Skills for the future – a look into the crystal ball Dr Emily Finch, Clinical Director, Addictions, South London and Maudsley NHS Trust

What did it use to look like? Strong emphasis on opiates, focus on numbers in treatment Alcohol services less prominent Joint commissioning influenced by health and criminal justice Financial growth in the sector, ring fenced budgets Strong national control from the National Treatment Agency Strong political interest Workforce Long careers in one organisation Professional groups assured of careers in addiction DANOS, University MSc courses

The people we treat? Opiate use declining Ageing treatment population – prematurely aged Increasing physical health needs Increasing mental health needs Increasingly socially disadvantaged Polydrug use increasing Addiction to medicines – associated with other physical and psychiatric comorbidities NPS – range of problems some complex some not

Alcohol is different? Vast amount of unmet need Broader range of interventions and needs Harmful and hazardous drinkers need evidence based brief interventions Treatment in non-treatment and non specialist situations Patients in different environments e.g acute hospitals Dependent drinkers requiring evidence based psychological and pharmacological treatment interventions Most severe drinkers require a full range of harm reduction and social interventions

How are we organised? Commissioning moved to local authorities with strong influence from public health NTA moved into Public Health England Creation of PHE Tobacco, Alcohol and Drugs Escalation of competition in the sector, regular retendering of services Strong emphasis on local political decision making Many innovative models emerging e.g. integrated care, focus on well being, “parity of esteem” – unsure of impact on substance misuse Less political attention Role of “Francis”. Drive to quality in health Fewer but larger non-statutory organisations, less role of the NHS

The Money Removal of ring fenced money Part of public health grant Competing with other public health priorities Use of retendering to remodel services and to reduce costs.

What is public health? Focus on health of the whole population Benefits for large groups not individuals Reducing inequalities Obesity, tobacco, exercise Prevention and wellbeing Alcohol – but generally at a population level Infectious diseases e.g. HCV Important benefits for our clients but little emphasis on more intensive treatments. This may disadvantage our treatment population

Gaining the skills Most training internal – within large organisations. But risk of TUPE Universities need to adapt and find ways to provide specialist education Broader range of skills needed e.g. smoking and brief interventions Professional groups are responding e.g. SMMGP. Role of Health Education England (HEE)? But… Change expected – populations less predictable and systems less predictable. Innovation necessary Need a long term view – retaining managers and leaders through uncertainty is difficult Need system leaders Maintaining a high quality motivated workforce a priority.

Focusing on outcomes and using the evidence Skills in evidence based interventions e.g RP, MI, 12 step facilitation, recovery skills Transferable skills New pharmacologies e.g. for tobacco and alcohol Health interventions e.g. for HCV Mental health interventions e.g. CBT New populations e.g. in the acute hospital and in primary care NICE and other evidenced based and recommended interventions

Recovery and beyond Broader range of skills to support clients full recovery May not need all skills in one person Embedding former service users into the workforce and supporting them properly Skills in working in partnership

Who is the workforce? Generalists e.g. in acute hospitals and primary care. Substance misuse skills may be one of many New specialities e.g. pain clinics, liver clinics Those with careers in substance misuse need to adapt with core skills embedded. Ex-service users Professionals who are specialists.

Doctors, nurses, psychologists Specialist training still remains e.g. RCPsych and RCGP But rapidly decreasing placement and training opportunities Sector is less attractive due to uncertainly and disruption Psychology and nursing – fewer speciality placements But more interest in generalist training e.g. for medical and nursing students

The role of addiction specialist doctors in recovery orientated treatment systems A resource for commissioners, providers and clinicians Outlines contribution of doctors Set out standards for training and supervision for commissioners Expectations of contracts Outlines ways of providing training for doctors

Solutions Specialists and generalists need different solutions. Clarity of who does what and who needs which skills. Preserve standard of training for specialists and professionals Use all opportunities to set standards Encourage universities and other training organisations to provide sustainable specialist training. Opportunities for generalists to train in SM both undergraduate and post graduate.

It’s a bit fuzzy but…… Money is likely to be the biggest problem but.. Keep supporting and motivating staff Acquire new skills where needed Building high standards in contracts at all opportunities Allow opportunities for creativity and innovation. New career paths in recovery Use every opportunity to create careers in the sector