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Guidance for commissioners of drug and alcohol services 1
Joint Commissioning Panel
for Mental Health
www.jcpmh.info
Guidance for commissioners of
drug and
alcohol services
Practical
mental health
commissioning
Joint Commissioning Panel for Mental Health www.jcpmh.info Co-chaired by: Membership:
2 Practical Mental Health Commissioning
Contents
Ten key messages Introduction What are Why are drug and
for commissioners drug and alcohol alcohol services
services? important to
commissioners?
04 06 08
What do we know What would a Supporting References
about current good drug and the delivery
drug and alcohol alcohol service of the mental
services? look like? health strategy
12 14 19 21
Guidance for commissioners of drug and alcohol services 3
Ten key messages for commissioners
1 Investment in drug and 6 Commissioning of drug and
alcohol services gets results. alcohol services should be
Treatment, as part of a based upon accurate and up
co-ordinated public health to date information about
approach is proven to be cost local needs.
effective for health services
and society as a whole. 7 Commissioners should ensure
Disinvestment brings with it a that local services have clear
risk of reversing the progress leadership, both clinical and
made over recent years. managerial, and that services
comply with professional
2 A strong evidence base and service standards.
exists for the range of
interventions that are 8 Commissioning of
effective in substance misuse. drug and alcohol services
Commissioning should be should be outcome based and
based upon this evidence make use of available data
using NICE quality standards. and information.
3 To be effective, the treatment 9 Services should place
system should be equipped recovery at the centre of their
to respond to the full range approach and commissioners
of complexity of need should recognise recovery as
represented by those who central to their commissioning
misuse substances. and strategic decision making.
4 A skilled workforce, working 10 Treatment is not simply
under appropriate supervision about patients – it should
and providing care within address the needs of families
national competence and carers, and work
frameworks, is key to with patients’ wider social
delivering good outcomes. networks.
5 Collaboration and partnership
gets results. The NHS and
voluntary sector have a
contribution to make in the
delivery of drug and alcohol
services.
4 Practical Mental Health Commissioning
Introduction
The Joint Commissioning The JCP-MH is part of the implementation Who is this guide for?
Panel for Mental Health arm of the government mental health
strategy No Health without Mental Health1. This guide has been written
(JCP-MH) (www.jcpmh.info) to provide practical advice
is a collaboration co-chaired by The JCP-MH has two primary aims:
on developing and delivering
the Royal College of General • to bring together people with mental local plans and strategies to
Practitioners and the Royal health problems, carers, clinicians, commission the most effective
College of Psychiatrists. commissioners, managers and others
to work towards values-based
and efficient drug and alcohol
It brings together leading services for adults.
commissioning
organisations and individuals
• to integrate scientific evidence,
with an interest in commissioning the experience of people with mental
Based upon clinical best practice guidance
for mental health and learning and drawing upon the range of available
health problems and carers, and
evidence, it describes what should be
disabilities. These include: innovative service evaluations, in order
expected of a modern drug and alcohol
to produce the best possible advice
• People with mental health problems service in terms of effectiveness, outcomes
on commissioning the design and delivery
• Carers and value for money.
of high quality mental health, learning
• Department of Health disabilities, and public mental health The guide will be of particular use to:
• Association of Directors and wellbeing services. • public health leaders who will hold
of Adult Social Services
The JCP-MH: responsibility for commissioning these
• NHS Confederation
services
• Mind • has published Practical Mental Health
• Rethink Mental Illness Commissioning2, a briefing on the key • Clinical Commissioning Groups (CCGs)
• National Survivor User Network values and principles for effective mental • wider local authority commissioners
• National Involvement Partnership health commissioning • and voluntary and independent sector
• Royal College of Nursing organisations.
• has so far published seven other practical
• British Psychological Society
guides on the commissioning of primary This guide does not cover drug and
• Representatives of the English
mental health care services3, dementia alcohol services for children or offenders,
Strategic Health Authorities
services4, liaison mental health services whose needs may be more specific.
(prior to April 2013)
to acute hospitals5, transition services6, More information can be found in the
• Mental Health Providers Forum
perinatal mental health services7, public publication Practice Standards for Young
• New Savoy Partnership
mental health services8, and rehabilitation People with Substance Misuse Problems10.
• Representation from
services9
Specialised Commissioning
• Healthcare Financial • provides practical guidance and a
Management Association. developing framework for mental health
• will support commissioners to deliver the
best possible outcomes for community
health and wellbeing.
Guidance for commissioners of drug and alcohol services 5
HOW WILL THIS GUIDE HELP YOU? • what good quality drug and alcohol • JSNA Support Pack for Commissioners
services look like (National Treatment Agency)18
This guide has been written
by a group of drug and alcohol • the benefits of providing good quality • No Health without Mental Health (DH)1
drug and alcohol services
professionals, people who use • Medications in recovery. Re-orientating
drug and alcohol services, and • how drug and alcohol services can drug dependence treatment (National
carers. The content is primarily make a contribution to a range of other Treatment Agency 2012)19
imperatives including those in the national
evidence-based, but ideas mental health strategy.
• Commissioning for Recovery
deemed to be best practice by (National Treatment Agency)20
The guide draws upon, and signposts
expert consensus have also been • Drug Strategy 2010 – Reducing Demand,
towards, previously published guidance and
included. policy. Among the key documents drawn
Restricting Supply, Building Recovery
(HM Government)21
upon are:
By the end of this guide, readers should be
• Healthy lives, healthy people:
better equipped to: • NICE quality standards for alcohol
our strategy for public health in England
dependence and harmful alcohol use
• understand what an effective range of (HM Government)22
(QS11)11
drug and alcohol services should look like
• the roles and competencies of doctors
• Alcohol dependence and harmful
• know the sorts of interventions that working in substance misuse23
alcohol use CG115 (NICE)12
should be available
• Alcohol use disorders: physical
• NICE quality standards for drug use
• understand how those interventions complications CG100 (NICE)24
disorders (QS23)13
can contribute to achieving recovery
• Alcohol disorders – preventing the
and make improvements in public mental • Drug misuse – psychosocial interventions
development of hazardous and harmful
health and wellbeing. CG51 (NICE)14
drinking PH24 (NICE)25.
