Doncaster Substance Misuse Strategy 2014 - 17

1

Content Page

National strategies 3 to 4Aims and objectives 5Action Plans 6 to 15Local picture 16 to 17Alcohol Related Deaths National landscape 18 to 19Drug Related Deaths 20 to 22Alcohol-related diseases 23Drug related diseases 24Commissioning for positive outcomes 25 to 26Social integration 27The cost of alcohol harm 28 to 29The cost of drug harm 30Harm reduction 31 to 32Alcohol diversion scheme 33 to 34DIP 35 to 36Substance misuse wrap around services 37Treatment data – Alcohol 38 to 41Treatment data – Drugs 42 to 47Next Steps 48

2

Background - National Strategies

Alcohol

Fifty years ago, the United Kingdom had one of the lowest drinking levels in Europe but it is now one of the few European countries whose consumption has increased over that period. Over the last decade we have seen a culture grow where it has become acceptable to be excessively drunk in public and cause nuisance and harm to ourselves and others.

A combination of irresponsibility, ignorance and poor habits – whether by individuals, parents or businesses – led to almost 1 million alcohol-related violent crimes and1.2 million alcohol-related hospital admissions in 2010/11 alone. The levels of binge drinking among 15-16 year olds in the UK compare poorly with many other European countries and alcohol is one of the three biggest lifestyle risk factors for disease and death in the United Kingdom after smoking and obesity. It has become acceptable to use alcohol for stress relief, putting many people at real risk of chronic diseases.Society is paying the costs – alcohol-related harm is now estimated to cost society £21 billion annually.

The problem has developed for the following reasons:

• Cheap alcohol is too readily available and industry needs and commercial advantages have too frequently been prioritised over community concerns. This has led to a change in behaviour, with increasing numbers of people drinking excessively at home, including many who do so before they go on a night out, termed ‘pre-loading’. In a recent study, around two-thirds of 17-30 year olds arrested in a city in England claimed to have ‘pre-loaded’ before a night out, and a further study found ‘pre-loaders’ two-and-a-half times more likely to be involved in violence than other drinkers.

• Previous governments have failed to tackle the problem. The vibrant café culture, much promised by the previous Government’s Licensing Act, failed to materialise. Too many places continue to cater for, and therefore remain blighted by, those who drink to get drunk, regardless of the consequences for themselves or others.

• There has not been enough challenge to the individuals that drink and cause harm to others, and of businesses that tolerate and even encourage this behaviour.The result is a situation where responsible citizens and businesses are paying the price for irresponsible citizens and businesses.

This strategy signals a radical change in the approach and seeks to turn the tide against irresponsible drinking. Such change will not be achieved overnight. It will require long-term and sustained action by local agencies, industry, communities and the Government. We will:

Take firm and fast action where immediate and universal change is needed.

Ensure that local areas are able to tackle local problems, reduce alcohol-fuelled violent crime on our streets, and tackle health inequalities.

3

Secure industry’s support in changing individual drinking behaviour.

Support individuals to make informed choices about healthier and responsible drinking, so it is no longer considered acceptable to drink excessively.

Our ambition is clear – we will radically reshape the approach to alcohol and reduce the number of people drinking to excess. The outcomes we want to see are:

• A change in behaviour so that people think it is not acceptable to drink in ways that could cause harm to themselves or others;

• A reduction in the amount of alcohol-fuelled violent crime;

• A reduction in the number of adults drinking above the NHS guidelines;

• A reduction in the number of people “binge drinking”;

• A reduction in the number of alcohol-related deaths; and

• A sustained reduction in both the numbers of 11-15 year olds drinking alcohol and the amounts consumed.

Drugs

The Drugs Strategy (December 2010) and Healthy Lives, Healthy People (November 2010) set out a new vision of a locally-led, recovery oriented system, under which most drugs and alcohol services will in future be commissioned by local authorities through Directors of Public Health, supported by Health & Wellbeing Boards. The Drugs Strategy set out clear aims to support recovery, encapsulated in three overarching principles – wellbeing, citizenship and freedom from dependence. It also aimed to reduce the use of illicit and other harmful drugs.

Drug dependency not only leads to crime, but also caused a wide range of health and social harms. Drugs can also lead to social exclusion and makes it difficult for people to play full and active roles in society.

There is further reform on the way treatment is provided, offering services such as training and support in getting work, alongside drug treatment.The new Recovery approach will mean more research to improve treatment outcomes, more personalised approaches and better information sharing between agencies.To improve the effectiveness of treatment given to those entering treatment, to use a wider use of new treatment approaches and to use a radical new focus on services to help drug users to re-establish their lives.The past year has seen increased numbers of people accessing treatment and improved effectiveness in the treatment people are receiving.

4

Aim and Objectives

Aim: Work together to promote recovery and protect individuals, families and communities from the harms caused by substance misuse.

Objectives for Drugs:1. Reduce illicit / other harmful substance use

2. Increase numbers recovering from dependence

3. Reduce the impact on families and communities

4. To provide active drug users access to injecting equipment, supported by appropriate education to reduce equipment sharing

5. Continue to review all DRDs in accordance with the Doncaster protocol and initiate recommendations

Objectives for Alcohol

Aim: Work together to promote recovery and protect individuals, families and communities from the harms caused by alcohol misuse in Doncaster.

Objectives: 1. Promoting safe drinking and establishing effective identification and

interventions

2. Reducing alcohol related crime and reducing the availability of alcohol

3. Reduce the harms of alcohol on the individual and the wider community

4. Increase the effectiveness and efficiency of our services

Local drivers

Doncaster Health and wellbeing board as identified alcohol as one of its priorities.

Key performance indicators include:

Increase the numbers accessing treatment Increase the numbers successfully being treated Reduce the numbers accessing accident and emergency for alcohol related

issues Reduce substance misuse related crime and disorder

5

Doncaster Drug Strategy 2014 - 2017

Objectives Plan (Drugs)Aim: Work together to promote recovery and protect individuals, families and communities from the harms caused by drug misuse in Doncaster.

Objectives:1. Reduce illicit / other harmful drug use2. Increase numbers recovering from dependence3. Reduce the impact on families and communities4. To provide active drug users access to injecting equipment, supported by appropriate education to reduce equipment sharing. And to

ensure that local policies and procedures are in place to reduce the incidence of drug related litter.5. Continue to review all DRDs in accordance with the Doncaster protocol and initiate recommendations

DrugsObjective Outcome Action Measure Target

Reduce illicit / other harmful drug use

Delivering new approaches to drug treatment and social re-integration

Keeping up to date with good practice and new initiatives

Treatment system that is flexible to adapt to the changing needs of substance misusers

Reduce

Reduction in illegal drug use across the population

Provide appropriate information and advice to the at risk population

Reduction in overall use of illegal drugs Reduce

Aid prevention by providing The information and engagement Reduction in overall use of

6

public information campaigns, communications and community engagement

should reflect the needs assessment recommendations as well as the community development work.

Advice and information available must reflect the Doncaster community that the services are aimed at.

Provide clear, targeted information to communities and professionals.

Ensure information relating to new drugs, associated harms and harm reduction advice is communicated.

illegal drugs and associated harms

Decrease

Increase numbers recovering from dependence

Develop a client-centred, recovery focused treatment system

PH England will provide support and monitor the implementation of guidance on the provision ofpersonalised and outcome focused treatment through:• effective clinical governance;• user and carer involvement;and• using completion andoutcomes data to improvetreatment targeting andeffectiveness

Successful treatment exits. Increase

Provide services for clients with Dual Diagnosis Ensure pathways exist between

substance misuse and mental

Combined multi-agency recovery plans Increase

7

health services in order to effectively treat clients with dual diagnosis.

Deliver services using a ‘whole systems’ approach (training, education, employment, debt and housing support)

Provide specialist support service for training, education, employment, debt and housing.

