Making Recovery Real: the public health future of drug and alcohol treatment

1. Making Recovery Real:the public health future of drug and alcohol treatment Bristol, 5 October 2012 Leeds, 11 October 2012 London, 15 October 2012

2. Progress madeChallenges Ahead Paul Hayes Chief Executive, NTA

3. Drug use is down

4. Fewer young people are in treatment

5. More drug users are recovering

6. Younger people are doing better

7. People who use heroin are getting older

8. Crime is down

9. Policy evolution • 2001 - Harm • 2005 - Completion • 2008 - Abstinence • 2010 - Recovery • 2012 - Consensus

10. Strang • Everyone can, not everyone will • 50 : 30 : 20 • Recovery and, not recovery instead • Humility • Partnership • Optimism • Sketch map not satnav

11. Reasons to be cheerful • Evidence  • Consensus  • Money  • Track record  • LA leadership  • Integration  • PHE  • Politics 

12. Worries • £ • NHS • Localism / stigma • Alcohol • Jobs and Houses • “New” drugs • Competence • Narrative of failure

13. Mission • “Give everyone who can, every chance to”

14. Drugs and alcohol and NTA into PHE

15. Drugs & alcohol in public health • Agenda will need to be championed, strategic partners engaged • Using the data, using the evidence, and making the arguments • Drugs, alcohol, ATM and prevention …

16. NTA into PHE • NDTMS & NATMS  Knowledge & Intelligence • Central policy function  Health Improvement • Local teams  Operations • Expertise, support, tools continue to be available…

17. Alcohol Public Health Outcomes Framework indicator will be based on the old NI39: estimates of the number of alcohol-related hospital admissions (ArHA) • Public Health Outcomes Framework – will be estimated numbers of alcohol-related hospital admissions (ArHA) • Prime Minister’s Implementation Unit – will monitor progress against the same indicator

18. Successful completions and non re-presentations will now be included (or is likely to be included) in the following indicator sets • Public Health Outcome Framework – Successful completion and non re-presentation (partnership only so far and baselines produced) • Prime Minister’s Implementation Unit – Successful completion and non re-presentation (national with expected increases month on month) • PHE day one metric – Successful completions (national with expected increases month on month) • Social Justice Outcome Framework – Proposed successful completion and non re-presentations

19. Drugs & alcohol in PHE • And the money…

20. The funding - current understanding(O rounded for ease) Public Health Grant approx £2 billion in total Pooled drug treatment budget £400m Substance misuse DH DIP funding £ 60m component Young people’s substance misuse treatment £25m of the Local drug treatment spend £160m Public Health Alcohol £???m Grant Prison substance misuse treatment £100m  National Commissioning Board HO DIP funding £ 35m  PCCs

21. Alcohol prevention and treatment: now and in the transition to Public Health England 21

22. alcohol strategy: what’s the problem Around 9 million people are drinking at levels which are above the NHS guidelines Of these 2.2 million people (7% of men and 4% of women) are most at risk of illness and death from alcohol Within this, around 1.6 million have a possible dependence on alcohol Alcohol harm costs the NHS about £3.5 billion per year Alcohol-related crime £11 billion per year Lost productivity due to alcohol about £7.3 billion

23. alcohol strategy: what does government want to achieve? change behaviour so people think it is not acceptable to drink in ways that cause themselves or others harm reduce alcohol-fuelled violent crime reduce the number of adults drinking above NHS guidelines reduce the number of people ‘binge drinking’ reduce the number of alcohol related deaths and sustain reduction in both the numbers of 11-15 years olds drinking and the amounts they consume

24. alcohol strategy: how government plans to achieve it Nationally: Introduction of a minimum unit price for alcohol to stem the flow of cheap alcohol Consult on a ban on multi-buy price promotions in shops A review, overseen by the Chief Medical Officer, of the alcohol guidelines A new density power to allow licensing authorities to consider local health harms when introducing Cumulative Impact Policies There will be an alcohol check within the NHS Health Check for adults from April 2013 TESCO EVERYDAY VALUE LAGER 2% (4X440ML) 2% ALC. £1.00(5.7P/100ML) STELLA ARTOIS (12X284ML). £8.00ANY 2 FOR £15.00)

25. alcohol strategy: what is expected of local areas? The strategy encourages local government, NHS, Police and Crime Commissioners and other partners to work together to use their new powers and responsibilities Local authorities and the new Health and Wellbeing Boards will be required to use the ring fenced public health grant to address local public health problems, including reducing alcohol related health harms Linking to funding via NHS Commissioning Board and CCGs for IBA and hospital based services Whilst local action is led and delivered by local government and their partners, PHE will be there to support this in every way it can

26. where we have been • Alcohol treatment system is dependent on local prioritization • Relationship to drug treatment – a nationally driven Government priority • Separate funding streams • No performance management of alcohol treatment. • Often locally integrated services 26

27. a complex system Child protection Supply reduction Demand reduction Mental Health Prison RECOVERY Outlet Density Minimum pricing Community treatment IBA Residential Acute Sector ATR Probation Adult Safeguarding 27

28. but guidance exists • Alcohol Learning Centre: http://www.alcohollearningcentre.org.uk/ • NICE suite of alcohol guidance: http://www.nice.org.uk/guidance/index.jsp?action=byID&o=11875 28