In doing this, the guide describes: • Drug misuse – opioid detoxification
This guide does not cover non-structured
CG52 (NICE)15
• the benefits of drug and alcohol services interventions for non-dependent drinkers.
• Improving outcomes & supporting
• the desirable team configurations for
transparency – a public health outcomes
drug and alcohol services
framework for England, 2013-16
• the policy context for drug and alcohol (Department of Health)16
services
• The Government’s Alcohol Strategy
(HM Government 2012)17
6 Practical Mental Health Commissioning
What are drug and alcohol services?
Effective treatment provides crime and housing). It also
a central means for people delivers the greatest gains for
dependent on drugs or alcohol individuals and the community.
to recover from their addiction There is no nationally agreed
and to live independent lives. model for the commissioning
It can deliver a wider range of and delivery of drug and alcohol
public health and social benefits, services. The result of this has
and can also bring about been a continuation of local
economic savings at the local plans for services that attempt
and national level (see page 9). to address not only local need,
Local authority-based public but also national imperatives.
health is now responsible for Although a locally based
commissioning drug and alcohol approach is important it can
prevention, treatment and have the negative consequence
linked recovery support. This of different and varied
shift will provide a platform for approaches across the country.
a more integrated approach However, the existence of NICE
to improving public health quality standards, the National
outcomes. This approach Drug Treatment Monitoring
addresses the root causes and System, local needs assessments,
wider determinants of drug Joint Strategic Needs Assessment
dependence and alcohol misuse, tools and the publication of
and the harm and impact they guidance such as this, means
have on people who use drugs that commissioners now have
or alcohol, carers, families and a wide range of tools to enable
communities (such as mental them to commission effectively.
health, employment, education,
THE SERVICES
Guidance for commissioners of drug and alcohol services 7
Drug and alcohol services are This is especially the case when providing • psychologists and other specialist
mainly provided by NHS Trusts services to those people with co-morbid therapists
illness, (e.g. substance misuse and mental • people who are experts by experience
or voluntary sector services, illness, or substance misuse and physical
although the private sector also health needs). This is often because people
• social workers/care managers.
plays a smaller role in provision. with co-morbid illness are often excluded Those working in drug and alcohol services
from general mental health services. are expected to work to a set of national
In the majority of cases, patients coming One of the functions of drug and alcohol occupational standards and, potentially,
to drug and alcohol services self-refer rather services is to work with this group. also the skills framework promoted by
than being referred by a GP. Drug and The Substance Misuse Skills Consortium.
alcohol services employ a range of expertise In parts of the country where Drug &
Alongside these are the competencies
including front line doctors, psychologists, Alcohol Action Teams (DAATs) are in
required by specific professional
senior nurses, and drug workers. This skill operation, these have introduced Local
bodies, including the Royal College of
mix makes them well equipped to conduct Area Single Assessment and Referral
Psychiatrists, Royal College of Nursing,
complex work with a client group often Systems (LASARS) as part of a national
Royal College of General Practitioners, and
perceived as challenging. pilot of drug recovery Payment by Results.
those representing other allied health and
The core function of LASARS is to assess
In the past, drug and alcohol services social care professionals.
and set a tariff, refer and in some cases
tended to be provided by separate drug review achievement of outcome. They The Substance Misuse Skills Consortium
and alcohol teams, but recently they are may also reduce the number of assessments is an independent, sector-led initiative to
more commonly delivered from teams that an individual has to undertake in order harness the ideas, energy and talent within
that deal with both. These aim to provide to access those services26. the substance misuse treatment field, to
a more integrated approach, particularly maximise the ability of the workforce,
for those people who have a problematic WHO WORKS IN THESE SERVICES? and help more drug and alcohol misusers
use of both substances. For some people to recover27. Commissioners will find
this approach has not been successful A wide range of people from helpful guidance in the Drugs and Alcohol
in relation to enabling access to services a number of disciplines and National Occupational Standards (DANOS)
(e.g. due to the stigma associated with specialisms work in drug and framework described later in this guide
particular types of substance misuse). alcohol services including: (page 14), but should be aware that it
Most secondary care services tend to does not cover all professional groups.
concentrate their interventions on people • medical staff including specialist
with addictions to drugs such as heroin, doctors (addiction psychiatrists and
crack cocaine and alcohol. However, a small number of highly specialist
other substances, for example emerging General Practitioners)
club drugs and prescribed drugs, may be • nurses (both mental health and
among those for which people are treated. general nursing)
Given the complexity of these problems • drug and alcohol support workers
and the range of needs, services are
• non-medical prescribers (especially
required to collaborate with other parts of
trained nurses or pharmacists)
the health, social care and criminal justice
systems. This is essential to the delivery of • peer mentors
effective high quality treatment. • pharmacists
8 Practical Mental Health Commissioning
Why are drug and alcohol services
important to commissioners?