Encourage joint working between treatment agencies, Jobcentres and sources of housing advocacy and advice, to plan and manage clients’ journeys through treatment and into work, helping them access the wider support they need to re-establish their lives.

Drive up standards across all treatment providers through new local clinical governance arrangements and by monitoring a range of treatment outcomes, including employment and health.

Ensure treatment is personalised and outcome-focused, making full use of new treatment approaches that are shown to be effective.

Sustained recovery capital, increase in successful treatment exits

Increase

Reduce the impact on families and communities

Ensure prompt access to treatment for all drug-misusing parents with a treatment need and all assessments taking account of the needs of the

Provide relevant support for family members and carers of those in treatment

Family / carer involved in treatment Increase

8

family.

Public information campaigns, communications (including website)and community engagement

Communities made aware ofthe work being done locally.Positive prevention messagescommunicated

Improved public perception of substance misuse services

Increase

Pregnant substance misusersgiven better care and support,with less pre-natal harm tochildren

Reduce substance misuse related crime

Encourage closer workingbetween treatment andmaternity services

Achieve greater outcomes for offenders that have substance misuse as a key component to their offending.

Specialist (substance misuse) midwife support uptake via CDT women’s service

Successful treatment exits for CJIT clients

Increase

Increase

To provide active drug users access to injecting equipment, supported by appropriate education to reduce equipment sharing and to ensure that local policies and procedures are in place to reduce the incidence of drug related litter

Provide needle exchange outlets across the Borough as identified from the HNA.

Ensure appropriate pathways / sign-posting between needle exchanges and treatment providers are in place.

Increased referrals into treatment.

Increase

Provide a range of paraphernalia to clients to promote harm reduction and a choice between injecting / smoking.

Ensure all needle exchanges offer a wide choice of paraphernalia & harm reduction materials.

Decrease in drug related harm and equipment sharing

Decrease

Liaise with partners to enable information sharing in relation to drug related litter to enable appropriate action.

Receive regular data on drug related litter incidences and inform needle exchanges of was to discourage clients from not disposing of needle waste etc correctly.

Decrease in number of drug related litter incidences reported.

Decrease

9

Continue to review all DRDs in accordance with Doncaster protocol and initiate recommendations

Identify patterns and trends to prevent reoccurring drug related deaths.

Direct and support a system of notification of DRD which is upheld by a Clinical Governance structure.

Decrease number of DRD’s that were preventable

Decrease

Build and monitor the current picture of local issues relating DRD to enable considered recommendations with the aim of reducing the prevalence of DRD and improving health and social care

Ensure an immediate response to a DRD where a present threat to the wider public exists.

Increase appropriate information sharing and utilise local data to prevent DRDs.

Increase

Support the national drug strategy by providing a system to accurately record and quantify DRD and provide a link to public health action and drug education.

Ensure the Drug Related Deaths Steering Group commits to meeting each quarter to review all information pertaining to actual or suspected DRD in the Doncaster area, undertakes analyse and interpret all information received on DRD and make reasoned recommendations for improvement and cascades information to all relevant agencies.

Increase DRD educational messages to prevent DRDs such as overdoes information and highlighting any local patterns and trends as they arise.

Increase

Doncaster Alcohol Strategy 2014 – 2017

Aim:

10

Work together to promote recovery and protect individuals, families and communities from the harms caused by alcohol misuse in Doncaster.Objectives: 1. Promoting safe drinking and establishing effective identification and interventions2. Reducing alcohol related crime and reducing the availability of alcohol3. Reduce the harms of alcohol on the individual and the wider community 4. Increase the effectiveness and efficiency of our services

Objective Outcome Action Measure TargetPromoting safe drinking and establishing effective identification and intervention

Identify/screen and treat patients before the onset of alcohol specific conditions in a local setting

Deliver; screening, brief interventions, extended brief interventions and community prescribing in primary care.

Number of screenings/brief interventions, extended brief interventions and community prescribing delivered Increase

Appropriate treatment is offered and received for those who have the greatest need

Ensure that individuals who drink hazardously receive the appropriate treatment Quality standards being met Increase

Those being admitted to hospital are being appropriately screened, treated and referred for their alcohol issues

Provide an alcohol screening and referral process based within Doncaster hospital through the substance misuse liaison nurse

Number of screenings and referrals from hospital to alcohol services Increase

Those putting themselves at risk through the harms of binge drinking are receiving the appropriate advice and treatment, to reduce alcohol related harm

Alcohol identification and referral service via the accident and emergency department at Doncaster hospital

Number of referrals made from A and E to alcohol services Increase

Reduction in alcohol related A&E admission. Greater Intelligence is required to adopt the Cardiff model of violence

Implement alcohol related data capture through the accident and department

Time, Location and incident recorded for alcohol related admissions recorded and provided

Increase

11

prevention.

Increase awareness of the harms of alcohol. Reduce alcohol related harms

Promote safe alcohol consumption in: The communityPrimary carePrisonPharmacyHospital Levels of alcohol related harm Reduce

Reduce levels of anti-social behaviour related to alcohol consumption

Work with licensing, police and other partners in establishing ‘reducing the strength’ campaign in relevant areas in the borough Levels of anti-social behaviour Reduce

Reduce levels of anti-social behaviour related to alcohol consumption

Work with relevant agencies to tackle antisocial behaviour in identified hot spot areas Levels of anti-social behaviour Reduce

Reduce the amount of counterfeit alcohol sold/consumed

Collaboratively work with licensing, best bar none, trading standards and other agencies to raise awareness and reduce the availability of counterfeit alcohol

Amount of counterfeit alcohol available Reduce

Increased standards of licensed premises

Raise standards of licensed premises by increasing participation of best bar none (BBN)

The numbers participating in BBN Increase

Increased standards of licensed premises

Provide public health intelligence to inform licensing decisions

Alcohol related incidences in licensed premises Reduce

Reduce alcohol related harm to children and young people

Continue to focus on underage drinking obtained in off and on licensed premises

Underage alcohol consumption Reduce

12

Greater intelligence and pathway for those affected by domestic violence and those perpetrating domestic violence

Aim to reduce alcohol related domestic violence

Alcohol related domestic violence Reduce

Increase awareness of the harms of alcohol. Reduce alcohol related harms

Support national social marketing by implementing local initiatives Alcohol related harms Reduce

Reduced alcohol related harm for CYP

Promote the harms of excess alcohol consumption in local schools and colleges, and other settings for children and young people

Levels of alcohol related CYP harm Reduce

Reduction in foetal alcohol syndrome

Promote the harms of excess alcohol consumption in pregnant women

Levels of harm in pregnant women and their child/children Reduce

Reducing alcohol related crime and reducing the availability of alcohol

Increase skill set of treatment provider to deal with domestic violence

Develop the skills of alcohol service workers in identifying and addressing domestic violence

Outcomes for those affected by DV Increase

Reduction in alcohol related offending

Achieve greater outcomes for offenders that have alcohol as a key component to their offending

Outcomes for offenders whose alcohol consumption is a key component of their offending Increase

Reduction in alcohol related offending

Increase the uptake of the alcohol diversion scheme and the positive outcomes from the scheme

Numbers coming through the diversion scheme Increase

Increased knowledge of alcohol services to the residents of the borough

Aim early interventions commission services to provide peer-led, local services to meet the needs of clients in a community setting Numbers accessing treatment Increase

13

Reduce alcohol related sexual exploitation

Target activity towards at risk groups of sexual exploitation Sexual exploitation Reduce

Reduce the harms of alcohol on the individual and the wider community

Reduce the impact of the cycle of dependency

Continue to adopt a family centred approach to treatment Family involved in treatment Increase

Reduce the impact of the cycle of dependency

Provide relevant support for family members and carers of those in treatment Family involved in treatment Increase

Reduce the impact of the cycle of dependency

Replicate identified good practice regarding families with complex needs Family involved in treatment Increase

