item no: 6 · treatment services within tameside are commissioned and delivered. 1.6 further...

ITEM NO: 6

Report To: EXECUTIVE CABINET

Date: 22 October 2014

Executive Member / Reporting Officer:

Cllr Lynn Travis (Executive Member – Health & Neighbourhoods)

Angela Hardman (Director of Public Health)

Subject: TRANSFORMING SUBSTANCE MISUSE SERVICES IN TAMESIDE

Report Summary:

The report provides an overview of proposals to transformationally redesign Drug and Alcohol community-based treatment and recovery services in Tameside in a way which:

Improves local health outcomes.

Enhances service quality, effectiveness and efficiency.

Reduces long term expenditure.

Recommendations: (1) That approval is given to: (i) decommission all current commissioned Drug

and Alcohol Treatment services and commission a single prime provider to develop and deliver a whole system approach.

(ii) undertake a procurement exercise using the open procedure to let a 10 year contract with safeguards as highlighted in 6.6.

(iii) delegate to the Director of Public Health in consultation with the Executive Director – Governance (Borough Solicitor) and Executive Director Finance authority to approve the evaluation criteria and the procurement documentation.

(2) That Cabinet affirm their aspiration for the anticipated budget for the services as detailed in paragraph 6.7 of the report but note that the annual budget each year will be subject to the Councils annual budget setting process.

Links to Community Strategy: The Community Strategy 2012-22 (and the Corporate Plan 2013-18) outlines the priorities for improving the borough of Tameside.

This proposal directly links to the Tameside Sustainable Community Strategy objective of ‘Healthy Tameside’.

It also contributes to the ‘Safe Tameside’ and ‘Prosperous Tameside’ objectives.

Policy Implications: None

Financial Implications:

(Authorised by the Borough Treasurer)

The financial modelling involves an initial increase in funding of £ 0.200 million per annum for two years when compared to the original 2015/16 budget. A long term reduction in expenditure will then follow alongside a planned reduction in demand through a transformational change in the way that services are delivered.

The contractual changes will result in a reduction in expenditure of £6.292 million over the ten year period when compared to a recurrent ten year annual budget at the level of service commissioned in 2014/15.

The commissioned services are currently financed from the ringfenced Public Health grant received by the Council. They will continue to be financed via this resource throughout the duration of the proposed long term contract. The contractual sum will also be included within the Council’s annual budget approval process.

It is essential that the contract includes an appropriate termination clause to ensure the Council is not committed to expenditure should priorities change and/or if there are significant reductions to Public Health grant funding allocations received by the Council during the ten year contractual period.

It should be noted that the 2015/16 public health funding allocation has been confirmed at £13.463 million but no details are available beyond this date.

The associated contract expenditure will be incorporated into future financial plans and monitored accordingly on a recurrent basis.

Legal Implications:

(Authorised by the Borough Solicitor)

Since 1 April 2013, under the Health and Social Care Act 2012, Local Authorities have a statutory duty to take steps to improve the health of their population. This includes responsibilities for commissioning a wide range of services, including Drugs and Alcohol treatment services.

A proposed contract term of 10 years is not unreasonable given the scope and scale of the transformation required on this project. The Council’s position will be safeguarded through the terms of the contract to give it flexibility to vary funding and services so transformation can be achieved.

An indicative budget for the term of the contract will enable tenderers to understand the Councils aspirations during the procurement phase whilst retaining flexibility for the Council in times of uncertainty caused by ongoing funding reductions. Whilst public health funding is currently ring-fenced the position over the long term is difficult to forecast.

The procurement will voluntarily follow the open procedure via the publication of a notice in OJEU. It will be necessary to determine robust evaluation criteria to enable the Council to identify the most economically advantageous tender. It is essential that officers from finance and legal services are involved in the procurement process as it progresses.

Risk Management: The risks of failing to redesign the service are that:

Tameside will continue to experience poor health outcomes.

Associated costs within the Public Sector will continue to rise.

The risks associated with the project are mitigated in line with the attached Risk Register (Appendix 4)

Access to Information: The background papers relating to this report can be inspected by contacting David Boulger, Strategic Public Health Manager.

