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Drug and alcohol services - Joint Commissioning Panel for Mental Health www.jcpmh.info
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
Drug and alcohol services - Joint Commissioning Panel for Mental Health www.jcpmh.info
Joint Commissioning Panel
for Mental Health
www.jcpmh.info

 Co-chaired by:

 Membership:
Drug and alcohol services - Joint Commissioning Panel for Mental Health www.jcpmh.info
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
Drug and alcohol services - Joint Commissioning Panel for Mental Health www.jcpmh.info
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.
Drug and alcohol services - Joint Commissioning Panel for Mental Health www.jcpmh.info
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.
Drug and alcohol services - Joint Commissioning Panel for Mental Health www.jcpmh.info
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
Drug and alcohol services - Joint Commissioning Panel for Mental Health www.jcpmh.info
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
Drug and alcohol services - Joint Commissioning Panel for Mental Health www.jcpmh.info
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
Drug and alcohol services - Joint Commissioning Panel for Mental Health www.jcpmh.info
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.
Drug and alcohol services - Joint Commissioning Panel for Mental Health www.jcpmh.info
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-2010
Guidance 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 homelessness
14   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 interventions
Guidance 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 needs
16   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 health
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