Increase the effectiveness and efficiency of our services

Cost effectiveness measured against outcomes and financial restrictions

Provide local alcohol services that are cost effective Outcomes Increase

Increase levels of care form hospital to community setting

Provide an appropriate pathway from hospital to a community setting

Numbers being referred from hospital to single point of access Increase

Accessible services with greater outcomes

Ensure services are monitored and improvements are made where necessary Outcomes for service users Increase

Greater outcomes for patientsHorizon scan for new forms of treatment and initiatives Innovation Increase

Greater outcomes for patients

Ensure services are inclusive to all and comply with relevant national and local policies Quality standards being met Increase

Greater outcomes for patients

Ensure services improve treatment outcomes for service users which include mental and physical health

Impact of determinants of health Reduce

14

Local picture

Doncaster has a current population of around 302,400 (2012 census) individuals of which 152,000 are female and 150,000 are male (all ages). Children aged 0-19 make up 24.2% of the population (70,300). School aged children from a BME group make up 9.2%; this is considerably lower than the Yorkshire and Humber average of 19.2%. Current life expectancy for males is 76.8 years and for females 81.4 years. The percentage of children living in poverty in Doncaster 16 years and under is 25% with the regional average at 22.5% and a national average of 21.9%. This information tells us that Doncaster; is more deprived, has a smaller ethnic minority and has lower life expectancy for both genders than areas in the surrounding areas and the England average.

How many people are drinking too much?

Higher risk drinkers Doncaster Barnsley Rotherham Sheffield

Drink at very heavy levels which significantly increases the risk of damaging their health and may have already caused some harm to their health

26,262 (13%)

11,762 (7%)

16,739 (9%)

50,570 (13%)

Increasing risk drinkers

Drink above the recommended levels which increases the risk of damaging their health

41,773 (20%)

33,425 (21%)

35,628 (20%)

81,824 (21%)

Lower risk drinkersDrink within the recommended alcohol guidelines

135,876 (67%)

113,208 (71%)

128,064 (71%)

263,965 (67%)

Source: NTA 2013

The table above demonstrates that Doncaster has one of the highest levels of ‘very heavy drinking levels’ in the area. Around a third of all ‘drinkers’ are at either high or increased risk.

The estimated number of dependent drinkers (18 to 75 years) for Doncaster is 5643 individuals of which 11% are in treatment; this is 2% lower than the national average. The conclusion from this data would be to increase access to treatment and awareness of the harms associated with excess consumption of alcohol.

In Doncaster males under the age of 75 who have an alcohol problem are likely to lose 12.2 months of life on average. This is 32% more than the lowest area (Sheffield). This indicates that the severity of alcohol related issues are far greater in Doncaster that in surrounding areas.

In Doncaster females under the age of 75 who have an alcohol problem are likely to lose 5.72 months of life on average. This is 28% more than the lowest area (Rotherham). This indicates that the severity of alcohol related issues are far greater in Doncaster that in surrounding areas.

15

Per 100,000 population Doncaster has a higher mortality for males of all ages when compared to those in the cluster. Doncaster has an alcohol related mortality rate of 18.43 individuals per 100,000 compared to the lowest Barnsley at 11.63 individuals per 100,000.

Those who have an alcohol problem in Doncaster are not accessing services early enough to help in early identification of the condition. This conclusion is drawn because the numbers admitted to hospital are not an outlier but the number of mortalities in Doncaster are. This would suggest those who are presenting are doing so too late. Therefore this is an area for an upsteam public health programme to help people recognise when they need help and remove any barriers to treatment.

Key facts – Public Health (source NDTMS)

PDUs - England PDUs (All Ages) 152374All Drugs (Over 18s) 183128PDUs - Yorkshire and the Humber Strategic Health AuthorityIn Treatment 20552In Treatment - YTD 23201Alcohol - England In Treatment 49088In Treatment - YTD 72940Alcohol - Yorkshire and the Humber Strategic Health AuthorityIn Treatment 5759In Treatment - YTD 8634

16

Alcohol Related Deaths National landscape

There were 2,532 alcohol-related deaths among men in 1991, increasing to 5,999 in 2008. Although the number of deaths has since dropped to 5,792 in 2011, there has been no significant decrease since 2009.

Similarly, the number of women dying from alcohol-related diseases rose from 1,612 in 1991 to a peak of 3,032 in 2008 before dropping off. However, annual fluctuations meant that more women died from alcohol-related causes in 2011 than in 2010 (2,956 compared with 2,925).

In each year since 1991, approximately twice as many men than women have died from alcohol-related diseases or disorders. In addition, male death rates were more than double those for women in most years between 1991 and 2011. Data on alcohol consumption in Great Britain presented in the General Lifestyle Survey (GLF) Overview Report (2010) showed that excessive consumption of alcohol was more common among men than women between 1992 and 2010. It is likely that the difference in consumption patterns is the main factor responsible for the higher number of deaths among men.

Age-specific alcohol-related death rates by sex and age UK 2012

Source: Office for National Statistics, National Records of Scotland, Northern Ireland Statistics and Research Agency

17

In 2012 there were 8,768 alcohol-related deaths in the UK, 42 fewer than in 2010 (8,790).

Males aged 30 and over are significantly more likely than females to die of alcohol-related causes. Over 66% of all alcohol-related deaths in the UK in 2012 were among males.

Age-specific alcohol-related death rates were highest for those aged 55 to 59 and lowest for those less than 30.

Alcohol-related death rates varied between English regions and tended to be highest in the North and lowest in the East of England over the last ten years.

Female alcohol-related death rates were higher in Wales than in England, in 2012.

Between 2007 and 2010 male alcohol-related death rates were significantly higher in Wales than in England. A three year decline in male death rates in Wales means this difference is no longer significant.

18

Drug Related Deaths

Drug-related deaths – deaths where the underlying cause is poisoning, drug abuse or drug dependence and where any of the substances controlled under the Misuse of Drugs Act (1971) are involved.

Doncaster developed its own protocol for the confidential review of drug related deaths in 2007 which is refreshed annually.The overall objectives of the policy are:

To direct and support a system of notification of DRD which is upheld by a Clinical Governance structure.

To support and manage the on-going systematic collection, analysis, interpretation and dissemination of appropriate information to assist the prevention of DRD.

To direct a proper level of inquiry utilising local investigative groups, ensuring this does not compromise any other inquiry.

To direct a proper level of inquiry ensuring appropriate levels of confidentiality are maintained throughout.

To ensure an immediate response to a DRD where a present threat to the wider public exists

To build a current picture of local issues relating to DRD which inform the improvement of commissioning of substance misuse services, and may also inform other relevant agencies who have contact with drug users.

To build and monitor the current picture of local issues relating DRD to enable considered recommendations with the aim of reducing the prevalence of DRD and improving health and social care.

To support the national drug strategy by providing a system to accurately record and quantify DRD and provide a link to public health action and drug education.

The Drug Related Deaths Steering Group commits to meeting each quarter to review all information pertaining to actual or suspected DRD in the Doncaster area, undertakes analyse and interpret all information received on DRD and make reasoned recommendations for improvement and cascades information to all relevant agencies.

