Waltham Forest Substance Misuse Needs Assessment and Treatment System Review Eric Ayesu-Boapeah – Senior Public Health Strategist Trevor Givans – Substance Misuse Commissioning Manager

Outline Purpose of HNA and Service Review Policy Context Prevention and Early Intervention -Key Issues and recommendations for Alcohol and Drugs Treatment Systems - Key Issues and recommendations for Alcohol and Drugs Young people in Transition Current Model Current Budget Future Model

Purpose of HNA and Service Review Identify the substance misuse related needs of the people of Waltham Forest Describe the wider impacts, risk and harms associated with the substance misuse Support the substance misuse service reconfiguration process Inform the commissioning strategy

Policy Context Underpins The Government’s Alcohol Strategy, March 2012 The Drug Strategy 2010 Our health and wellbeing today Public health outcomes framework Health and social care act 2012 Commissioning for Recovery (NTA 2010) JSNA

Prevention and Early Intervention Key Issues and recommendations -Alcohol

Key Issues - Alcohol Higher alcohol related hospital admissions and projected to go up based on the historical data. About 20% of WF residents identified as risk drinkers Alcohol specific hospital admissions for men in WF in 2010/11 were significantly higher than England and London. The admission rate for women in WF is higher than London average but the differences are not statistically significant.

Key Issues - Alcohol 3,026 alcohol related recorded crimes in WF in 2011/12. Most alcohol related incidents occur in the following wards – High Street, Lea Bridge, Wood Street and Leytonstone. These wards have higher indices of multiple deprivations than the WF average.

Alcohol Related Hospital Admissions, Waltham Forest, 2002/ /12

Recommendations Review current Alcohol liaison nurse post to ensure that it would include case finding and deliver IBA; medical management of patients with alcohol problems; liaison with community alcohol and other specialist services Embedding IBA in frontline staff as part of their initial assessment process. This will help to reduce alcohol use to low risk level Full analysis of alcohol-related hospital admissions in WF is undertaken to establish which particular groups need to be targeted

Recommendations Review current alcohol treatment pathway to include prevention, early intervention, treatment and recovery Embedding school based substance misuse education and interventions into the WF school nurses programme. Greater utilization of outreach and safer neigbourhood services to identify street drinking hotspots to refer into appropriate services

Recommendations Population level awareness raising and social marketing targeted at groups at risk of hazardous or harmful drinking. This includes health promotion in pub settings Examine the potential to use local authority powers to limit proliferation of alcohol outlets. For example, local licensing departments can take into account the links between the availability of alcohol and alcohol related harm when considering a license application.

Prevention and Early Intervention Key Issues and recommendations - Drugs

Key Issues - Drugs 1,463 people aged 15 to 64 classified as OCUs in WF. Estimated 5,033 class A; 14,765 any drugs; 11,409 cannabis. WF is categorised in the ‘HIGH’ group for prevalence of Hepatitis C Virus (HCV) together with 24 other borough in London, which means that over 50% of those who injected in the last year were HCV positive.

Key issues- Drugs 1,076 drugs offences recorded by police in WF between August 2011 to July 2012, compared to the 1,526 offences recorded between August 2010 and July % reduction Three wards in the borough accounted for 27.4% of all drugs recorded offences in the borough, with High Street ward accounting for 11.9%; Forest 8.6% and Hoe Street 6.9%.

Recommendations Ensure wider coverage and better uptake of blood borne viruses screening and immunisation Increase drug awareness training through frontlines staff Engage community based generic services (tier 1) to identify signs of substance misuse e.g. domestic violence, safeguarding and risks of hidden harm.

Recommendations Ensure substance misuse is incorporated into any health promotion work in schools including Pupil Referral Units and alternative provisions

Treatment System Key Issues and recommendations -Alcohol

Key Issues - Alcohol About 464 clients had contact with alcohol treatment services during the last 12 months (April 2012 – March 2013) New presentation were 72% (332)- higher than England average 68% - The referral from GP (6%) in WF was lower than England (18%) 66% (306)of the users left the treatment service – higher than England average (64%) WF received most of its referrals from ‘Self, Family and Friends’

Referral source into treatment of all new presentations (YTD), 2012/13

Recommendations Reconfigure current Alcohol Treatment service to include clear referral pathways between hospital, community specialist services and primary care

Treatment System Key Issues and Recommendations - Drug

Key Issues 492 new referrals were made into the treatment system in 2011/12 Overall there were 1,206 clients in treatment with 13% of those clients having been in the treatment system over two years 467 clients left the treatment system which accounts for about 39% of those in treatment in 2011/12 Low referral rate from GPs 2% (8); 24% from criminal Justice systems; 42% were self referrals; drug service 16% and others 17%

Key Issues - Drugs WF had 267 adult opiate clients and 188 adult non- opiate clients in treatment per 100,000 population Between 2010 and 2012 on average about 95 opiate users each year successfully completed treatment. This amounts to 21% (20) being represented in the treatment services During the same period, a higher proportion of non- opiate clients (95%) compared to opiate clients (67%) successfully completed their treatment service within a year

