Health & Adult Social Care Select Committee
26 September 2019
Substance Misuse Services in West Sussex
Report by Director of Public Health

Summary Following a full tendering process, a five + two year contract for a Health, Wellbeing and Recovery Service was awarded to the national health and social care charity, Crime Reduction Initiatives (CRI) which has since been re-branded Change, Grow, Live (CGL). The new service commenced in May 2016. In June 2017, the former Environment & Community Services Select Committee (ECSSC) received an update on the procurement and service implementation. ECSSC asked that there was a review of the new service approximately 18 months after its implementation and recommended that this was brought for scrutiny to the Health and Adult Social Care Select Committee. The focus for scrutiny The Health and Adult Social Care Select Committee is asked to consider the progress made regarding the effectiveness of service arrangements and performance relating to substance misuse services in West Sussex and based on the high level Public Health Outcome Framework (PHOF) outcomes consider whether the service is achieving the necessary health outcomes for this cohort of the West Sussex population. The Chairman will summarise the output of the debate for consideration by the Committee.

1.	Background and Context

In 2014/15 a large scale review of substance misuse services had been undertaken which resulted in the drafting of a new service design and service specification. A contract was awarded to the national health and social care charity CRI, since re-branded CGL. The new service commenced in May 2016.

The service is an all age, county-wide service working with individuals who misuse a range of substances: alcohol, illegal drugs, novel psychoactive substances, over the counter medication. The service provides:

Harm reduction and needle syringe provision

Engagement and early interventions

Structured treatment which can include specialist prescribing support

Assessment for onward referral to residential support (detoxification and rehabilitation)

Blood Borne Virus testing and vaccination

Education, training and employment support

Peer mentoring

Support to families and carers

1.4	The Young People’s Team in the service works with people up to 25 years, and the Adult Team(s) works with people 25+ years and with no upper age limit.

2.	Assumptions of Prevalence - Alcohol and Drug Misuse

2.1	There are few information sources which capture data relating to population-level prevalence of alcohol and/or drug misuse. Applying prevalence from national surveys and research to the West Sussex population:-

It is estimated that between 1,400 and 4,100 West Sussex residents use opiates and/or crack with 70% being aged 35 years or older.

5,500 to 9,300 residents are estimated to have a dependency on alcohol, and potentially in need of specialist treatment.

2.2	The Public Health England Risk Factors Intelligence (RFI) team has used data from the Health Survey for England, collected between 2011 and 2014, to estimate that:

23.7% of adults (over 18) in West Sussex are drinking above the lower risk limits of 14 units per week,

14.4% of adults (over 18) engaged in binge drinking on their heaviest drinking day in the past week.

Both of these figures are similar to the England average.

Estimates of Alcohol Dependence in England based on the Adult Psychiatric Morbidity Survey 2014 suggest that 2,710 children live with an adult with alcohol dependency.

3.	Local Performance

West Sussex County Council managers have access to data collated by the National Drug Treatment Monitoring System (NDTMS). This is available on www.ndtms.net. It provides a view of the most up to date performance.

3.2	In addition, West Sussex County Council receives quarterly reports direct from the service on national and locally agreed metrics. Service performance reports are for the Young People’s Service and for the Adults’ Service. The commissioner shares six monthly performance with district and borough councils at a local level.

3.3	Public Health England use three key measures of treatment outcomes for individuals 18+ years:

Number and proportion of opiate drug users that leave drug treatment successfully who do not re-present to treatment within 6 months.

Number and proportion of non-opiate drug users that leave drug treatment successfully who do not re-present to treatment within 6 months.

Number and proportion of alcohol users that leave alcohol treatment successfully who do not re-present to treatment within 6 months.

3.4	In West Sussex there has been improvement in all three of these measures, with significant improvement in treatment outcomes for opiate drug users and alcohol users. (See Appendix 1, Figures 1-4).