Among the reasons why 1 SOCIAL IMPACT 2 PUBLIC HEALTH IMPACT
drug and alcohol services are The Government’s drug strategy identifies The public health consequences of drug
important to commissioners are: that drug and alcohol problems not only and alcohol use are also significant.
negatively impact on the lives of people The primary harms include transmission of
1 drug and alcohol use can using these substances, but are also the blood borne viruses, including Hepatitis B,
have a significant and “key causes of societal harm, including C and HIV. Estimates suggest that around
crime, family breakdown and poverty”21. 216,000 individuals are chronically infected
negative impact on individuals
For example: with hepatitis C in the UK34.
and wider society
• crime – there were 278,000 recorded There are also various forms of harm that
2 drug and alcohol use can also drug offences in the UK in 2009/1028 and may be caused by addiction to drugs or
have a public health impact 9% of the population were engaged in alcohol including acute harms:
illicit drug use in 2010/1129. As a society,
3 considerable economic costs although drugs cost the UK £15 billion
• death by overdose
are associated with drug and • intoxication
each year29, investment in drug services
• accidental injury
alcohol use has been estimated at approximately
• suicide
£1.3 billion per year28. However, drug
4 there is a relatively common treatment has been shown to be effective
• precipitation or exacerbation of mental
use of drugs and alcohol illnesses such as psychosis.
in preventing drug-related offending,
among the UK population with an estimated five million offences Chronic harms can also occur, including:
being prevented in 2010-11 alone30.
5 these harms, impacts and Each year, alcohol is associated with
• cirrhosis and other liver damage
costs can be reduced through • consequences of injecting – for example,
500,000 recorded crimes in England,
abscesses, vein damage, endocarditis
effective treatment, with 125,000 instances of domestic violence
• sexually transmitted diseases
important economic savings. and 1,000,000 assaults31.
• dependence including withdrawal
• family difficulties – families with parental symptoms
substance misuse frequently appear in • hypertension
social services statistics: around one in • stroke
five families referred to children’s social • coronary heart disease
services in the UK have a history of • pancreatitis
alcohol or drugs problems, rising to one • depression
in two families on the Child Protection • anxiety disorders.
Register and affecting three out of four
families involved in care proceedings32.
• poverty – English local authority areas
with higher levels of deprivation will
have higher numbers of problem drug
users, and higher admission rates for drug
treatment services33. The Marmot Review
published in 2010 highlighted a range of
health inequalities and set out actions to
address them, including an approach to
substance misuse to alleviate the impact
of alcohol in particular on people living in
more deprived settings33.
Guidance for commissioners of drug and alcohol services 9
3 ECONOMIC COSTS 4 PREVALENCE box 2: Types of drug use36
Alcohol Drugs Recreational use
There were 1.2 million alcohol-related Prevalence of substance misuse varies for Many people are able to use
hospital admissions during 2010/1117. different types of substances. Recent years psychoactive substances in a recreational
Alcohol consumption has nearly trebled have shown different patterns of use, with manner that causes no problems to the
since 1950 with more than seven million a trend towards an increase in the misuse individual or those around them.
people drinking at harmful or hazardous of over the counter medicines and new
This pattern of use is usually
levels and who together account for about substances, including those known as club
characterised by moderate levels of
80% of all spending on alcoholic drink35. drugs such as mephedrone, ketamine and
consumption and periods when the
It costs the NHS in England up to legal highs.
person stops using the substance
£2.7 billion a year to treat the chronic
without difficulty.
and acute effects of drinking24. The BOX 1: Reasons for
Government’s alcohol strategy indicates drug and alcohol use Harmful use
that alcohol-related harm is now estimated A pattern of psychoactive substance
People use drugs and alcohol for a
to cost society £21 billion annually17. use that is causing damage to health.
variety of reasons. For many people
Drug use this use of substances does not turn The damage may be physical or
into what is termed misuse. It is psychological.
Drug use costs the UK £15.4 billion
each year, including welfare benefit equally important to bear in mind Dependent use
expenditure costs of approximately that no-one starts using substances Dependence has both psychological
£1.6 billion per year21. with the intention to develop misuse and physiological elements.
problems. Some of the reasons why
people begin to use drugs and/or Psychological dependence involves a
alcohol might include: because the need for repeated doses of the drug to
initial reactions and experiences are feel good, or avoid feeling bad.
pleasurable; response to social or family Physiological dependence is associated
circumstances, such as bereavement/ with tolerance, where increased doses
loss, unemployment, relationship of the drug are required to produce the
difficulties, loss of accommodation; effects originally produced by lower
response to peer pressure; to remove doses, and development of withdrawal
stress or other psychological difficulties; syndrome when the drug is withdrawn.
criminal or other antisocial antecedents.
Withdrawal syndrome is characterised
by physiological and psychological
symptoms that are specific to a particular
drug. The term ‘dependence’ is often
used interchangeably with ‘addiction’.10 Practical Mental Health Commissioning
box 3: Prevalence of • In the same period there were almost – 44% of mental health service users
drug and alcohol use 168,000 prescription items for drugs for either reported drug use or were
the treatment of alcohol dependency assessed to have used alcohol at
• Estimates from the 2010/11 British
prescribed in primary care settings or hazardous or harmful levels in the
Crime Survey show that 36% of adults
NHS hospitals and dispensed in the past year43.
aged 16-59 have used illicit drugs in
community which is a 63% increase
their lifetime, which equates to almost • The term ‘co-morbidity’ covers a
compared to 200339.