19

Age-standardised mortality rates for deaths related to drug poisoning and drug misuse, by sex, deaths registered in 1993–2012 (England & Wales)

Between 1993 and 2004 trends in female mortality rates from drug poisoning were relatively stable. From 2004 rates began to decline, reaching their lowest level in 2007 (25.0 deaths per million population). Female mortality rates have increased every year since 2009, reaching 30.1deaths per million population in 2012. Female mortality rates from drug poisoning have shown the opposite trend to male mortality rates in recent years. The male mortality rate from drug misuse has dropped significantly from its peak of 55.7 deaths per million population in 2001. Over the period 2001 to 2010 drug misuse rates were subject to fluctuations. Between 2001 and 2003 the rate decreased significantly from 55.7 in 2001 to 42.8 per million population in 2003. Between 2003 and 2009 the rate generally increased reaching 55.4 deaths per million population in 2009. From 2010 onwards the mortality rate has steadily decreased, dropping to 39.2 deaths per million population in 2012, the lowest rate since 1996. Despite some annual fluctuations, the female mortality rate from drug misuse has tended to increase since 1993. The mortality rate peaked in 2008 at 15.5 deaths per million population, then dropped significantly in 2009, but increased slightly again between 2009 and 2010. Since 2010, the female mortality rate from drug misuse has been relatively stable, at 14.1 deaths per million population in 2012.

20

Doncaster Drug Related Deaths 2012

From January 2012 to January 2013 Doncaster’s Coroner’s Office has reported 17 drug related deaths.

Of the deaths 15 were male, 2 female.

The graph below shows the ages of the deceased which range from youngest death of 18 to the oldest of 48.

18-25 26-30 31-35 36-40 41-45 46-500

1

2

3

4

5

6

A steering group was held on 18th December 2012 whereby members reviewed the schedule of deaths and made any necessary recommendations where they saw fit. These included:-

Liaising closely with NHS Doncaster Serious Incident Lead as a number of the deaths listed has also been reported into the PCT by provider agencies.

Organising an awareness campaign amongst service users advising on the dangers of mixing substances with alcohol.

Liaise with local GP’s that any changes to medication prescribing carried out by themselves must be reported to the specialist service. This action was felt imperative to ensure the various prescribed medications did not adversely react with those issued by specialist service. An example being some are prescribed pain killers that may be in a concerning moderation to that of the methadone prescription.

To organise a campaign aimed at Carers to advise of any warning signs in which they must watch for i.e. snoring loudly is a sign that the respiratory system is subdued significantly. A number of witness statements taken with regards to drug related death files admit to hearing the deceased snoring at some point prior to them losing consciousness.

Of note the most concerning issue that continued to appear is the excessive drinking of the individuals prior to their death. Service users are frequently reminded of the dangers of consuming alcohol whilst taking prescribed medication such as methadone however the advice offered is clearly not consider

21

Alcohol-related diseases

Some of the diseases caused by excessive consumption of alcohol are not immediately evident and may take several years to manifest. For example, alcoholic liver disease may not cause any symptoms until extensive, irreversible damage has been done to the liver. As a result, the risk of dying from alcohol-related diseases is greater among men and women who have been consuming excessive quantities of alcohol on a regular basis over a period of years.

The age-specific death rate for men was highest among those aged 55 to 59 years (46.9 per 100,000 population) and lowest among those aged 20 to 24 years old (0.4 per 100,000 population).  A similar trend was found among women, with the highest death rate among those aged 55 to 59 years old (22.4 per 100,000 population) and lowest among those aged 20 to 24 years old (0.3 per 100,000 population).

In 2011, there was very little difference between the age-specific death rates for 20 to 24 year old men and women, suggesting that although men tend to consume more alcohol than women at this age, the health implications of regular excessive drinking are unlikely to be seen in younger people.

The GLF Overview Report (2010) showed an encouraging decline since 2005 in the proportion of men and women drinking more than the recommended number of units of alcohol a week (21 and 14 respectively). This improvement could influence alcohol-related death figures but any impact would be unlikely to be reflected in the figures for some time given the slow onset of alcohol-related diseases.

22

Drug-related diseases/conditions

Problematic drug users experience increased rates of morbidity and mortality due to their substance misuse, and although drug misuse exists in every sector of society, it is most prevalent in areas of social deprivation where individuals are more likely to experience poorer health outcomes, independent of substance misuse. (RCGP 2011)

Generally, there is a greater prevalence of certain illnesses amongst the drug-misusing population, including viral hepatitis, bacterial endocarditis, HIV, tuberculosis, septicaemia, pneumonia, deep vein thrombosis, pulmonary emboli, abscesses and dental disease. (DOH 1999)

Evidence suggests that HIV transmission among injecting drug users (IDUs) has increased since 2002. In 2012, around one in 75 IDUs had become infected within three years of starting to inject - an increase from around one in 400 in 2002. One third of those IDUs with HIV remain unaware of their infection despite most IDUs in contact with services reporting ever having a voluntary confidential test.

Combining data from across the UK indicates that around two-fifths of IDUs have been infected with hepatitis C. However, there are marked variations in hepatitis C prevalence, from around a quarter infected in areas such as Wales and the North East of England, to around two-thirds infected in other areas, including London and Glasgow.

The transmission of hepatitis B continues among IDUs. However, this may have declined in recent years. Around one in six IDUs had been infected with hepatitis B in 2008.

Injecting site infections remain common, with around one-third of IDUs reporting an injection related abscess, sore, or open wound in the last year. These include problems ranging from localised injection site infections through to invasive disease associated with meticillin-resistant Staphylococcus aureus and severe group A streptococcal infection.

Figures from the 2010 community profiles drawing on data from the 3 year period 2006/07 – 2008/09.  Unfortunately drug specific admissions did not feature in the 2012 profiles

Gender Drug specific emergency admissions % split

Male 227 69%Female 102 31%Total 329

This equates to a Directly Standardised Rate (DSR) of 38 admissions per 100,000 population.

23

Commissioning for positive outcomes

Doncaster Public Health’s Drug Strategy Unit intend to commission adult services to meet the consistently changing needs of the population of Doncaster; whilst ensuring we have an upstream approach to prevention and awareness raising.

We aim to ensure our treatment services are run in a person centred and recovery focused environment.

We endeavour to provide services that address all aspects of an adult’s life, including substance misuse, housing, work, education, training, healthcare, offending, spirituality, family life, relationships, community participation and support networks.

Core Principles:

1. Commissioning for Positive Outcomes

To work in line with the strategic direction of the most current National Drug and Alcohol Strategy and guidelines and recommendations

To deliver a single point of access model with a more time-bound, segmented prescribing pathway, expansion of mutual aid, volunteering and mentoring, and an integrated drug and alcohol structured day care/structured day programme

To increase the practising standard of the community pharmacy needle exchanges.

To continue to welcome former service users and concerned others and provide them with opportunities to become members of our volunteer team

Maintain a Harm Reduction Strategy as part of the treatment system

2. Maintaining and Improving Access to Treatment

The single point of access model (SPOA) for both drug and alcohol use will produce major improvements in access for clients by streamlining processes and making efficiencies in delivery

To ensure brief intervention, peer support, mutual aid, socialisation and networking to enhance recovery capital, relapse prevention, one to one support, group work, advice and information, motivational enhancement and advice on ‘DIY’: safer drinking and home drugs detox is offered to all clients. (Referrals will be made for structured interventions)

To ensure the points of access are viable and access is matched to the geographical locations of clients

Deliver awareness campaigns each year contributing to the prevention agenda On-going service user evaluation To ensure there is a seamless transition between prison and community service

settings Identify need and unmet by producing a Health Needs Assessment each year

3. Delivering Recovery and Progress within Treatment

24

Implementation of changes to the prescribing pathway which includes greater emphasis on moving people forward and delivering progress within treatment

To continuously ensure that the harm reduction agenda is balanced within the recovery focused services

To review and improve provisions for Parents and Carers To closely monitor the number of new clients beginning a treatment journey who

have children within their care to ensure all aspects of hidden harm are covered Promote best assessment practices around Hidden Harm for social care teams

and other front line professionals who have a responsibility around hidden harm and the safety of children

To ensure the commissioning team react to the potential future changing patterns of drug use in the Borough, along with the ever changing population of demographics

4. Achieving Outcomes and Successful Completions

To implement integrated drugs and alcohol structured day care and structured day programmes based at Doncaster Alcohol Services and New Beginnings

To implement best practice models of recovery as outlined in current guidance To ensure Employment Training and Education are part of a service users

recovery plan Work with providers to achieve successful outcomes for service users To deliver aftercare from the outset

Social integration

25

“Social reintegration of drug users into their local communities is recognised as a key component of comprehensive drug strategies, setting a focus on improvement of social skills, promoting education and employability, and meeting housing needs. Addressing the social needs of clients in drug treatment can play a role in reducing their drug use and sustaining long-term abstinence” (Laudet et al., 2009).