Key issues WF Opiate users re-presenting to the treatment services were higher than the cluster average between 2011 and 2012 On average about 203 non-opiate users each year successfully completing treatment services between 2010 and Of these, 6% (12) re-presented into the treatment services WF non-opiate users representing to the treatment services was lower than the cluster average between 2010 and 2012

Key issues - Drug 9% (40) of the drug treatment population had dual diagnosis issues 278 admissions were logged in 2011/12 where there was a primary or secondary diagnosis of drug related mental health and behavioral disorders

Key Issues - Drugs 351 opiate clients in contact with DIP but were not engaged with the treatment system in WF in 2011/12. Of this, 89% (311) were men and 11% (40) were women 448 non-opiate clients in contact with DIP but were not engaged with the treatment system in WF in 2011/12. Of this, 91% (406) were men and 9% (42) were women

Referrals routes to the treatment system

Representation by opiate clients, 2012/13

Non-opiate clients and representation, WF,

Clients in contact with DIP but not engaged with the treatment system - Community and Prison Combined, WF 2011/12

Drug related dual diagnosis- London admissions, 2011/12

Recommendations Improve recovery focus stepped approaches which does not focus solely on abstinence. Increase access to GP Shared Care and primary care services for more stable service users. Increase access to Employment, Training, Education to ensure clients have access to supported housing and encourage diversionary activities which steer clients away from substance misuse such as sport, art, music etc.

Recommendations Increased partnership and promotion work to develop stronger links between community based generic services to reinforce and strengthen recovery and lessen the risks of relapse. Ensure all staff across all sectors, who regularly come into contact with clients with substance misuse or dual diagnosis (mental health and substance misuse), have the appropriate training and support relevant to their needs

Recommendations Commissioners to develop robust performance management systems to ensure effective monitoring Investigate reasons behind lack of engagement with treatment system particularly high attrition rate in criminal justice Robust mobile care planning across treatment system partnership

Young People – Key Issues Young people struggle with the transition to adult services and there are the obvious issues of their vulnerabilities within adult services and the appropriateness of these facilities for their needs There is no dedicated service in the borough to deal with young adults whose main substance is cannabis or cannabis and alcohol. Currently 722 deals with these clients or most of them would drop out. However the service is being reviewed due to recent budget cuts

Young People - Recommendations To have a dedicated person in 722 and a counterpart within adult services to deal specifically with clients aged (transition phase). There should be an allocation of funding for this post from adult services.

Current Model

Considerations for Treatment Models Size and scope of specialist provision Size and scope of primary care provision Integrated or separate drug & alcohol pathways/services Choice/personalisation Buildings Sustained funding Ensuring continued provision while re-tendering

Considerations for Treatment Models Size of aftercare element Support to parents/families Care navigation through system Single point of entry and single assessment or multiple entry points Workforce development Harm reduction Referral Pathways

Treatment Models

INTEGRATED RECOVERY – LOTS MODEL (Model 1) Self/Community referrals & representations Direct professional referrals LOT 1 Outreach – Engagement – Access & Mentoring & Recovery – Aftercare Services Open access – meet/great – outreach – integrated assessment - service navigation –– service user/carer, peer mentoring support & advocacy – aftercare – prison resettlement – ETE Services LOT 2 Psychosocial Intervention & DIP/IOM Services Structured Day Programme – Structured Counselling – keyworking - recovery/treatment support – abstinent groups – alcohol & stimulant specific groups & DIP/IOM & integrated access to Tier 4 Services (residential rehab) LOT 3 Clinical Intervention Services Specialist Prescribing Services – GP Shared Care – BBV & NX – Supervised Consumption –Alcohol Community Detoxes – Hospital Liaison – integrated access to Tier 4 services (Inpatient Detox) Satellites Multiple Access Point Integrated Case Management System RECOVERY CAPITAL SUPPORT & COMMUNITY INTEGRATION Multiple Exit Points

INTEGRATED RECOVERY WITHIN 1 SERVICE - (Model 2) Single Access Point Integrated Case Management System Integrated Recovery Services Specialist Prescribing & GP Shared Care BBV – Healthcare Needle Exchanges incl Pharmacy NX’s & Supervised Consumption Alcohol Services Structured Counselling Structured Day Programme Service user/carer involvement Recovery services incl Peer Mentoring & ETE services DIP/IOM Assertive Outreach Aftercare Single Exit Point Tier 4 RECOVERY CAPITAL SUPPORT & COMMUNITY INTEGRATION

Multiple Access Point Integrated Case Management System Integrated Recovery Services Specialist Prescribing & GP Shared Care BBV – Healthcare Needle Exchanges incl Pharmacy NX’s & Supervised Consumption Structured Counselling Structured Day Programme Service user/carer involvement Recovery services incl Peer Mentoring & ETE services DIP/IOM Assertive Outreach Aftercare Multiple Exit Points Tier 4 RECOVERY CAPITAL SUPPORT & COMMUITY INTEGRATION Alcohol INTEGRATED RECOVERY WITH SEPARATE SATELLITE PROVISION & ALCOHOL SERVICE (Model 3 ) Satellites

Integrated Primary care/Community based Led