Skills for the future – a look into the crystal ball

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

2. 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

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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.

9. 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

10. 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

11. 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.

12. 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

13. 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

14. 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.

15. 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