12 million people. Among this group, broad spectrum of mental health
almost 9% or 2.9 million adults had • Quantities of alcohol consumption and substance misuse problems
used illicit drugs in the last year29. across the population have been rising. that an individual might experience
Recent research shows that 24% of concurrently. The nature of the
• The National Treatment Agency
adults engage in hazardous drinking relationship between these two
reported that in 2009-10 in England
while nearly 4% engage in harmful conditions is complex. Possible
there were 306,000 users of opiates
drinking. Almost 6% of adults are mechanisms include:
and/or crack cocaine corresponding to
known to be dependent on alcohol40.
almost 1% of the adult population (this – a primary psychiatric illness
Higher consumption of alcohol is
number represents the total number of precipitating or leading to
associated with depression and the risk
users, rather than those in treatment substance misuse
of suicide is eight times higher among
alone). In 2011 reported use of – substance misuse precipitating,
those with current alcohol misuse or
mephedrone in the last 12 months was worsening or altering the course
dependence. Alcohol misuse by young
1.4% and ecstasy 1.4% among 16-59 of a psychiatric illness
people is associated with a six-fold
year olds31. – intoxication and/or substance
increased risk of depression41.
• Investment in drug treatment services dependence leading to
• The Royal College of Psychiatrists psychological symptoms
is widely recognised to have been a
report, Our Invisible Addicts showed – substance misuse and/or
factor in the reduction of illicit drug use.
that the misuse of drugs in older people withdrawal leading to psychiatric
• Around 200,000 people get help for (65 and over) is a problem that is likely symptoms or illnesses44.
drug dependence in England every to grow and that misuse in the over-40s
year, with around 135,000 being has increased significantly in recent • The complexity of issues can make
treated on any given day37. years42. By 2031 there is predicted diagnosis, care and treatment more
to be a 50% increase of complex difficult, with service users being at
• Nearly one third of users in the last
substance misuse in the over 65s (e.g. higher risk of relapse, readmission to
seven years successfully completed their
excessive alcohol consumption as well hospital and suicide44.
treatment and did not return, which
as inappropriate use of prescribed and • Dual diagnosis: a challenge for the
compares favourably to international
over the counter medications). reformed NHS and for Public Health
recovery rates38.
Co-morbidity England has reinforced the need for
• Drug misuse in this country remains
commissioners to develop effective
a significant factor in poor health • The 2002 Co-morbidity of
services for dual diagnosis and that
outcomes, criminality and worklessness Substance Misuse and Mental Illness
those services are central to the
and continues to have far reaching Collaborative study (COSMIC)
achievement of key policy objectives,
effects upon individuals, families and concluded that:
including drug recovery43.
society as a whole. – 75% of users of drug services and
High risk groups
Alcohol 85% of users of alcohol services were
experiencing mental health problems • There are a number of groups of
• Alcohol consumption in the UK has
people who may be at higher risk
almost trebled since 1950 with more – 30% of the drug treatment of misuse of drugs and alcohol.
than 7 million people drinking at harmful population and over 50% of those in As an example, recent research
or hazardous levels. Together they treatment for alcohol problems had has shown that drug use among
account for about 80% of all spending ‘multiple morbidity’ Lesbian Gay Bisexual and Trans-
on alcoholic drink35. Since 2002/03 there
– 38% of drug users with a psychiatric gender groups is higher than among
has been a 40% increase in admissions
disorder were receiving no treatment their heterosexual counterparts,
to hospital where the primary diagnosis
for their mental health problem irrespective of gender or the different
was attributable to the consumption of
age distribution in the populations45.
alcohol39.Guidance for commissioners of drug and alcohol services 11
5 Effective treatment can Good quality drug and alcohol services are These figures tell a story of success in
reduce harm and increase important to commissioners for more than terms of improving access and outcomes
economic savings purely financial reasons. They can help in drug services. However they do not
people to achieve their recovery potential highlight the variation in service provision
Commissioners know that drug and alcohol
and as such benefit individuals directly. and quality across the system. In part this
misuse affects an individual’s health and
Intervening early can reduce the chances has been a consequence of the varying
impacts their local communities. The
of ongoing misuse and the consequent priority commissioners have placed upon
impacts outlined in this guide should all be
harms it may cause, thus reducing demand investment in high quality drug and alcohol
of interest and importance to commissioners
on the use of NHS and other public services services. We also know that some services
as they seek to meet the health needs of
in the future. have found it hard to offer a comprehensive
local populations, and deliver improved
range of interventions and to link effectively
public health and wellbeing. This can be particularly important given
with other services, particularly in cases of
the statistics in relation to co-morbidity.
Where provided by trained and experienced co-morbidity and complex needs.
Within the substance misuse treatment
staff, the evidence base for drug and
sector, the prevalence of dual diagnosis has In terms of alcohol services, there were
alcohol treatment is strong, demonstrating
been estimated at around 75% for those just over 111,000 clients in contact with
the positive impact that such services can
in drug services48, and 85% for those in structured treatment aged 18 and over who
have. From a purely economic point of
alcohol services49. In mental health service cited alcohol as their primary problematic
view, investment in effective treatment
settings, prevalence studies50 have indicated substance in 2010-11. More than four-fifths
and recovery services makes sense for
that around one-third of people with serious (82%) of all clients waited less than three
commissioners as they seek to ensure good
mental health problems (such as psychosis weeks to commence treatment. The number
value for the public purse. The National
and bipolar disorder) have some level of of new treatment journeys commencing
Institute for Health and Clinical Excellence
substance use problems. in the year increased to almost 74,000 in
(NICE) produced clinical guidance for these
2010-11. The number and proportion of
services in 2007, accompanied by a Costing Commissioning quality drug and alcohol
successful completions also increased from
Report for their implementation. The services will help to address the health
approximately 31,000 (48%) in 2009-10 to
Costing Report indicates that: and well being needs of the local
nearly 36,000 (54%) in 2010-1152.
population, reduce the burden on services
• the total savings through implementing
and help achieve improved value for money. These figures show improvement, but
the guideline attributable to healthcare
the relative lack of investment in alcohol
have been estimated as being almost Drug services have developed significantly
services and minimal prioritisation of
£4 million46 over recent years, in part due to increased
alcohol treatment explains in part why
investment and clear delivery imperatives.