The level of social exclusion among drug treatment clients is generally high, potentially preventing individuals from making a full recovery and undermining treatment gains. Quarter 4 TOP data 12/13 for Doncaster showed that of new presentations, 44 were of no fixed abode and 121 clients identified as having a housing problem.

Regarding employment, Quarter 4 TOP data 12/13 for Doncaster showed that 6% of the 353 clients who did not report working at the start of treatment, reported working at the 6 month review.

There is increasing recognition that development of services tackling marginalisation and stigmatisation will improve the chances of clients' successful social reintegration and increase their quality of life.

“Solid partnership arrangements to support the families of drug misusers are required. Developing mutual aid networks may help to establish self-help arrangements among recovering drug misusers. Local communities and wider society also have a responsibility to help drug misusers reintegrate into the community: for example, by removing any barriers to employment. Drug treatment has been proven to reduce drug misuse, reduce crime, improve health, and protect against blood-borne viruses and overdose (NTA 2013).

To achieve recovery focused outcomes, the treatment system needs to become more responsive to individual needs. Personalised packages of care constructed around individuals’ aspirations and capabilities need to be developed, drawing on good professional care planning, and treatment systems need to be responsive to what service users want from treatment.

Most individuals come into treatment wanting to become free of their drug of dependency. The treatment system needs to achieve an appropriate balance, equally comfortable with positively routing those who are capable of benefiting quickly through abstinence based treatment, and retaining those who are not yet able to leave treatment supported in services.

Cost of alcohol related harm

26

Alcohol misuse in England is estimated to cost society around £21.3 billion annually; with a cost of £4.1 billion to the NHS, £6.9 billion* caused by crime and licensing, £8.9 billion in costs to the workplace/wider economy and £1.7 billion on social services for children and families affected by alcohol misuse. Breaking these costs down to the Public Health England (PHE) North Region gives an overall total of around £6.2 billion with a cost to the NHS of £1.3 billion, cost caused by crime and licensing of £1.9 billion*, cost to the workplace/wider economy of £2.5 billion and cost to social services of £504 million.

* Crime costs include healthcare related costs such as violence-related A&E attendances due to alcohol. This section of the crime costs have been removed from the overall total to avoid double counting between the NHS and crime costs.

NHS: £25.38m

CRIME AND LICENSING: £41.82m

WORKPLACE: £37.38m

SOCIAL SERVICES: £11.51m

TOTAL COST+: £114.22m+Total cost excludes crime related healthcare costs

OVERALL COST PER HEAD

DONCASTER: £378YORKSHIRE AND THE HUMBER PHE CENTRE: £397PHE NORTH REGION: £413ENGLAND: £402

The adjacent chart shows the cost per head broken down by the four cost sub-categories.

27

DONCASTER COST BREAKDOWN

22.2%

35.0%

32.7%

10.1%

COST PER HEAD OF POPULATION

£84

£138

£124

£38

£78

£133

£158

£34

£88

£129

£168

£34

£77

£131

£167

£32

NHS Crime Workplace Social Services

PHE

CENT

RE

DONC

ASTE

R

PHE

NORT

HRE

GIO

N

ENG

LAND

The table below shows the rank out of the 72 PHE North Region (NR) local authorities (1 = highest cost per head, 72 = lowest cost per head) and also percentage differences between the local authority and the PHE Centre, PHE NR and England costs per head.

* Total cost excludes crime related healthcare costs

28

PHE Centre PHE NR EnglandNHS 46 8% -4% 9%Crime 21 4% 7% 6%Workplace 70 -22% -26% -26%Social Services 17 13% 13% 19%Total 53 -5% -8% -6%

Cost per head compared to:LA Rank

COST SUMMARY TABLES FOR YORKSHIRE AND THE HUMBER LOCAL AUTHORITIES

NHS Crime Work place

Social Services Total* NHS Crime Work

placeSocial

Services Total* PHE LA Rank

Local AuthorityBarnsley £19.91 £25.28 £37.74 £7.43 £89.35 £86 £109 £163 £32 £385 48Bradford £41.65 £71.69 £70.59 £17.92 £199.42 £80 £137 £135 £34 £381 50Calderdale £16.07 £23.36 £41.31 £7.05 £86.92 £79 £114 £202 £35 £426 25Craven £4.57 £4.59 £7.13 £0.93 £17.06 £82 £83 £128 £17 £307 69Doncaster £25.38 £41.82 £37.38 £11.51 £114.22 £84 £138 £124 £38 £378 53East Riding of Yorkshire £27.38 £39.14 £51.78 £6.62 £123.20 £82 £117 £155 £20 £368 56Hambleton £7.26 £6.57 £11.03 £1.51 £26.11 £81 £73 £123 £17 £291 71Harrogate £12.49 £11.74 £22.26 £2.88 £48.85 £79 £74 £140 £18 £308 68Kingston upon Hull £23.11 £51.87 £38.94 £13.24 £124.72 £90 £203 £152 £52 £487 5Kirklees £29.89 £55.30 £74.67 £13.99 £171.68 £71 £131 £177 £33 £406 36Leeds £58.42 £114.88 £133.83 £32.03 £334.62 £78 £153 £178 £43 £446 17North East Lincolnshire £12.66 £29.18 £26.12 £7.67 £74.38 £79 £183 £164 £48 £466 7North Lincolnshire £13.49 £27.07 £29.54 £5.81 £74.77 £81 £162 £176 £35 £446 16Richmondshire £3.99 £3.83 £8.56 £0.92 £17.15 £75 £72 £161 £17 £322 66Rotherham £21.75 £28.29 £39.02 £9.90 £97.80 £84 £110 £151 £38 £380 52Ryedale £3.82 £3.62 £5.69 £0.85 £13.82 £74 £70 £110 £16 £266 72Scarborough £9.27 £13.78 £15.54 £1.73 £39.64 £85 £127 £143 £16 £365 57Selby £5.44 £7.11 £14.03 £1.53 £27.79 £65 £85 £168 £18 £333 64Sheffield £37.97 £67.78 £81.50 £20.55 £205.38 £69 £123 £148 £37 £372 54Wakefield £24.82 £53.30 £53.58 £10.11 £139.67 £76 £163 £164 £31 £428 23York £13.17 £23.38 £37.52 £4.28 £77.26 £67 £118 £190 £22 £391 44

PHE Centre Cheshire and Merseyside £217.73 £276.11 £429.76 £80.76 £993.55 £90 £115 £178 £34 £412 -Cumbria and Lancashire £175.26 £264.02 £330.12 £51.59 £808.92 £89 £135 £168 £26 £412 -Greater Manchester £238.47 £381.34 £470.29 £95.61 £1,169.84 £89 £142 £175 £36 £436 -North East £264.97 £296.31 £440.06 £97.81 £1,086.84 £102 £114 £169 £38 £419 -Yorkshire and The Humber £412.56 £703.59 £835.54 £178.47 £2,101.64 £78 £133 £158 £34 £397 -

PHE North Region £1,309.03 £1,921.37 £2,509.23 £504.24 £6,164.27 £88 £129 £168 £34 £413 -England £4,090.31 £6,939.23 £8,892.05 £1,703.33 £21,326.03 £77 £131 £167 £32 £402 -

Area Name

Cost of Alcohol (millions) Cost per head of population

The cost of Drug harm

The economic costs of substance use (Health care)

Studies of the health-related costs of substance use indicate an annual spend of nearly £3bn on alcohol misuse in England, in the region of £5 billion on smoking-related ill health in the UK, and just under £500m on Class A drug use in England and Wales.