3.5	Improvements have been sustained without a reduction in numbers being treated. (See Appendix 1, Table 1).

3.6	Prior to new service start, PHE had deemed West Sussex a ‘priority area’. This meant that when using public health dashboard composite measures and benchmarking comparison with the top quartile range of comparator local authorities, West Sussex was under-performing against the key indicators. In comparison with similar authorities West Sussex was relatively lowly ranked on the three performance measures, but this has improved since 2017 (see Appendix 1, Tables 2 and 3). In June 2019, PHE noted the sustained progress and advised that services now achieved treatment outcomes within an acceptable range. West Sussex remains a priority area for reducing drug-related deaths.

3.7	Commissioners continue to work closely with CGL to mitigate the impact of increasing demand. In 2019 areas of focus have included: a county-wide capacity mapping exercise; publication of service trajectories and targets with renewed focus on reviewing caseloads to ensure those individuals ready to exit treatment are not remaining on caseloads for longer than required; review and refresh of targets in sub-contracts.

3.8	Caseload reviews had identified that many people are presenting to treatment for alcohol when they are seriously unwell, i.e., very late. This supported the Council’s local strategic intention to effectively address alcohol need in West Sussex and to invest a further £400,000 of Public Health Grant in alcohol early intervention services. The new early intervention services are listed in Appendix 2. Their focus is to offer support to people drinking at risky but not dependent levels, and to prevent problems from escalating. Objectives are to divert some people away from needing specialist support in the future, and to ensure that those who need treatment are less advanced when they present to specialist services.

4.	Drug Poisoning Deaths

Each year the Office for National Statistics (ONS) publishes the number of drug poisoning deaths, sometimes referred to as drug-related deaths. These are identified according to the code (as defined in the International Classification of Diseases) used to describe the underlying cause of death; data are related to the year in which a death is registered.

In August 2019, ONS released the most recent round of figures. Nationally these are certainly very concerning, as set out at the link below:

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathsrelatedtodrugpoisoningenglandandwalesreferencetable

The link to the local authority level is here:

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/drugmisusedeathsbylocalauthority

4.3	This provides the following information:

In the period of 2016-2018 there were 119 deaths with an underlying cause of drug poisoning. Of these 119 deaths 82 were further classified as “drug misuse deaths”. These are deaths due to drug abuse or drug dependence or where the underlying cause of drug poisoning relates to a substance controlled under the Misuse of Drugs Act 1971. In the previous period, i.e. between 2015-2017 there were 124 deaths, 82 were drug misuse deaths.

In West Sussex, the age standardised rate (per 100,000 population) has declined slightly in recent years against the national continuing upward trend (See Appendix 3 - Figure 5). The West Sussex rate is below the national rate.

The majority of drug poisoning deaths are classified as drug misuse. In 2016-2018, 69% of deaths were classified as misuse (See Appendix 3 – Figure 6).

4.4	Locally deaths of people who are known to treatment services, as a current or recent service user at time of death, are monitored. The service completes for each person a Death Investigation Report and submits the Report and Learning/Recommendations to the commissioner for review. These deaths may be due to any cause, including causes related to drugs and drug misuse but also cancer, accidents etc.

4.5	The service, commissioning team and Public Health leads continue to work with PHE on a shared priority to reduce further deaths in treatment. In 2019/20, work will be shaped by the findings and recommendations of the recently completed Public Health Audit into Drug Related Deaths. See next section.

5.	Local Drug Related Deaths Audit

Following a rise in drug-related deaths, staff in the West Sussex Public Health and Social Research Unit worked with the local Coroner’s office to undertake an audit of drug-related deaths. This involved reviewing individual files of 123 deaths registered in 2015, 2016 and 2017.

A range of factors were noted including the circumstances of death, toxicology data, mental health and service history. Over eighty columns of variables, including twelve free-text columns were generated.

Of the total 123 cases, 39 reviewed (32%) were of people who had been known to the local treatment provider. A report of this audit is being drafted and will be disseminated later this year. The cases reviewed were highly complex and person specific. Headline findings have already been shared with service managers and the commissioner, with a series of questions for further discussion.

An important service development has been the delivery of specialist overdose training and provision of Naloxone which is a safe and effective antidote to opiate overdose and an important tool in tackling drug related deaths. Information was provided to ECSSC in 2017. Appendix 4 gives an update, broken down by geographical area.