Telephone: 0161 342 3402.

e-mail: [email protected]

mailto:[email protected]

1. BACKGROUND 1.1 Over the previous 12 months, both an internal review and independent external review of

Drug and Alcohol Treatment Services in Tameside have taken place. 1.2 Both have found that the current Drug and Alcohol Treatment provision within Tameside is

not fit for purpose, leading to poor health outcomes and increased cost across the Public Sector and within the wider local economy.

1.3 Both have found that the current Drug and Alcohol Treatment provision is not commensurate

with the local and national strategic context and does not adequately meet the needs of local people and the local community.

1.4 Further details of the review findings can be found within the Supporting Document entitled

‘Transformation Paper # 1 – The Case for Change’ (Appendix 2). 1.5 There is an aspiration to undertake transformational change of the way Drug and Alcohol

Treatment services within Tameside are commissioned and delivered. 1.6 Further details of the proposed changes can be found in the Supporting Document entitled

‘Transformation Paper # 3 – A Pathway to Change’ (Appendix 3) 1.7 At a Greater Manchester level, the endorsement of a city region Alcohol Strategy has also

provided a context within which to undertake a wider strategic review of our local approach to tackling alcohol related harm.

1.8 The Greater Manchester Alcohol Strategy has 3 objectives:

Reduce alcohol-related Crime, Anti-Social Behaviour and Domestic Abuse;

Reduce alcohol-related health harms; and

Establish diverse, vibrant and safe night-time economies. 1.9 At a local level we have commenced an overarching review of our strategic approach to

Alcohol, underpinned by the GM Strategy and under the leadership of Cllr Lynn Travis and the Strategic Alcohol Group.

1.10 The transformation of Drug and Alcohol treatment services provides one facet of a wider

programme of change and improvement. 2. COUNCIL LEGAL OBLIGATIONS 2.1 Since 1 April 2013 as a result of the Health and Social Care Act 2012, Local Authorities have

a statutory duty to take steps to improve the health of their population. This includes responsibilities for commissioning a wide range of services, including Drugs and Alcohol treatment services.

NHS Constitution

2.2 When councils are undertaking their public health functions they must have regard to the NHS Constitution. The constitution sets out rights for patients, public and staff. It outlines NHS commitments to patients and staff, and the responsibilities that the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively. All NHS bodies and private and third sector providers supplying NHS services are required by law to take account of this constitution in their decisions and actions.

2.3 Local authorities have a statutory duty to have regard to the NHS Constitution when exercising their public health functions under the NHS Act 2006. In particular, this means that when making a decision relating to public health functions, a local authority must properly consider the Constitution and how it can be applied, in so far as it is relevant to the issue in question.

2.4 This does not mean that local authorities must apply the Constitution in the same way as

NHS bodies do – they can consider the particular context in which they are operating. In some cases, it will be clear that the local authority is exercising a specific public health function under the NHS Act 2006, such as the weighing and measuring of school children, providing contraceptive and other sexual health services or providing NHS health checks. In other cases, the question will be whether the provision of that service is a step which the local authority is taking under its duty in section 2B of the NHS Act 2006 – i.e. its duty to take such steps as it considers appropriate for the purpose of improving the health of the people in its area.

2.5 Local authorities should also consider how to make sure that the people who use those

services (and the wider population of those who might) know that the Constitution exists as a clear guide to the standard of service they should expect. Accordingly as part of any service review and/or procurement there will be consideration of whether the provision is compliant with the NHS constitution. As the current contractual arrangements were put in place by the Primary Care Trust there is a presumption that the arrangements are compliant with the Constitution. The procurement exercise will incorporate reference to and seek observance to the NHS constitution.

3. CONSULTATION AND STAKEHOLDER ENGAGEMENT 3.1 Extensive stakeholder engagement, including service users and their families, has been

undertaken as part of both the independent external review and the internal review. 3.2 This report and the appendices have been co-designed by an Alcohol and Drugs

Transformation Group consisting of:

Tameside Council – Public Health;

Tameside Council – Poverty and Homelessness;

Tameside Council – Neighbourhoods and Communities;

Tameside Council – Commissioning Support;

Tameside and Glossop Clinical Commissioning Group;

GP Clinical Leads;

Greater Manchester Police;

Greater Manchester Probation Community Rehabilitation Company;

Pennine Care NHS Trust;

Lifeline / Branching Out. 3.3 Principles of co-design and collaboration will continue to underpin the tender process,

transition phase, and future service delivery. 3.4 It is acknowledged that public health services are within scope of the Care Together

programme. The Tameside and Glossop Clinical Commissioning Group have been involved in the co-design. As part of the proposed tender exercise, it is proposed to include reference to the Care Together programme and include provision within the contract to novate the contract to the Integrated Care Organisation if required.