• an additional £37 million of savings these services have been described as being
The investment in drug services has led to
to society have been estimated outside of patchy and in some places underdeveloped.
improved access to services coupled to a
the NHS in the criminal justice system46
reduction in waiting times for treatment Commissioners need to take account of the
• at an individual level research has shown and support: necessity to enable providers to (a) offer
that for every £1 spent on treatment, the NICE guideline approved psychological
• of the approximately 204,000 clients
an estimated £2.50 is saved47. and pharmacological treatments and
aged 18 and over in treatment contact
(b) plan service developments that align
during 2010-11, just over 191,000 were
with public health needs and imperatives,
in treatment for 12 weeks or more, or
as well as emerging quality standards
completed treatment free of dependency
developed by NICE.
before 12 weeks (93%)
• nearly all clients waited less than three
weeks to commence treatment (96%)51
– successful completion of treatment in
2011-12 was up by almost three times
the level seven years prior (approximately
11,000)38.12 Practical Mental Health Commissioning
What do we know about current drug and alcohol services?
The last decade saw considerable • the Alcohol Strategy: published in • ‘Any Qualified Provider’: the market
investment in the planning March 2012, this sets out the environment in the NHS and social
Government’s proposals to address care has expanded to admit a wider
and provision of drug services alcohol use. It focuses on plans to deal range of independent and voluntary
in England and more people with ‘binge drinking’. It also aims to sector providers.
have had access to services. reduce alcohol related violence and
• Health and Wellbeing Boards (HWBs):
For example in drug services, disorder and reduce the number of
The aim of HWBs is to consider how
there has been a doubling in people drinking to damaging levels.
prioritising health improvement
the number of people receiving www.homeoffice.gov.uk/publications/
and prevention will best deliver benefits
alcohol-drugs/alcohol/alcohol-
treatment, while waiting times strategy?view=Binary
for the health and wellbeing of the
have reduced significantly. local population.
• the mental health outcomes strategy
• Public Health England (PHE): PHE
The picture is less encouraging in relation for people of all ages: ‘No Health
will take on the responsibility for the
to alcohol services. Recent reports suggest without Mental Health’ makes a
monitoring of drug treatment through its
that PCTs on average spent only 0.1% of commitment to ‘parity of esteem between
Knowledge and Information Directorate55.
their budgets on alcohol services53. The mental and physical health services’,
Directors of Public Health will be located
Health Select Committee reported in 2010 and has a clear objective to improve the
within local authorities, which will have
that many commissioners did not have physical health of those with a mental
responsibility for health improvement
a strategy for alcohol services and it was disorder54. The strategy is now supported
within their areas.
acknowledged that the picture in relation by an Implementation Framework.
to provision was patchy35. In the past www.dh.gov.uk/prod_consum_dh/ • outcomes: Improving outcomes &
18 months the policy direction has shifted, groups/dh_digitalassets/documents/ supporting transparency – A public
not only in respect of drug and alcohol digitalasset/dh_124058.pdf health outcomes framework for England,
services but across health and social care 2013-16 was published in early 2012.
more broadly. NHS reforms It sets out two outcome measures to
improve and protect the nation’s health
Below we set out the key areas of policy A range of changes to the way in which
and wellbeing, and improve the health of
that impact on the commissioning of drug services are commissioned and delivered
the poorest fastest:
and alcohol services. are contained in the Health and Social
Care Act. They include: – outcome one: increased life expectancy,
Government strategies: drugs, i.e. taking account of the health quality
• Clinical Commissioning Groups: hold
alcohol, and mental health as well as the length of life
the local budget for health care and are
• the Drug Strategy: ‘Reducing demand, responsible for deciding what services – outcome two: reduced differences
restricting supply, building recovery: should be delivered and by whom. They in life expectancy and healthy life
supporting people to live a drug-free life.’ will be accountable to NHS England. expectancy between communities
Published in December 2010, this has an (through greater improvements in more
• NHS England: will support and regulate
emphasis on supporting recovery from disadvantaged communities).
the CCGs, and it will have a limited
drug and alcohol dependence. The first
commissioning function in respect of The outcomes have four domains and a
annual review of the drug strategy was
specific national services. set of indicators. Table 1 (overleaf) sets
released in May 2012. www.homeoffice.
out the outcomes that are of relevance to
gov.uk/publications/alcohol-drugs/drugs/
drugs and alcohol services.
drug-strategy/drug-strategy-2010Guidance for commissioners of drug and alcohol services 13
The drug strategy: ‘Reducing • improve the ability of patients to These are among some of the central
demand, restricting supply, building gain and maintain appropriate elements that the alcohol strategy seeks
recovery: supporting people to live employment and/or training as part to deliver that specialist alcohol services
a drug-free life’ of their recovery can contribute to.
Commissioning which leads to good • provide accurate information on NICE guidelines
drug and alcohol services as described drugs and alcohol through substance Drug and alcohol services should
in this guide will support the delivery misuse education. be commissioned to provide a
of the national drug strategy. By
These are among some of the central range of interventions, including
commissioning for outcomes and
elements that the drug strategy seeks those recommended by NICE. Of
recovery, commissioners can enable
to deliver. particular importance is the need for
services to:
commissioners to ensure services
• enable people to be free from The Government’s alcohol strategy will deliver NICE guideline TA114 in
dependence on drugs or alcohol Effective alcohol services will support respect of the management of opioid
the delivery of the objectives described dependence56 and NICE Guideline
• prevent/reduce drug related deaths
in the Government’s alcohol strategy. CG51 in respect of psychosocial
and blood borne viruses
Commissioners should commission interventions for drug misuse14.