6.	External Bids which support wider treatment outcomes

West Sussex has had success in securing monies from PHE in bidding rounds. These are listed for information in Appendix 5. Although not directly related to the focus for scrutiny in this paper, the bids have brought valuable income to wider partnership objectives and treatment.

7.	Resources

The cost for the service must be met within the available budget. The 2019/20 contract price for the service is £5,109,778. There is Police and Crime Commissioner Income of £104,000 but other than this the service is funded entirely by the Public Health Grant.

In 2017/18, the service was required to find £75,000 savings which was achieved through a reduction in posts.

8.	Issues for consideration by the Select Committee

The Health and Adult Social Care Select Committee is asked to consider the progress made regarding the effectiveness of service arrangements and performance relating to substance misuse services in West Sussex and based on the high level PHOF outcomes consider whether the service is achieving the necessary health outcomes for this cohort of the West Sussex population.

9.	Consultation

These matters have not been part of public consultation. The service reports on service user consultations undertaken and actions taken. In drafting this paper, advice has been taken from subject matter experts and technical experts in the Public Health Directorate.

10.	Risk Management Implications

The service is operating at stretch but it is meeting its contractual expectations and service requirements. There is sustained progress in meeting treatment outcomes.

11.	Other options considered

11.1	Not applicable.

12.	Equality Duty

The service has a network of Inclusion Champions working through the organisation to share Equality, Diversity and Inclusion best practice. The service provides information on whom they employ (paid staff and volunteers) and who uses the service, and their outcomes and experiences.

13.	Social Value

Central to the service approach is building resilience and recovery from drug/alcohol dependency, which can contribute towards stronger and effective communities.

14.	Crime and Disorder Implications

Ensuring continuity of the service and the opportunity to further improve performance and quality contributes to the Council’s responsibility to minimise crime and anti-social behaviour.

15.	Human Rights Implications

It is important that the service is accessible and delivers quality provision to people from across different equalities groups.

Anna Raleigh

Director of Public Health

Contact:	Philippa Gibson, Senior Commissioning Manager

Philippa.gibson@westsussex.gov.uk

Appendix 1 Latest Performance Data

Figure 1	Percentage of opiate drug users that left drug treatment successfully who do not re-present to treatment within 6 months. West Sussex Aug 2015 to June 2019

Figure 2	Percentage of non-opiate drug users that left drug treatment successfully who do not re-present to treatment within 6 months. West Sussex Aug 2015 to June 2019

Figure 3	Percentage of alcohol users that left drug treatment successfully who do not re-present to treatment within 6 months. West Sussex Aug 2015 to June 2019

Source: Data extracts from the National Drug Treatment Monitoring System (NDTMS)

Figure 4	Percentage of alcohol users that left drug treatment successfully who do not re-present to treatment within 6 months. West Sussex Aug 2015 to June 2019

Table 1	Number of People in Treatment

West Sussex - Annual Data 2001/2 to 2017/18

2009/10	2010/11	2011/12	2012/13	2013/14	2014/15	2015/16	2016/17	2017/18
Opiate	1,207	1,157	1,136	1,152	1,132	1,121	1,087	1,135	1,139
Non-opiate only	182	134	156	186	160	138	141	229	256
Alcohol only	1,012	770	772	764	707	627	627	803	939
Non-opiate & alcohol	336	296	293	250	210	204	201	267	392

Source: Data extracts from the NDTMS

Table 2	Performance June 2017 and June 2019

% of users who are treated successfully and have not represented to services within 6 months
Opiate Users	Non-opiate	Alcohol
PHE Published data (relates to 2017)	5.9%	28.1%	29.8%
Latest available data (June 2019)	7.8%	31.0%	36.0%

Table 3	Estimated Ranking of West Sussex amongst CIPFA Statistical Neighbours

Ranking (out of 16 LAs)	% of users who are treated successfully and have not represented to services within 6 months
Opiate Users	Non-opiate	Alcohol
PHE Published data	15th	14th	16th
Latest available data (June 2019)*	5th	10th	7th

*this is an estimated ranking. Figures may be revised on PHE publication

Appendix 2 Early Intervention Services, Alcohol.