4. OPTIONS APPRAISAL 4.1 Following the independent external review and the internal review, 3 primary options were

considered:

Option 1: Remain ‘as is’ and continue to commission a range of individual services.

Option 2: Decommission current services and commission 2 new services:

(i) Children and Young People aged up to 25 (ii) Adults aged over 25

Option 3: Decommission current services and commission a single provider to deliver all Drug and Alcohol Treatment Services through direct delivery and/or sub-contracting.

4.2 All parties involved in the review and consultation felt that Option 1:

Would not address the challenges that exist within the current system;

Would not improve health outcomes or meet the needs of service users, their families, or the wider Tameside community;

Would not improve effectiveness and efficiency;

Would not reduce long-term demand across the Public Sector. 4.3 Option 2 would address some of the challenges identified within the review, but is faced with

four drawbacks:

It would not fully enable the development of a coherent system and would retain a transition ‘barrier’ between services for children and services for adults;

It would not fully enable a whole family approach to Alcohol and Drug use in line with wider Public Service Reform work around Complex Dependency;

It would not maximise the opportunities for effectiveness and efficiency. 4.4 Option 2 also faces a more practical problem relating to the procurement process. Due to

the nature of the current system, all of the TUPE risk would fall within the remit of the adult contract, whilst a greater proportion of the financial envelope could be allocated against the Children and Young Person’s contract. This could make the Adult contract financially unviable for any potential prime providers.

4.5 Option 3 would:

Maximise the opportunities for transformational systemic change;

Create a more coherent, effective and efficient system;

Create opportunities for the development and delivery of a wider range of evidence-based interventions;

Maximise the opportunities for additional inward investment from a Prime provider 4.6 The partners identified in 3.2 unanimously agree that Option 3 would be the preferred option

and recommends this to the Executive Cabinet. 5. TERM OF THE CONTRACT

5.1 Fundamentally transforming Substance Misuse services in a manner which achieves exceptional outcomes, whilst maximising financial savings requires a long term approach delivered in incremental phases.

5.2 It is proposed, and strongly supported by independent experts, current service providers, and the multi-agency task and finish group, that a 10 year contract be awarded. A 10 year approach is proposed for the following reasons:

The scale of the challenge is significant, complex and inter-generational and reforming

the system to meet it will require a long term approach. Creating a recovery-orientated system which enables meaningful and sustained long-

term recovery requires the establishment of enhanced pathways which promote the attainment and retention of recovery capital over a significant timeframe.

The budget proposals include a frontloading of additional investment, followed by long

term budget reduction. A shorter contract would serve as a disincentive for the provider to undertake the required transformational changes as they would not necessarily be expected to manage the long term budget reductions. This could jeopardise the overall project and the likelihood of the Council maximising the long term savings opportunities.

A long term contract will maximise the opportunities for a prime provider to bring in

additional investment which adds value to the contract allocation and will equip the provider with the impetus and confidence to deliver truly transformational change.

Shifting resources away from the maintenance and management of a long term cohort

of individuals with complex needs takes time to ensure that ethical, clinical and service needs are met.

The transformation of treatment services alone is not sufficient and is only one element

of a long term strategy which will also focus upon universal provision / wellness, social norming and cultural acceptability of harmful alcohol use, public service reform / complex dependency, removing the stigma associated with treatment and recovery, disrupting the supply chain for illegal drugs and illicit alcohol, and reducing the demand for drugs through an increased awareness of risk.

5.3 The approach being proposed has also been identified by representatives of the Advisory

Council on the Misuse of Drugs and a number of large Drug and Alcohol Charities as being a potential national exemplar of good practice

6. FINANCIAL IMPLICATIONS 6.1 The 2014/15 budget for Drugs and Alcohol treatment in Tameside is £4.292 million. 6.2 The current proposed Drug and Alcohol budget for 2015/16 is £3.843 million. 6.3 Reducing the funding allocated to Drug and Alcohol treatment without initial transformational

change would be counter-productive and would lead to poorer health outcomes and increased costs across the Public Sector.

