linkwork sessions to identify needs
       and set goals

Commissioning source

   •   Supporting People


Michael Varnam House (Framework Housing Association)

Interventions/services provided

   •   24 hour 10 bed hostel with sleep-in staff
   •   16 satellite units visited daily by staff
   •   24 hour supervision to support detoxification and controlled drinking
   •   Provide information on available treatment options and harm reduction
   •   Facilitates access to treatment services
   •   Liaise with treatment providers to support completion of treatment
       programmes
   •   Help in setting up and maintaining home or tenancy
   •   Agreed support plan for all service users
   •   Facilitate planned move-on to independent accommodation


                                         152
   •   Developing domestic/life skills, social skills
   •   Help in managing finances and benefit claims
   •   Emotional support, counselling and advice
   •   Supervision and monitoring of health and wellbeing
   •   Peer support and befriending

Client group

   •   18+
   •   Primary group - people with alcohol problems
   •   Secondary group – people with drug problems
   •   People must be motivated to change their current behaviour (all clients will
       undertake a 28 day period of abstinence, followed by either a controlled
       drinking programme or continued abstinence)
   •   Intended stay for all residents in 6-24 months

Funding/commissioning sources

   •   Supporting People


Studio House (Two Ways Limited)

Interventions/services provided

   •   Abstinence-based accommodation
   •   14 beds
   •   Weekly support hours per person – 13.2 hours
   •   Access to specialist drug/alcohol services
   •   Night time cover 11.30 – 8 am sleep in nightshift
   •   On-call worker for emergencies
   •   2 workers on duty from 8 am to 7 pm Mondays-Fridays
   •   Weekly key working
   •   Day programme to build practical skills and confidence
   •   Help in finding other accommodation
   •   Help in setting up/maintaining home or tenancy
   •   Developing domestic / life skills and social skills
   •   Help managing finances and benefit claims
   •   Help accessing other services
   •   Access to ETE
   •   Access to GPs and dental services

Client group

   •   People with alcohol problems who are willing to undergo period of abstinence

Commissioning source

   •   Supporting People




                                         153
Woodborough Road (Stonham Housing Association)

   Interventions/services provided

   •   Abstinence based accommodation
   •   5 self contained bed sits
   •   22 hours of weekly support per person
   •   Night time on-call service 5pm-7am weekdays and full time weekends
   •   Support is available through staff based at Ken Wilde House, which is staffed
       24 hours a day, 7 days a week
   •   Floating support from staff at Ken Wilde House
   •   ‘Dry and clean’ semi-independent, self-contained accommodation
   •   Help in finding other accommodation
   •   Help in setting up and maintaining home or tenancy
   •   Developing domestic/life skills and social skills
   •   Help in managing finances and benefit claims
   •   Help in gaining access to other services
   •   Average stay 6 months
   •   Maximum stay 24 months

Client group

   •   People with alcohol problems
   •   Single people

Commissioning source

   •   Supporting People


YMCA “Dry Floor” (Double Impact)

Interventions/services provided

   •   5 bed spaces
   •   Second stage abstinent-based self catering with shared facilities

Client group

   •   Ex drug users (including those that are alcohol free)
   •   Single homeless
   •   18+
   •   Medium support needs

Commissioning source

   •   Supporting People


Other temporary housing services available for those with substance/alcohol
misuse problems




                                         154
Aidan House (Framework)

Interventions/services provided

   •   16 units of temporary supported accommodation for single mothers with
       children
   •   Support with:
   •   Making benefit claims
   •   Budgeting and debt repayment
   •   Developing life skills
   •   Accessing ETE
   •   Access local services
   •   Access to drug & alcohol treatment

Client group

   •   Women with children
   •   16+
   •   Non-chaotic substance misuse
   •   May experience episodes of mental ill-health


Aidan Tenancy Support Team (Framework)