• improve mental and physical health services that will:
Drug and alcohol services should
and wellbeing
• contribute to a reduction in the also be able to demonstrate adherence
• contribute to a reduction in crime and number of alcohol-related deaths to the NICE quality standards (boxes
re-offending 6 and 7).
• a reduction in the number of adults
• improve the ability of patients drinking above the NHS guidelines.
to access and sustain suitable
accommodation
table 1
Domains Improving the wider Health improvement Health protection Healthcare public health
determinants of health and preventing premature
mortality
Indicators People with mental illness Hospital admissions caused People presenting with HIV Mortality from causes
or disability in settled as a result of self-harm at a late stage of infection considered preventable
accommodation
Re-offending Successful completion of Public sector organisations Mortality from liver disease
drug treatment with board-approved
sustainable development
management plans
Employment for those People entering prison Mortality from
with a long-term health with substance misuse communicable diseases
condition including those issues who are previously
with a learning difficulty/ not known to community
disability or mental illness treatment
Domestic abuse Alcohol related admissions Suicide
to hospital
Violent crime (including Self reported wellbeing Excess under 75 mortality
sexual violence) in adults with serious
mental illness
Statutory homelessness14 Practical Mental Health Commissioning
What would a good drug and alcohol service look like?
A good drug and alcohol • appropriate and timely access to Workforce standards
service should be comprised prescribing including opioid substitution Commissioners will need to commission
therapy including methadone, drug and alcohol services that can
of a number of elements. buprenorphine, giving access to injectable demonstrate that they meet the necessary
This section sets out some of treatments where this is clinically indicated statutory standards as set out by the
the key issues for commissioners relevant professional regulatory bodies.
• medically assisted withdrawal for alcohol,
to think about. opioids and other drugs Individual professionals working in drug
Key components of a good • access to appropriate in-patient beds for and alcohol services should be able to
quality service those people who require a period of demonstrate and meet a range of core
admission standards and competencies.
A comprehensive drug and alcohol service
will have the following features: • peer led support – where people provide There are a number of other advisory and
knowledge, experience, emotional, social regulatory bodies including NICE, CQC
Assessment of patients’ needs and Royal Colleges of Psychiatrists and
or practical help to each other (peer
• the provision of comprehensive support relies on the assets, skills and General Practitioners, Nursing & Midwifery
assessment of need, including risk knowledge in the community, and the Council, General Medical Council, British
assessment using recognised tools recognition that local people can offer Pharmaceutical Association, British
help in ways that are sometimes more Psychological Society, the Health Care
• ensuring that assessment of need includes
effective than professional help)55 Professions Council, and British Association
not only the needs that arise from their
of Social Workers.
substance use, but identifies the recovery • a directory of all local services should be
goals and outcomes the service will seek available to both professionals and the This guide has described the range of
to achieve with the patient public – commissioners should ensure that professionals that are often employed in
such a directory exists in a range of ways drug and alcohol services. To be able to
• taking account of the physical needs of
that enable easy access to information provide the right range of interventions
the patient including the harms associated
and services, commissioners and providers
with substance misuse, including blood • signposting to other services, such as will need to ensure there is a mix of
borne virus screening needle exchange, sexual health, housing, appropriately qualified and skilled staff
• taking account of the psychiatric and employment, mental health services working within the service.
psychological needs of the patient, including talking therapies
The Drugs and Alcohol National
including psychosis, depression, cognitive • be a source of information and advice Occupational Standards (DANOS) specify
impairment and broader issues of health to other services, including colleagues the standards of performance that people
and wellbeing in primary care, general hospitals, adult in the drugs and alcohol field should
• taking account of social factors including social care and children’s services be working to. They also describe the
housing and homelessness, employment • fulfil responsibilities relating to knowledge and skills workers need in
and social and family networks. child protection and adult and child order to perform to the required standard.
safeguarding DANOS can be used to ensure that services
The provision of a range of interventions,
have a competent workforce and that
which may include: • the provision of support for families and everyone has the knowledge and skills
• structured psychological and psycho- carers, including the conducting of carer to deliver services to the required quality
social interventions – commissioners assessments to identify support needs. standards27.
should refer to NICE guidance and quality
standards for more information about
specific interventionsGuidance for commissioners of drug and alcohol services 15
The DANOS standards are applicable to a The NICE Quality Standards for drug and Commissioners will be able to review
range of professionals working in substance alcohol services provide a comprehensive performance by using data from the
misuse services including commissioners of range of outcomes that commissioners National Drug Treatment Monitoring
substance misuse services, drugs and alcohol should ensure their local services are System (NDTMS) and use other NHS and
workers, psychiatrists, psychotherapists, delivering against. The quality standards can social care national outcome frameworks
social workers and probation officers who be found in boxes 6 and 7. to ensure delivery of improved outcomes.
regularly work with substance misusers27.
The sorts of skills that should be expected to
be present within drug and alcohol services box 4: Model of service delivery and core principles
should include: A good drug and alcohol service will • providing interventions that are
• assessment of substance misuse usually function best as a specialist, evidence based and should implement
• risk assessment and management integrated team that includes a range the relevant NICE guidance
of professional health and social care
• care planning • providing a therapeutic environment for
staff, under single management.