6.4 Investment in Drug and Alcohol Treatment generates significant savings across the Public

Sector and economic benefits within society. 6.5 As such, it is proposed to initially increase the funding which is allocated for Drug and

Alcohol Treatment, before bringing it back in line with the original 2015/16 baseline, and then making future cost savings through the reduction in demand and the enhanced effectiveness and efficiency that will be enabled through a transformed operating model.

6.6 Delivering complex transformational change of this nature requires time and it is proposed that the budget and contract are awarded on a 10 year basis, with the following safeguards to mitigate the associated risk:

Inclusion of a 12 month no fault break clause;

Making the uplift of funding in years 1 and 2 dependent upon the attainment of agreed indicators of improvement;

Provision of robust and meaningful performance management;

Inclusion of a clause within the contract confirming that the proposed budget is aspirational and will be subject to annual review under the Council’s normal budget setting process.

6.7 The overall budget proposals are as follows:

Year

Budget

£ million

Comparison to Baseline £ million

2015/16 (Original Budget) 3.843 N/A

2015/16 (Proposed Budget) 4.043 + 0.200

2016/17 4.043 + 0.200

2017/18 3.843 0

2018/19 3.843 0

2019/20 3.643 - 0.200

2020/21 3.643 - 0.200

2021/22 3.443 - 0.400

2022/23 3.443 - 0.400

2023/24 3.343 - 0.500

2024/25 3.343 - 0.500

Total 36.630 - 1.800

6.8 The total investment will be £36.630 million under these proposals. This represents:

A reduction in expenditure of £1.8 million during the ten year period when compared to a recurrent annual budget allocation at the original 2015/16 commissioned level of service.

A reduction in expenditure of £6.292 million during the ten year period when compared to a recurrent annual budget allocation at the 2014/15 commissioned level of service.

6.9 Further details regarding the budget, contract length and rationale for reducing long term

expenditure are included in Appendix 2. 7. PROCUREMENT 7.1 The services concerned are classified as part B services under the Public Contract

Regulations. Whilst there is no formal requirement to tender the contract through the Official Journal of the European Union (OJEU), the Council will advertise the contract through OJEU to maximise publicity.

7.2 It is proposed to advertise the contract using the open procurement route. This means that

the Council will make available to any economic operator who requests one, a copy of the invitation to tender document. The Council will then have to evaluate any qualifying tenders received. This will be done by applying selection and award criteria to find the most economically advantageous tender.

7.3 Given the specialist nature of the services it is not anticipated that there will be excessive submissions. Whilst the restricted procedure would ensure that a more manageable tender exercise can take place, this route which involves a pre qualification questionnaire and ranking economic operators in order and inviting a predetermined number to submit a tender, this route potentially would result in a missed opportunity for innovation as it limits the number of tenders received.

7.4 It is proposed that the tender timescales are as follows:

Commencement of Tender Process – November 2014

Award of Contract – March 2015

Go Live – August 2015 7.5 Officers will continue to develop and the tender documentation and contract which will be

used during the procurement. This will include the development of a robust evaluation criteria against which all tenders received will be evaluated. The contract will need to include provision for the safeguards detailed in paragraphs 3.4 and 6.6.

8. RISKS 8.1 As part of the review of Drug and Alcohol Treatment Services a Risk Assessment has been

undertaken by the Strategic Public Health Manager. A copy is contained in Appendix 4. 8.2 The risks associated with the project will be kept under constant review and in consultation

with key stakeholder’s appropriate action taken. 9. EQUALITY IMPACT 9.1 An Equality Impact Assessment has been undertaken as part of the review. A copy is

contained in Appendix 1. 9.2 The EIA has considered the following protected characteristics: Disability, Racial Equality,

Gender Equality, Sexual Orientation, Gender Reassignment, Age Equality, Religion and belief, Pregnancy and maternity, Marriage and civil partnership. It is not anticipated that the proposals would disproportionately affect any of the above protected characteristics. On the contrary, it is envisaged that the proposals will enhance the service offer and ensure that services are better able to respond to the needs of specific groups who may be under-represented or poorly served by the current offer. It is specifically felt that these changes will enhance the service provided to young people aged 18 to 25.