Interventions/services provided

       •   Support with:
       •   Resolving housing issues and repairs
       •   Maximising benefit entitlements
       •   Budgeting and debt
       •   Emotional and personal support
       •   Developing parental skills
       •   Developing and maintaining positive social networks
       •   Accessing ETE
       •   Help with gas, electric, and water accounts
       •   Maintaining the safety and security of your home
       •   Access drug and alcohol treatment services
       •   Between 3 months – 2 years support

   Client group

       •   Parents or expectant mothers who are risk of losing their home


36/57 Bentinck Road (Framework)

Interventions/services provided

   •   9 bed hostel and nearby 3 bed shared house
   •   Day staff on site with emergency call out
   •   Developing life skills
   •   Help finding other accommodation
   •   Help in gaining access to other services


                                        155
    •    Help in managing finances and benefit claims
    •    Help in setting up and maintaining home or tenancy
    •    Peer support and befriending
    •    Supervision and monitoring of health and well-being
    •    Access ETE opportunities
    •    15.9 hours of high level housing related support per service user per week

Client group

    •    Older people with support needs
    •    Primary client group: 50-95+
    •    Secondary client group: People with alcohol problems
    •    Single men only

Commissioning/funding source

    •    Supporting People


32 Bentinck Road (Framework)

Interventions/services provided

    •    17 bed residential care home

Client group

    •    Older men with alcohol problems and associated cognitive impairment / and
         or self care difficulties linked to long term alcohol use

Commissioning/funding source

•       Adult Services, Nottingham City Council


Colville House

Interventions/services provided

    •    15 units of temporary accommodation and housing support
    •    Staffed 24 hours a day, 7 days a week
    •    Individual support plan and key worker
    •    Support with:
    •    Maximising benefit entitlements
    •    Budgeting and debt repayment
    •    Emotional and personal support
    •    Improving domestic skills
    •    Accessing ETE
    •    Accessing specialist services e.g. for substance misuse
    •    Accessing appropriate move-on support




                                          156
Client group

   •   Young women aged 16-25 with substance misuse issues who don’t have
       children


London Road (Framework Housing Association)

Interventions/services provided

   •   57 units of direct access emergency accommodation
   •   Staffed 24 hours a day
   •   Support with:
   •   Benefit claims
   •   Housing applications
   •   Budgeting & debt repayment
   •   Practical advice around housing and resettlement options
   •   Dealing with official agencies
   •   Developing daily living skills
   •   Accessing specialist services
   •   Accessing ETE services
   •   Move on to other accommodation

Client group

   •   Single homeless

Commissioning/funding source

Supporting People


Noelle House

Interventions/services provided

   •   10 bed women-only temporary supported housing
   •   Keyworker support
   •   Support with:
   •   Maximising benefit entitlements
   •   Budgeting and debt repayments
   •   Emotional and personal support
   •   Accessing ETE
   •   Access to drug and alcohol treatment

   Client group

   •   Women 16+
   •   Priority given to black women, lesbians (singles and couples)
   •   Women with HIV status
   •   Women escaping domestic violence




                                        157
Park House & Lake Street (Framework)

Interventions/services provided

   •   15 units of accommodation for single homeless
   •   Staffed 8:30 am – 8 pm Monday – Friday; 10am – 6:30om on Saturdays;
       12pm – 6pm on Sundays
   •   Support with:
   •   Making benefit claims
   •   Budgeting and debt repayment
   •   Accessing ETE
   •   Accessing local services (GP/dental)
   •   Referrals to specialist agencies for other support needs

Client group

   •   Single homeless
   •   16+
   •   Clients are known to the street outreach team
   •   Substance misuse/alcohol misuse problems
   •   Mental health difficulties


Somerville House

Interventions/services provided

   •   Temporary accommodation for single homeless men with multiple needs
   •   15 single rooms; 1 shared room
   •   Staffed 24 hours a day
   •   Support with:
   •   Advice on benefit entitlements
   •   Improving budgeting skills
   •   Accessing ETE
   •   Finding suitable move-on accommodation

   Client group

   •   Single homeless men aged 16+
   •   May require support as a result of substance/alcohol abuse