Hospital admissions arising from diseases or conditions directly and indirectly related to substance use; make a large contribution to the costs to the NHS. The most recent data available indicates that each year there are over one million admissions related to alcohol consumption, and over 45,000 admissions attributable to smoking among people over 3517.

In relation to illicit drug use, there are around 5,800 admissions for drug-related mental health and behavioural disorders each year and over 11,500 admissions for drug poisoning. These statistics, however, do not take into account other types of drug-related hospital admissions, for example, those related to respiratory disease, HIV-related illness, chronic liver disease associated with hepatitis C infection and injection site infections. In addition, older people who continue to use drugs and require the support of health services are emerging as an important but relatively under-researched population.

Gordon et al (2006) calculated the costs per year per ‘problematic’ drug user incurred by the health sector, by social care and due to drug-related death and crime in the table below:

Element Cost per year per problematic drug user

Proportion of total cost per year

Total cost £44,231 100%Inpatient care £531 1.2%Inpatient mental health £265 0.6%A&E £221 0.5%Community mental health £177 0.4%Primary care – GP visits £88 0.2%Neonatal effects £44 0.1%Infectious diseases £44 0.1%Total health care costs £1,371 3.1%Drug related deaths £2,654 6%Social care £177 0.4%Drug related crime £40,029 90.5%

The annual cost associated with problem drug misuse is £26,000 per person, of which 9.5% or £2470 represents healthcare costs.

29

Harm Reduction

Nationally

The use of substances is a common and enduring feature of human experience. A harm reduction approach neither condones nor encourages the use of any substances. It is a practical response that accepts that use and abuse of substances exists in contemporary society. A harm reduction approach includes a range of polices, programmes, services and actions.

The harm reduction approach recognises that some individuals do not feel able to stop using drugs altogether, or may not want to at this time. Professionals can offer advice; information and treatment interventions that can help individuals reduce the harm they may be causing to themselves or others. Interventions and treatment can include reducing the sharing of injecting equipment, through to stopping injecting, substitution on opioid drugs for heroin misusers and abstinence from illegal drugs.

Harm reduction interventions work to reduce the health, social and economic harms to individuals, communities and society that are associated with the use of drugs (1). This approach supports those who seek to moderate or reduce their drug use, particularly via the engagement with drug treatment that provides prescribed substitute medication, but it neither excludes nor presumes a treatment goal of abstinence.

(1) UK Harm Reduction Alliance (2007) www.ukhra.org

There is a need to continue with a robust Harm Reduction Strategy that addresses the continuing health care needs of an ageing drug using population.

Nationally, the key factors influencing good practice in harm reduction are:

Harm reduction embedded in the system Prompt and flexible access Action to reduce deaths from overdose Competent staff

(Good Practice in Harm Reduction NTA October 2008)

Locally

Doncaster has a noteworthy record in its early acceptance of the harm reduction approach and its provision of harm reduction services such as needle and syringe exchange schemes which were established in Doncaster in 1989.

We have built on existing good work in order to deliver a planned, effective multi-agency response to reduce or eliminate the harms (behaviours, diseases or deaths) of substance misuse, aimed primarily at individual substance misusers, but including their partners, families and local communities.

30

Work already achieved:

• All services have established overdose warning procedures in place.• An increase in the number of needle exchange pharmacies from 4 to 14.• Widening the range of needle exchange paraphernalia to include foil and

steri-cups across all outlets. • Establishing a specialist needle exchange service within the Depot at

Mexborough.• Successful submission of business case to the PCT resulting in a Blood

Borne Virus Nursing Liaison Team is now operational and will ensure pathways into treatment and working arrangements for BBV positive clients.

• Updated needle exchange LES and guidance manual in accordance with the new NICE Guidance.

• Delivery of harm reduction training from the Alliance for volunteers and mentors and Safer Injecting Training (delivered by DIP) for all front line staff.

• Established confidential enquiries procedure for learning from the causes of drug related deaths, and a South Yorkshire drug related deaths initiative.

• Introduced a peripatetic model for our specialist needle exchange worker across all needle exchange sites to drive up quality.

All clients are supported to develop individualised care / recovery plans including the use of Opioid Substitution Therapy. ‘Journey to Recovery groups’ are also held for all new / re-presenting clients to attend in order to agree a balanced approach between harm reduction and recovery which is not time limited.

31

Alcohol Diversion Scheme

The primary aim of the Doncaster Alcohol Diversion Scheme (DADS) is to reduce alcohol related offending and to ensure that anyone who passes through the criminal justice system for an alcohol-related offence is given access to the help they require to drink alcohol in a way that was less damaging to themselves, their family and their community.

The scheme is aimed at offenders who commit minor offences where alcohol is a contributory factor, including drunk and disorderly, drink driving, assaults, including domestic related assaults, and any other offences that the police custody officers deem appropriate.  The scheme initially focussed on offences committed within the town centre, but has since been extended to cover all neighbourhoods in Doncaster due to its success. 

Fixed Penalty Notice (FPN) Fee Waiver Scheme

It was clear quite quickly that a change of direction was required to tackle alcohol-related crime in Doncaster. Over a third of Doncaster’s alcohol-related crime was dealt with by use of a FPN fine.  After research into police custody arrest figures as well as taking on board the lessons learnt from the conditional caution, it was decided that fixed penalty ticket offenders would benefit from alcohol knowledge. This meant an expansion of the Alcohol Diversion Scheme to include the Central Ticket Office at Sheffield which is responsible for overseeing the administration of FPNs.

The intention of the FPN fee-waiver scheme Is that any offender issued with a FPN would have the £80 fine waived if they volunteered to attend, and successfully complete, an alcohol awareness session and a follow-up one-to-one session at DAS within 28 days of receiving their FPN.  

The FPN fee waiver scheme commenced in Doncaster on the 1st of February 2009.   In the six months from February to July 2009, there were 207 FPN tickets issued for alcohol-related offences, of which there were 67 referrals (a 32% take-up rate) to the scheme. In February, the initial take-up rate was 23%. The take-up rate grew steadily until it reached 45% in July 2009. Of the 67 referrals, 49 clients successfully completed the fee waiver scheme (a 69% success rate).

Alcohol Conditional Bail Order

In August 2009 it was felt that the scheme was still missing a significant proportion of alcohol-related offending. Research of police custody records showed that 64% of alcohol-related offenders were charged directly to court, meaning they were ineligible for either of the existing schemes. The agencies under the umbrella of the Alcohol Diversion Scheme felt that a more pro-active/coercive approach (which targeted mid-level offences) was required to target this offending behaviour. The adoption of a conditional bail scheme to compliment the other schemes enabled the partnership to engage this otherwise inaccessible group who, due to their offending history or difficult demeanour, may only be charged to court.

32

The conditional bail scheme is more of a coercive method of getting such individuals to access alcohol services before they got to court.  This condition is imposed on any individual charged with an alcohol related offence. As is the case with the conditional cautioning and FPN fee waiver schemes, the treatment provider have to be able to provide an initial harm minimisation session within days of the subject being charged to court.

The conditional bail scheme commenced in Doncaster on the 28 th of September 2009. All persons charged to Doncaster Magistrates Court for offences in which the consumption of alcohol had played a part (assaults, public order) are given a bail condition by the police custody sergeant to attend alcohol services on the day before their court hearing.  This is to allow a one to one assessment with the alcohol arrest referral worker.  The worker then compiles a court report which indicated the required number of further sessions (e.g., group work, follow-up, 1-1 session).  The magistrate, the clerk of the court, the CPS solicitor, the defence solicitor and probation worker all receive a copy of the court report on the day the offender appears in court.   When the offender appears in court, magistrates can take into consideration whether or not the offender had complied and attended their appointment with the alcohol treatment provider when considering sentence. Magistrates can also include the requirement for further treatment sessions. 