10. RECOMMENDATIONS 10.1 As detailed at the front of this report.

Equality Impact Assessment Form

Subject Transformation of Substance Misuse services in Tameside

Service / Business Unit Service Area Directorate

Community, Adults and Health Services

Adults/Children’s Services

Communities, Children’s, Adults and Health

EIA Start Date (Actual) EIA Completion Date (Expected) Completion Date (Actual)

2/9/2014 15/9/2014 To be completed by Corporate Performance

Lead Contact / Officer Responsible

David Boulger/Francine Cooper/Nick Ellwood

Service Unit Manager Responsible

David Boulger

EIA Group (lead contact first)

Job title Service

David Boulger Strategic Manager Public Health Services

Nick Ellwood Planning & Commissioning Officer Commissioning & Performance

Francine Cooper Planning & Commissioning Officer Commissioning & Performance

SUMMARY BOX

Tameside faces significant and costly challenges in relation to the misuse of Drugs and Alcohol within the Borough, which affect the entire system and in particular Health, Social Care, Criminal Justice, Welfare and the local Economy. Whilst there are some pockets of good practice, including recovery-orientated provision, the current system as a whole is no longer effective, efficient, or fit for purpose. The existing system is neither congruent with the national strategic context nor the needs of local people. Transformational change is required to fundamentally reshape the way that Drug and Alcohol Treatment Services are delivered in Tameside. This change will see the emergence of a recovery-orientated system for all those who are dependent on Drugs or Alcohol, and for those whose Drug or Alcohol use is harmful or hazardous. Our aspiration is for excellence, as this is the only way we can ensure that Drug and Alcohol use ceases to cause significant harm within Tameside. Between 1st January and 14th July 2014, Tameside Council utilised an Independent Consultancy, Red Quadrant, to undertake a wide ranging analysis of the current extent of Drug and Alcohol use in Tameside and the effectiveness of the current service provision. Their key findings can be found in transformation papers #1: “The Case for Change” and #3 “A Pathway to Change” which are both attached.


Section 1 - Background

BACKGROUND

The current Drug and Alcohol Treatment system within Tameside is no longer fit for purpose and requires transformational redesign. The local approach to reducing drug dependency is rooted in a bygone era and is ill-equipped to respond to changing patterns of drug misuse and associated risks. The local approach to reducing alcohol dependency is insufficient to tackle the scale of the issue and is limited in scope. Whilst there are some pockets of good practice, the current treatment system is fragmented and lacks a meaningful and coherent focus on recovery, prevention or early intervention. Overall, the current Drug and Alcohol Treatment System in Tameside does not meet the needs of the Tameside Community. As a result, the costs of substance misuse related harm have increased exponentially over the past decade and will continue to do so unless remedial action is taken. Tameside is not alone in experiencing these challenges, but the level of harm that currently exists within Tameside is disproportionately high. At a local level, the current system could not sufficiently meet the aspirations of the Health and Wellbeing Board or Care Together. The national strategic environment, with a renewed emphasis on Recovery and Whole System reform, provides an opportunity to adopt a transformational approach to redesigning Substance Misuse services in Tameside. At present, the Tameside approach is not congruent with the expectations that exist at a national level, but there is no reason why this cannot be remedied. The emerging evidence base in relation to Recovery-focussed treatment is highly encouraging, but is largely untapped within Tameside. This provides real optimism that transformational redesign could lead to significantly better outcomes. The change required is substantial, and implementing it will be hugely ambitious. However, the outcomes could be equally significant as we strive to significantly improve the wellbeing of local people, and reduce the financial drain that substance misuse currently places upon public services and the local economy.

Section 2 – Issues to consider & evidence base

ISSUES TO CONSIDER

Meeting our Equality Duty In considering the Equality Act and the wider legal framework it could be argued that the current system does not meet the specific needs of group covered under the Act. As such, this transformation project will lead to a significant improvement for these groups as opposed to any reduction or deterioration in service provision. The specification for the transformed service is underpinned by a series of key principles which are


captured in Transformation Paper # 3. 3 of these principles specifically relate to ensuring that our Equality Duty is met and that potential providers can be held to account in relation to issues of Equality and Diversity. These are as follows:

Congruent with both the needs of local people and the national strategic context.

Developed through co-design with service users, their families, and specialist local service providers.