• knowledge of the law in respect of drugs patients that is non-judgmental where
Commissioners and patients should
and alcohol they can expect to receive a good
expect any services to have at its core
quality assessment of their needs and a
• knowledge of other relevant legislation the aim of providing a holistic and
range of evidence based treatments
including the Mental Health Act, the personalised care package for patients
Mental Capacity Act and Safeguarding that is both tailored to their specific • working with patients to enhance
• knowledge of other local services and needs and which is focused on recovery. their recovery potential and address
agencies including the criminal justice not only their substance dependence
The Expert Reference Group that has
system, housing, adult social care, but also the other factors impacted by
developed this guide, has produced the
children’s services. that dependence, including housing,
set of core principles described below to
employment and social and family
Commissioners and providers should also be assist commissioners. These state that a
networks
able to ensure that the workforce is suitably good drug and alcohol service should be:
equipped to meet the quality standards • providing continuity of care in
• commissioned on the basis of local
described by NICE for the delivery of specific supporting people in recovery
need and recognise the motivations
intervention in drug and alcohol services. that underpin drug and alcohol use • establishing, maintaining and building
on good links with other services,
Outcomes • staffed by an appropriately
including mental health services and
qualified and skilled group of staff
There is increasing emphasis on the delivery have a good knowledge of other local
working within agreed standards of
of outcomes in health services, not just in resources
competence with the necessary levels
terms of the wider public health outcomes
of supervision and support – there • using data and information to enable
described earlier in this guide, but more
should be sufficient staff to ensure regular and accurate performance
specifically those that apply to the service
there is the capacity to maintain the monitoring and review of effectiveness
provided and the outcomes experienced by
service and outcomes
the patient. Commissioners may apply their
own outcomes at local level, in partnership • able to manage the full range of • providing value for money to
with providers, as part of their planning and complexity of need, including being commissioners and the public purse.
review processes. able to address the issues of co-
morbidity including mental and
associated physical health needs16 Practical Mental Health Commissioning
What would a good drug and alcohol service look like? (continued)
Commissioning process box 5: commissioning principles
The commissioning process has been • the commissioning process is a effectively address the complexity
well described in a range of JCP-MH continuous cycle through three key of issues that those with addiction
guides, including Practical Mental Health stages: strategic planning, procuring present – this should include co-
Commissioning, published in March 20112. services and monitoring and morbidity with mental health and
The National Treatment Agency has evaluation2 – commissioning should physical health problems
also developed specific guidance for the be a dynamic process that is about
• ensure there is an appropriate
commissioning of recovery focused drug identifying and prioritising need
range of services that are able to
and alcohol services with a set of resources and apportioning resources to meet
meet demand and secure required
to support the Joint Strategic Needs those needs and achieve positive
clinical treatment, reintegration and
Assessment process18. outcomes in a spiral of continuous
recovery outcomes20, and decide
improvement2
Both documents provide commissioners which provider(s) will best meet the
with helpful information about the • examine the current services, local needs and procure clinically
commissioning process and are statutory, independent and voluntary effective services. In doing so
recommended for further reference. sector to determine what exists now commissioners should be particularly
Alongside those documents, the top-tips and what might be needed in the mindful of issues of quality and
in box 5 should help commissioners in future – understand the drug and patient safety, and where appropriate
their thinking when commissioning a alcohol treatment system locally, commissioners should stimulate the
drug and alcohol service. and address recovery challenges20 local market to ensure the value for
money, the right range of provision
• the Joint Strategic Needs Assessment
and improved outcomes
process should be used to establish
local patterns of need and in • use the national benchmarks as
partnership with other stakeholders a guide for quality and standards
agree local priorities for investment and including NICE guidance for
development and decommissioning drug and alcohol services and
where necessary – taking account of interventions, CQC standards and
service re-design, changing service relevant good practice guidance.
models and practice, and ensuring the Work in partnership with providers
provision of an appropriately skilled to ensure contract compliance and
and experienced workforce continuous improvements in quality
and outcomes20, and ensure linkage
• ensure that service providers are able
to clinical and corporate governance
to deliver a range of services, with
requirements and monitor delivery,
an appropriate mix of staff that will
effectiveness, outcomes and costs.Guidance for commissioners of drug and alcohol services 17
box 6: NICE Quality Standards for Alcohol Dependence and Harmful Use11
Statement 1 Statement 8
Health and social care staff receive People needing medically assisted
alcohol awareness training that alcohol withdrawal are offered
promotes respectful, non-judgmental treatment within the setting most
care of people who misuse alcohol. appropriate to their age, the severity
of alcohol dependence, their social
Statement 2
support and the presence of any
Health and social care staff physical or psychiatric co-morbidities.
opportunistically carry out screening
and brief interventions for hazardous Statement 9
and harmful drinking as an integral People needing medically assisted
part of practice. alcohol withdrawal receive medication
using drug regimens appropriate to
Statement 3
the setting in which the withdrawal
People who may benefit from specialist is managed in accordance with NICE
assessment or treatment for alcohol guidance.
misuse are offered referral to specialist
alcohol services and are able to access Statement 10
specialist alcohol treatment. People with suspected, or at high
risk of developing, Wernicke’s
Statement 4
encephalopathy are offered thiamine
People accessing specialist alcohol in accordance with NICE guidance.
services receive assessments and
interventions delivered by appropriately Statement 11
trained and competent specialist staff. Adults who misuse alcohol are
offered evidence-based psychological
Statement 5
interventions, and those with alcohol
Adults accessing specialist alcohol dependence that is moderate or
services for alcohol misuse receive severe can in addition access relapse
a comprehensive assessment that prevention medication in accordance
includes the use of validated measures. with NICE guidance.
Statement 6 Statement 12
Children and young people accessing Children and young people accessing
specialist services for alcohol use specialist services for alcohol use are
receive a comprehensive assessment offered individual cognitive behavioural
that includes the use of validated therapy, or if they have significant
measures. comorbidities or limited social support,
Statement 7 a multi component programme of care
including family or systems therapy.