Alcohol Street Bail

On the 9th of October 2009 an early intervention scheme as part of a wider police initiative, Operation Alligator, commenced in Doncaster town centre with the intention to reduce violent crime and drink related offending within the town centre and also reduce re-offending.   Additional police staff patrolled the town centre on Tuesday, Friday, Saturday and Sunday evenings between 10.00pm and 4.00pm.  Offenders were given street bail for minor public order offence and served with notices to leave the town centre.  They were also given an appointment to attend the police station on the next Thursday following the date of the offence at the conditional cautioning surgery.

Prior to the offenders attendance at the police station on the Thursday evening the police officer in charge prepared a file containing all relevant evidence which was discussed with the evidence review officer or duty inspector at the police station.  When the offender attended the session at the police station they were either referred onto the conditional caution scheme or FPN fee waiver scheme with alcohol treatment service or charged to court with a requirement that they attend treatment before their court attendance.

The Operation Alligator initiative had a direct effect on the conditional caution scheme figures. In the three months between October and December 2009, 110 people were referred for cautions via the initiative.  Overall in this period there were 114 conditional cautions issued compared to the 10 cautions from October 2008 to September 2009. This increase was reflected in the successful completion rates. Out of the 114 cautions issued between October and December 2009, 94 clients attended the group session and 85 of these clients successfully completed their caution (a 90% completion rate compared to 80% for October 08 to September 09).

33

Substance-related crime

Although it is difficult to estimate the number of offences that are related to alcohol or illicit drug use, it is well established that there is a link between substance use and acquisitive crime. The 2005 Offending Crime and Justice Survey included questions on offending among young people aged 10 to 25 years related to alcohol and illicit drug use. For 18% of all violent offences and 10% of all property offences, offenders were under the influence of alcohol only. For 3% and 2% of all violent offences and all property offences, respectively, offenders were under the influence of illicit drugs only.

In 2008, the Home Office calculated that the costs associated with alcohol-related crime were between £8.75bn and £14.78bn. These costs were mainly incurred as a result of less serious wounding, criminal damage, sexual offences and causing death by dangerous driving. The costs associated with drug-related crime were last updated in 2003-04 and estimated at £13.32bn. The estimation of these costs included the following offence categories: fraud, burglary, robbery and shoplifting.

DIP

The Drug Intervention Programme (DIP) plays a key role in tackling drugs and reducing crime. Introduced nationally in 2003, it aims to get adult drug misusing offenders who misuse specified class A drugs (heroin and cocaine/crack cocaine) out of crime and into treatment and other support.

Many of the offenders who benefit from DIP are among the hardest to reach and most problematic drug misusers, and are offenders who have not previously engaged with treatment in any meaningful way. The key benefit of DIP is that it focuses on the needs of these offenders by providing new ways of cross-partnership working, as well as linking pre-existing ones, across the criminal justice system, healthcare and drugs treatment services and a range of other supportive and rehabilitative services. Delivery at local level is through partnerships using a Criminal Justice Integrated team (CJIT) with a case management approach to offer treatment and support to offenders from the point of arrest through to beyond sentencing and resettlement into the community. Through sharing information on the treatment needs of service user offenders, a professional multi-skilled team is able to provide tailored solutions to meet the needs of these offenders.

The main aim of DIP is to reduce drug related acquisitive crime, by assertively engaging with drug using offenders, from the point of arrest to sentence, and following completion of a prison sentence and/or probation supervision, and get them into treatment. (“Out of crime, into treatment”)

The main objectives of DIP are: Reduction of criminal behaviour associated with the use of drugs Reduction of harmful or risk taking behaviour associated with the use of drugs Reduction or cessation of the use of drugs To break the cycle of drugs, crime and prison

34

The three core functions of DIP are: The successful IDENTIFICATION of drug misusing offenders A comprehensive and standard ASSESSMENT of their treatment and other

support needs Effective consistent CASE MANAGEMENT to help break the cycle of drugs

and offending

35

Substance misuse wrap around services

Employment is an important component of recovery – it brings benefits to individuals and society. It was significant that the Government announced early on a review of planned changes to the benefit system specifically for people with drug and alcohol problems (these included giving Jobcentres the power to require claimants to undergo drug testing). The Government’s approach - to ensure that the benefit system supports people to engage with treatment and recovery.

Treatment providers are well placed to provide life skills and employment preparation support from the start of treatment - services can deliver a range of support and interventions: motivation and confidence-building; ‘life skills’; volunteering opportunities and accessing training and education providers/service.

There are a number of barriers for people in recovery, and for some with chronic health problems and complex needs, employment may be an unrealistic or very distant aspiration – for others a premature (or inappropriate) return to employment can set back recovery. Barriers include: a lack of available opportunities (often compounded by stigma associated with treatment and recovery); funding which does not incentivise ‘holistic’ work with people in recovery; a lack of engagement and commitment by other (non-treatment) services.

There is concern about a disinvestment in employment-related support, capacity and expertise, particularly since publication of the drug strategy in December 2010. Funding for dedicated Drug Co-ordinators in Jobcentre Plus ended in March 2011 – although there was variation across areas, the outreach role with treatment providers and developing referral routes was generally positive and provided a clear point of contact and liaison. In addition, there is a concerning gap in work-related support for people in treatment and recovery since the ending of Progress to Work and the roll-out of the Work Programme.

Jobcentre Plus:

Jobcentres have an important role, alone and in partnership, to positively support and engage people with drug and alcohol problems. Some progress has been made, but many with drug and alcohol problems remain reluctant to reveal this to Jobcentre staff.

Moving On Project:

As part of a complete after care package the Moving On Project aims to deliver advice and guidance to clients on housing issues, managing money and personal finances- including debt advice and liaison with creditors were necessary, along with removing the barriers faced by substance misuse clients/ ex clients i.e. health, crime, skills, housing, debt etc and provide an individual personal service to substance misusers as they move towards employment, training and accessing/ maintaining tenancies.

36

Treatment data - Alcohol

Data Source: NDTMS – Quarter 4 – 2012/2014

Graph 1 illustrates that Barnsley has the highest number of clients in treatment followed by Doncaster, Rotherham and Sheffield. However, only 55% (514) of those clients were a new presentation to treatment in the period above, Sheffield has the highest number 76% (413), followed by Doncaster 70% (602) and Rotherham with just 50% (297).

Graph 1

Doncaster Rotherham Sheffield Barnsley

842

595542

936

602

297

413

514

Number of clients in treatment year to date (YTD) - alcohol is the primary drugNumber of clients with a new presentation to treatment YTD - alcohol is the primary drug

Leaving Treatment

Graph 2 below - Doncaster has the highest number of clients exiting the treatment system YTD where alcohol is the primary drug with a total of 494, followed by Barnsley 479, Sheffield 365 and Rotherham 359. This demonstrates that Doncaster has a greater alcohol issue when compared to the areas in the cluster.

37

Doncaster Rotherham Sheffield Barnsley

494

359 365

479

Number of clients exiting the treatment system YTD - alcohol is the primary drug

Client Demographics

Age Group

Graph 3 below illustrates the age group at the mid-point of the year for all clients in treatment YTD as a proportion of all in treatment. The graph also demonstrates that despite all the areas having different sizes of population that the age groups are very similar in terms of a proportion. Rotherham has a slightly small proportion of 30 – 39 individuals while Sheffield has a slightly small proportion of 50 – 59 compared to other areas.

Doncaster Rotherham Sheffield Barnsley0%

10%20%30%40%50%60%70%80%90%

100%

Age group at mid-point of the year

over 6560-6450-5940-4930-3918-29

Gender

Graph 4 illustrates the gender split across the 4 areas is almost identical as a proportion of all those in treatment.