£400,000 of Public Health Grant has been invested in implementing evidence-based alcohol early intervention services countywide to meet the needs of adults who are drinking at levels putting them at increasing risk or higher risk of harm.

These are quantifiable categories which denote drinking at levels hazardous or harmful to health but not physically dependent upon alcohol.

The early intervention services are:

Opportunistic screening and Brief Advice in 50 community pharmacies across the county. 720 people screened January – August 2019 of whom 307 are drinking at risky levels (14 of whom may be alcohol dependent). All offered appropriate advice and signposting to support.

‘DrinkCoach’ Digital Alcohol Early Intervention Service providing a web-based alcohol test and Skype coaching, with sessions available at evenings and weekends making the service convenient for working people or otherwise not willing or able to attend face to face appointments.

Dedicated Alcohol Advisors, based within the West Sussex Wellbeing Programme offering face to face alcohol early interventions.

All services will be reviewed with independent evaluations commissioned for the DrinkCoach and Wellbeing Services.

Appendix 3 Drug Poisoning Deaths

Figure 5	Age-standardised mortality rate for deaths related to drug poisoning

Rate per 100,000 Population

West Sussex, South East and England 2001-2003 to 2016-2018

Source: Office for National Statistics (ONS)

Figure 6	Number of Drug Deaths broken down by Drug Misuse/Non-drug misuse

West Sussex 2001-2003 to 2016-2018

Source: Office for National Statistics (ONS)

Appendix 4 Service Issue of Naloxone Kits, Broken Down by Area

2016-17	2017-18	2018-19	2019-20 to date	Total
Adur	21	20	23	8	72
Arun	148	132	135	43	458
Chichester	64	43	71	16	194
Crawley	97	129	146	44	416
Horsham	37	41	53	27	158
Mid Sussex	51	37	57	21	166
Worthing	157	161	175	34	527
Pharmacies	22	28	7	6	63
Total Issued	597	591	667	199	2054

Appendix 5 West Sussex – successful bids to PHE 2015-19

Year Awarded	Capital	Revenue	Lead Service Provider	Summary
2015	£675,000	£0	ANA	ANA Works Supported Housing. Provision of safe, drug and alcohol free supported accommodation - 2 properties in Horsham.
2015	£200,000	£0	Worthing Churches Homeless Project (WCHP - now Turning Tides)	WCHP Oxford House - Worthing
2016	£23,704.84	£0	Fit Body Fit Mind	Refurbishment of gym in Littlehampton.
2016	£31,380.00	£0	Stonepillow	Stonepillow Learning & Training Project (Revive) Social enterprise supporting people leaving drug and alcohol treatment.
2016	£280,000	£0	WCHP(now Turning Tides)	Purchase of a HMO / Recovery property in Littlehampton.
2017	£200,000	£0	WCHP(now Turning Tides)	Purchase of a HMO / Recovery property in Littlehampton.
2019	£188,465	£0	Stonepillow	Redevelopment of a resource hub in Bognor Regis for rough sleepers and vulnerably housed.
2019	£0	£422,045	CGL	Supporting Alcohol Dependent Parents and their Children Therapeutic service for children Support for expectant parents
TOTAL	£ 1,598,549.84	£422,045
Shortlisted 2019 Outcome to be confirmed	£0	£359,460	Stonepillow	Rough Sleeping Grant: Testing models of access to health care

2014 Adult Psychiatric Morbidity Survey includes questions relating to alcohol use

Hay, G., Gannon, M., MacDougall, J., Millar, T., Eastwood, C. and McKeganey, N. (2006) Local and national estimates of the prevalence of opiate use and/or crack cocaine use (2004-05). In Singleton, N., Murray, R. and Tinsley, L. (Eds.) Measuring different aspects of problem drug use: methodological developments. Online Report OLR 16/06. London. Home Office.

West Sussex statistical comparators are Cambridgeshire, Devon, East Sussex, Essex, Gloucestershire, Hampshire, Kent, North Yorkshire, Northamptonshire, Oxfordshire, Somerset, Staffordshire, Suffolk, Warwickshire, Worcestershire