                                       158
Annex c

Record of activity undertaken for treatment system review

Type of activity                With who                  Date
Stakeholder event               All stakeholders          09/06/08
Stakeholder event               All stakeholders          01/09/08
Questionnaire consultation      All stakeholders          16/06/08 – 30/06/08
Briefing and consultation       Joint Commissioning       03/06/08
                                Group
Briefing and consultation       Service Managers          06/06/08
                                Meeting
Discussion                      Derby CSP                 13/06/08
Briefing and consultation       CDP Clinical Lead         12/06/08
Briefing and consultation       CDP Exec Board            19/06/08
Consultation                    Probation                 14/07/08
Briefing and consultation       Joint Commissioning       14/07/08
                                Group
Case file audit                 Chill Out Sound Support   22/07/08
Case file audit                 Wells Spring              22/07/08
Case file audit and interview   Compass The Point         28/07/08
Meeting                         Young Peoples             19/06/08
                                Commissioning Manager
Case file audit                 HLG                       30/07/08
Meeting                         Phoenix Futures Area      05/08/08
                                Manager
Meeting                         Drugs Liaison Midwife     07/08/08
Briefing and consultation       Joint Commissioning       13/08/08
                                Group
Meeting                         Supporting People         18/08/08
Briefing and consultation       Service Managers          15/08/08
                                Meeting
Interview                       Chill Out Sound Support   18/08/08
                                Service Manager
Meeting                         NTA                       20/08/08
Consultation                    CDP Clinical Lead         28/08/08
Case file audit and interview   Phoenix Futures           28/08/08
Speak Out Event                 Boston St Hostel          10/07/08
Speak Out                       London Rd Hostel          22/07/08
/Interviews/Questionnaires
Questionnaires/Discussion/      ASUF                      16/07/08
S-A-A visited to consult
Questionnaires/Discussion/      Drug Forum                30/07/08
Feedback from stakeholder
event.
Questionnaires/Discussion       Mental Health/DD Forum    31/07/08
Questionnaires/Discussion       Carers Forum              26/06/08
Service visit/Interview         The Sanctuary             07/07/08
Case file audit                 BAC IN                    29/06/08
Case file audit                 Joanne Sherwood, Well     22/07/08
                                Spring Surgery
Interview / Service Review      Regents House –           23/07/08



                                        159
                                Jeanette McCallen
                                (service manager) and
                                keyworkers.
Case file audit                 New Pathwaves              05/08/08
Interview                       Sohan Sahota, New          05/08/08
                                Pathwaves (service
                                manager)
Discussion                      Drug and Alcohol Forum     06/08/08
                                – Areas 4, 6 and 8
Case file audit                 NADT                       12/08/08 and 18/08/08
Interview / Practice Scoping    Direct Access, County      14/08/08
Service Shadowing /             BAC IN, David Jammeh,      19/08/08
Interview                       keyworkers and clients
Team Meeting / Interview        Dual Diagnosis Team        27/08/08
Meeting                         Housing Policy and         25/06/08
                                Supporting People
File audit & service manager    Aspire Mentoring           27/06/08
interview
File audit, service manager     Double Impact, gate        30/06/08
and staff interviews            mentors and debt worker
File audit & service manager    FT2                        03/07/08
interview
Interview                       Neil Brookes (Chill Out    18/08/08
                                Service Manager)
Presentation                    CDP Exec Board             16/06/08
Case File Audit                 The Health Shop            23/07/08
Case File audit and follow-up   APAS                       23/07/08
with staff                                                 3/09/08
Meeting                         Kate Rush (Housing         25/06/08
                                Support Strategy) &
                                Esther Lyons (Supporting
                                People)
File audit                      APAS                       23/07/08
Meeting                         Stephen Willott (CDP       28/08/08
                                Clinical Lead)
Interview                       APAS staff                 03/09/08
Email                           Kath Childs (GOEM)         20/06/08
Email                           Richard Martin (Derby      25/06/08
                                DAAT)
Email                           Mary Hague (Derbyshire     25/06/08
                                DAAT)
Email                           Kate Whittaker (ASHH)      26/06/08
Presentation                    Independent Advisory       28/06/08
                                Group




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