38

Male Female Male Female Male Female Male FemaleDoncaster Rotherham Sheffield Barnsley

66%

35%

65%

33%

67%

34%

68%

32%

Gender

Ethnicity

Table 1 illustrates the ethnicity of individual clients who were in contact with the treatment system at any point during the year to date. Ethnicity is taken from the latest journey. Where clients have provided inconsistent ethnicity information across the journey ethnic status is reported as such. Over 90% of the treatment population for each of the 4 areas is represented by White British

Doncaster

Rotherham

Sheffield

Barnsley

White British 796 538 483 910White Irish 3 4 2 4Other White 13 2 5 13White & Black Caribbean 4 2 8 0White & Black African 0 1 2 0White & Asian 2 1 1 0Other Mixed 3 0 4 1Indian 2 1 3 0Pakistani 0 1 2 0Bangladeshi 0 0 0 0Other Asian 3 0 0 0Caribbean 1 0 0 0African 0 0 0 0Other Black 1 1 4 0Chinese 0 0 0 0Other 7 0 3 2Not Stated 1 44 3 6Unknown/Missing 6 0 22 0

39

Drinking Days and Units

Table 2 illustrates the number of individuals in treatment who have drunk between 1 – 100+ units every day throughout a 28 day period. Doncaster, Rotherham and Barnsley have around 13 – 16% of the total population who consumer around 20 – 29 units per day whilst, Sheffield only has 10.5%, however, Sheffield does have 14% who consume a slightly smaller number of units between 10 – 19. Doncaster has the smallest % of individuals out of the 4 areas that drink between 1 – 19 units per typical drinking day, but 50% of the population who drink between 20 – 39 units per day – the highest in South Yorkshire.

Table 2

Drinking Days and Units - all in treatment (YTD)

Number of units on a typical drinking day

28 drinking days in the past 28 days

Doncaster Rotherham Sheffield Barnsley

0 0 0 0 01-9 33 9 22 2610-19 74 82 74 13020-29 109 83 57 14930-39 97 70 28 10140-49 48 40 8 7750-99 49 25 17 70100+ 1 6 1 9Missing or Invalid 0 0 0 0

40

Treatment data - Drugs

Data source NDTMS – Quarter 4 – 2012/13

Graph 1

Doncaster Rotherham Sheffield Barnsley0

500

1000

1500

2000

2500

1640

1330

2435

1256

484276

518268

575385

710

401

Numbers recorded as being in effective treatment - All Adults Numbers starting a new treatment journey - OCUNumbers starting a new treatment journey - Adults

Graph 1 demonstrates those clients recorded as being in effective treatment for the 12 month period of 1st January 12 – 31st December 12 along with those who start a new treatment journey. The graph illustrates that Doncaster has the second largest number of clients in treatment in a 12 month period with more than 30% clients than Sheffield; however, clients starting a new treatment journey for both OCU and Adults are very similar in both these areas. Both Rotherham and Barnsley are very similar in terms of numbers in treatment.

Graph 2: Leaving Treatment 1st April 2012 – 31st March 2103

Doncaster Rotherham Sheffield Barnsley

170 169

241

132

356

208

346

233

Number completed - planned exit Number unplanned -

41

Graph 2 demonstrates the numbers of clients leaving treatment in both a planned and an unplanned way. Both Doncaster and Sheffield have a similar number of unplanned exits from the treatment system however; Sheffield has a significantly higher number of planned exits. Compared to the Yorkshire & Humber region as a whole the four South Yorkshire areas are relatively the same, however, if we look at the treatment exits as a proportion of those in treatment, the data looks considerably different. The graph and table below demonstrates the number of clients who leave treatment in a successful way as a proportion of all those in treatment.

Graph 3

Doncaster Rotherham Sheffield Barnsley0%

10%20%30%40%50%60%70%80%90%

100%

1789 1391 2518 1316

167 163 237 125

Number in treatment in the last 12 months number of successful completions in the last 12 months

Doncaster Rotherham Sheffield Barnsley

Number in treatment in the last 12 months 1789 1391 2518 1316

number of successful completions in the last 12 months 167 163 237 125

Successful completions as a proportion of all in treatment (rolling 12 months)

9.3% 11.7% 9.4% 9.5%

42

Client Demographics

Graph 4 - Age Group

Doncaster Rotherham Sheffield Barnsley

18 - 19 20 - 29 30 - 39 40 - 49 50 - 59 60+

Gender Graph 4 demonstrates age group at mid-point of the year for those in treatment. Numbers across the four areas are very similar as a proportion; however Sheffield has a significantly higher number of clients between the ages of 40 – 49.

Graph 5

Doncaster Rotherham Sheffield Barnsley0%

10%20%30%40%50%60%70%80%90%

100%

1299 1043 1828 955

493 357 695 386

Male Female

Graph 5 demonstrates the proportion of male and female in treatment in the four areas. The split is approximately 70 – 30 similar to that of the county.

43

Graph 6 - Accommodation Need

Doncaster Rotherham Sheffield Barnsley0

100

200

300

400

500

600

44 21 38 31

121

3182

46

433

306

517

318

NFA - urgent housing problem Housing ProblemNo Housing problem

Graph 6 demonstrates the housing needs of clients who are starting a new treatment journey however, not all clients reported in this section. Compared to the above four areas along with the Yorkshire and Humber region, Doncaster has a significantly higher proportion of clients who report that they have a housing problem at the start of a new treatment journey.

44

Individuals with Children Alcohol clients

Graph overleaf illustrates has a %, the number of individuals that have a level of contact with children. (Whether the client has a child and whether or not they live with that child) and the ‘children’ (the number of under 18 year old who live in the same household as the client at least 1 night per week). Doncaster and Sheffield have over 60% of their treatment population that are parents either living with or without their children. Doncaster has a further 46% (n277), which is the highest in the region that are parents but do not live with the child, however, Doncaster also has the lowest % of individuals that are not parents and do not have contact with child, with just 21% (n127) compared to Rotherham who has 43% (n129). Barnsley has the highest % of individuals that are not parents but have contact with a child at 35% (181) compared to Sheffield who just have 3% (n11).

Parent Living with own children

Other child contact: Living with children

Other child contact: Parent not living with

childred

Not a parent/no child contact

both fields blank or

"decline to answer"

0%5%

10%15%20%25%30%35%40%45%50%

DoncasterRotherhamSheffield Barnsley

45

Individuals with Children Drugs clients

Doncaster Rotherham Sheffield Barnsley0%

10%

20%

30%

40%

50%

60%

70% 61%

37%

26%

52%

Number of individuals living with children ( New treatment YTD)

Graph 5 demonstrates has a proportion of those individuals who are starting a new treatment journey who report that they are living with children. Doncaster is significantly higher than the other areas along with the Yorkshire and Humber region which is just 28%.

46

Next steps

The next steps with this strategy will be:

To engage with local areas and key partners and explore what this strategy means for them

To enable local areas and key partners to work up their plans for implementation and delivery of the prevention, early intervention, enforcement and recovery approaches set out in the strategy

To encourage Doncaster to work together in the joint design and commissioning of services

To continue to develop and publish the evidence base on what works On-going monitoring of the action plan

We are committed to using evidence to drive the very best outcomes for individuals and communities. Doncaster public health is currently developing an evaluation framework to assess the effectiveness and value for money of the Drug and Alcohol Strategy whilst working in partnership with PHE.

Advice and information available will reflect the Doncaster community that our services are aimed at to aid prevention and upstream working. We will ensure information relating to alcohol, new drugs, associated harms and harm reduction advice is communicated. This also allows us to respond to new and emerging evidence, to respond flexibly to the changing nature of the drugs trade and the outcomes being achieved.

We are also committed to reviewing this strategy on an annual basis in order to build in further initiatives. The information and engagement should reflect the needs assessment recommendations as well as the community development work.

47