29. a complex funding system Supply reduction Child protection LA LA/PHE Demand reduction Mental Health CCG Prison NCB Outlet Density Minimum pricing LA-Licensing IBA CCG LA/PHE NCB Community Treatment LA/PHE Residential LA/PHE ATR Probation NOMS LA/PHE Acute Sector CCG Adult Safeguarding LA 29

30. where we need to get to • Quality Treatment System- Driven by local need • NICE and other guidance • Appropriately qualified staff • Appropriately commissioned • Inspected by CQC • NATMS • Recovery focussed • Mutual Aid • Wider than the medical interventions • Greaterintegration • PHE for substance misuse • Across multiple domains- A two way street. 30

31. between now and April 2013 • Whilst local action is led and delivered by local government and their partners, PHE will be there to support this in every way it can after April • Before then, support to commissioners and DsPH via regional alcohol commissioner forums, focusing on the High Impact Changes (Dept. of Health) and Alcohol Strategy priorities • We will also be working with 14 areas in more depth, building on the work of the Alcohol Improvement Programme 31

32. regional alcohol support • Regional alcohol networks will be promoted, based on existing arrangements where in place • themed events to draw in key stakeholders such as DsPH and providers and focus on key delivery themes: • IBA, • hospital based services and • NICE compliant specialist treatment • Regional alcohol commissioner forums will be central to the networks and focus on policy updates and priorities • we will explore the use of action learning sets and web forums (via the Alcohol Learning Centre) • continued investment in existing alcohol services in all settings 32

33. tools to support delivery The following tools will be provided to all areas: 33

34. more in-depth support to the 14 areas • 14 areas have been offered additional support and expertise from alcohol programme managers • Each region has at least one area • Moving forwards this will help PHE shape its alcohol role • Leeds • Bradford • Newcastle • Middlesbrough • Nottingham • x2 in the NW • Brighton and Hove • Portsmouth • Hammersmith and Fulham • Cambridgeshire • Sandwell • Birmingham • Bristol

35. Medications in recovery: re-orientating drug dependence treatmentReport of the Recovery Orientated Drug Treatment Expert Group

36. Content • The problem • The chair’s interim report • The group’s final report • Implementation

37. The problem • 2010 drug strategy: • “Substitute prescribing continues to have a role to play in the treatment of heroin dependence, both in stabilising drug use and supporting detoxification. Medically-assisted recovery can, and does, happen… • However, for too many people currently on a substitute prescription, what should be the first step on the journey to recovery risks ending there. This must change.”

38. Towards a solution • NTA asked Professor John Strang to chair a group to provide guidance on the proper use of medications to aid recovery • Expert group comprised clinicians, managers, service user representatives, commissioners, researchers and others • Chair’s interim report published July 2011

39. The interim report - outline • Common ground in the group: strong body of evidence for the effectiveness of opioid substitution treatment (OST) but people in treatment could be better supported in their recovery • Existing guidance (NICE and orange book), and the evidence on which it is based, already describes much of what is best practice • 12 immediate steps that can be taken to improve the recovery orientation of treatments that include prescribing • But will also need a renewed emphasis on improving people’s recovery • Areas of work for the group’s final report

40. RODT - 12 immediate steps overview • Increase recovery-oriented ambition and progress by: • examining current practice to make sure there is balance between overcoming dependence and reducing harm, and that recovery care planning is good • checking clients are working towards abstinence and, as more people are ready to come off, make sure they are properly supported • making sure clients are still getting real benefit from prescribing and, if necessary, optimising treatment: adding psychosocials and/or getting dose right • doing more to support people to recover: visible exits from treatment, social networks, employment, housing • making sure staff are competent in all these interventions. • Strang J (2011) Recovery-orientated drug treatment an interim report by Professor John Strang, chair of the expert group. NTA

41. The group’s final report

42. The treatment system’s achievements Numbers in treatment

43. The treatment system’s achievements

44. The treatment system’s achievements • Global HIV prevalence in people who inject drugs

45. The treatment system’s achievements • Drug treatment prevented an estimated 4.9m offences in 2010-11

46. The treatment system’s achievements

47. The group’s final report A lot done. A lot more to do!

48. The group’s final report – July 2012 • High-quality treatment system that substantially improves health • Heroin is sticky • Leaving treatment is important but it isn’t recovery • Lots of people haven’t recovered • Done right, OST is effective but a platform for recovery • Don’t end it too early • Some people recover fast, some don’t – all need recovery support

49. The task set for the field by the group’s report • “Well-delivered OST provides a platform of stability and safety that protects people and creates the time and space for them to move forward in their personal recovery journeys. OST has an important and legitimate place within a recovery orientated system of care.” • “We need to ensure OST is the best platform it can be but focus equally on the quality, range and purposeful management of the broader package of care it sits within.”

50. McLellan and White commentary • Opioid maintenance and recovery-oriented systems of care: it is time to integrate • “Recovery status is best defined by factors other than medication status. Neither medication assisted treatment of opioid addiction nor the cessation of such treatment by itself constitute recovery. Recovery status instead hinges on broader achievements in health and social functioning - with or without medication support.” • A Thomas McLellan & William White