Families and carers of people who
misuse alcohol have their own needs Statement 13
identified, including those associated People receiving specialist treatment for
with risk of harm, and are offered alcohol misuse have regular treatment
information and support. outcome reviews, which are used to
plan subsequent care.18 Practical Mental Health Commissioning
What would a good drug and alcohol service look like? (continued)
box 7: NICE quality standard for drug use disorders13
The quality standard Statement 5
describes markers of high- People in drug treatment are given
quality, cost-effective information and advice about the
following treatment options: harm-
care that, when delivered
reduction, maintenance, detoxification
collectively, should and abstinence.
contribute to improving the
Statement 6
effectiveness, safety and
People in drug treatment are offered
experience of care for people
appropriate psychosocial interventions
with drug use disorders. by their keyworker.
Statement 1 Statement 7
People who inject drugs have access People in drug treatment are offered
to needle and syringe programmes support to access services that promote
in accordance with NICE guidance. recovery and reintegration including
housing, education, employment,
Statement 2
personal finance, healthcare and
People in drug treatment are offered mutual aid.
a comprehensive assessment.
Statement 8
Statement 3
People in drug treatment are offered
Families and carers of people with appropriate formal psychosocial
drug use disorders are offered an interventions and/or psychological
assessment of their needs. treatments.
Statement 4 Statement 9
People accessing drug treatment People who have achieved abstinence
services are offered testing and referral are offered continued treatment or
for treatment for hepatitis B, hepatitis C support for at least six months.
and HIV and vaccination for hepatitis B.
Statement 10
People in drug treatment are given
information and advice on the NICE
eligibility criteria for residential
rehabilitative treatment.Guidance for commissioners of drug and alcohol services 19
Supporting the delivery of the mental health strategy
The JCP-MH believes that commissioning Shared objective 4:
which leads to good drug and alcohol more people will have a positive
services as described in this guide will
support the delivery of No Health without
experience of care and support.
Mental Health. Addressing drug and alcohol dependency
alongside mental health problems (where
Shared objective 1: they are present) can improve the chances
More people will have of the patient experiencing a more holistic
service that should have a positive impact
good mental health.
on their health and wellbeing. A joined-
Commissioning effective drug and alcohol up approach is more likely to improve a
services will enable the identification of person’s experience of services. The use
associated mental health problems and of peer support and mutual aid can be a
ensure access to appropriate assessment, helpful means through which to engage
diagnosis treatment and support. those who use services in a contribution,
not only to recovery, but to building a
Shared objective 2: positive experience of care and treatment
more people with mental for others57.
health problems will recover.
Shared objective 5:
Many people with drug and alcohol
fewer people will suffer
problems have co-morbidity, therefore
effective services will be able to jointly
avoidable harm.
work with people, alongside mental health Assessing the risk of harm and providing
services utilising a recovery oriented a service that will have as one of its aims
approach that enables them to achieve an objective to reduce it should help to
greater independence and enhance their reduce the incidence of harm, reduce
prospects of sustained recovery. the need for future intervention such as
hospital admission and ongoing treatment,
Shared objective 3: and provide patients with strategies for
more people with mental remaining free from both harm and
health problems will have dependence on drugs and/or alcohol.
good physical health.
Shared objective 6:
Ensuring the provision of effective drug fewer people will experience
and alcohol services will enable those
stigma and discrimination.
people who have co-morbid mental health
problems to have their physical health By commissioning services that recognise
needs properly assessed and treated. the connections and linkages between
The identification of these needs and drug and alcohol misuse and mental health
action to address them will result in problems, commissioners will be actively
improved physical health. addressing the stigma and discrimination
that many people experience as a
consequence of their addiction and/or
mental health needs.20 Practical Mental Health Commissioning
Drug and Alcohol
Expert Reference Group Members
• Owen Bowden-Jones • Jonathan Campion Development process
(ERG Chair) Director for Public Mental Health This guide has been written by a group
Consultant Psychiatrist and Lead and Consultant Psychiatrist of drug and alcohol service experts,
Clinician for Club Drug Clinic South London and Maudsley in consultation with patients and carers.
Central and North West London NHS NHS Foundation Trust Each member of the Joint Commissioning
Foundation Trust Panel for Mental Health received drafts
• Kostas Agath of the guide for review and revision, and
• Andre Geel Medical Director advice was sought from external partner
Chartered & Consultant Addaction organisations and individual experts. Final
Clinical Psychologist revisions to the guide were made by the
Central and North West London • Lesley Andrews Chair of the Expert Reference Group in
NHS Foundation Trust Head of Service collaboration with the JCP’s Editorial Board
Kent Drug and Alcohol Action Team (comprised of the two co-chairs of the
• Chris Fitch JCP-MH, one user representative, one
Research and Policy Fellow • Martin Barnes carer representative, and technical and
Royal College of Psychiatrists Chief Executive project management support staff).
Drug Scope
• Diane Goslar Acknowledgements
Service user consultant • Mick Davies This guide was led and written by
Regional Manager
Steve Appleton, Owen Bowden Jones,
• Emily Finch Huntercombe Group
and Chris Fitch.
Clinical Director
South London and Maudsley NHS • Nuzhat Anjum Steve Appleton
Foundation Trust Head of Public Health Commissioning
NHS Redbridge Steve Appleton is the Managing Director
• Ellie Gordon of Contact Consulting, a specialist
Clinical and Transformational Lead • Pete Burkinshaw (Observer) consultancy and research practice working
for NHS Continuing Healthcare Skills and Development Manager at the intersection of health, housing and
North Yorkshire and Humber National Treatment Agency social care. He has held operational and
Commissioning Support Unit strategic posts in local authorities and
• William Butler the NHS, with a specialist interest in the
Chair (at time of guide development) health, housing and social care needs
Substance Misuse Skills Consortium of people with mental health problems,
substance misuse needs, learning disability,
older people and offender healthYou can also read