Equipped to meet the needs of particular vulnerable groups and groups covered under the core equality strands.

Finance This transformation project it not driven by a need to make savings, albeit that the transformational change being sought will inevitably reduce the costs associated with Targeted and Specialist treatment medium and long term which can be reinvested in Prevention and Early Intervention Shifting resources away from maintenance and management of a long term cohort of individuals with complex needs takes time to ensure that ethical, clinical and service needs are met. This shift requires a period where the previous delivery model is given space to change, whilst the new model is embedded and gradually becomes the dominant cultural approach. To enable this to happen, an initial uplift in investment will be required to create and model the new operating model, parallel to the maintenance of the existing model before a shift in approach. Over time, this additional investment will reduce, and will then move into an overall long term reduction in the financial commitment as follows. Proposals for the new contract include more investment during the formative years of the contract with an ‘invest to save’ approach in future years. This will allow the transformation plans to be fully embedded ensure that the new service is recovery focussed as opposed to treatment focussed This financial modelling does not take into consideration the potential associated cost savings and reductions in demand that a high performing Drug and Alcohol Treatment System could generate in relation to Health, Social Care, Welfare and Criminal Justice, and the potential positive impact upon the wider local economy. Reducing expenditure of Drug and Alcohol Treatment either too quickly, or without accompanying service transformation could be financially counter-productive and highly risky. There is a robust evidence base, accepted by the National Audit Office, which highlights the value for money provided by investment in Drug and Alcohol Treatment. Key facts are as follows:

The annual cost of alcohol-related harm to society is £21 billion.

The annual cost of drug addiction to society is £15.4 billion, and in 2011 alone the cost of deaths linked to drug misuse was £2.4 billion.

Every £1 spent on Drug Treatment saves £2.50 in wider costs to society.

Every £1 spent on Young People’s Drug and Alcohol Treatment and Interventions brings a benefit of between £5 and £8.

Drug treatment prevents an estimated 4.9 million crimes per year, saving an estimated £960 million to the Public, Businesses, Health and Criminal Justice.

For every £1 taken out of the Treatment System, there is likely to be a £1.80 increase in the Cost of Drug-related Crime.

Understanding the issues and characteristics


Extensive consultation and analysis has been undertaken to ensure that the proposals reflect the needs of the local community. This has involved engagement within service users and their families, engagement with services and key stakeholders and analysis of available data, intelligence and evidence For more detailed information relating to the case for change and the proposed changes, please refer to transformation papers attached to this EIA: 1 – The case for change 3 – A pathway to change

LIST OF EVIDENCE SOURCES

In addition to the items listed above, these proposals also considered the following sources of guidance: https://www.gov.uk/government/publications/drug-strategy-2010--2 https://www.gov.uk/government/publications/alcohol-strategy https://www.gov.uk/government/publications/putting-full-recovery-first-the-recovery-roadmap http://www.nta.nhs.uk/uploads/dtie2012v1.pdf https://www.gov.uk/government/publications/acmd-recovery-from-drug-and-alcohol-dependence-an-overview-of-the-evidence-2012 https://www.gov.uk/government/publications/acmd-second-report-of-the-recovery-committee-november-2013 https://www.nice.org.uk/guidance/cmg38 http://www.nta.nhs.uk/uploads/commissioning_for_recovery_january_2010.pdf http://www.nta.nhs.uk/uploads/medications-in-recovery-main-report3.pdf http://www.nta.nhs.uk/uploads/commissioners-guide-to-mutual-aid.pdf

Section 3 – Impact

IMPACT

APPENDIX 1

https://www.gov.uk/government/publications/drug-strategy-2010--2

https://www.gov.uk/government/publications/alcohol-strategy

https://www.gov.uk/government/publications/putting-full-recovery-first-the-recovery-roadmap


http://www.nta.nhs.uk/uploads/dtie2012v1.pdf

https://www.gov.uk/government/publications/acmd-recovery-from-drug-and-alcohol-dependence-an-overview-of-the-evidence-2012


https://www.gov.uk/government/publications/acmd-second-report-of-the-recovery-committee-november-2013


https://www.nice.org.uk/guidance/cmg38

http://www.nta.nhs.uk/uploads/commissioning_for_recovery_january_2010.pdf

http://www.nta.nhs.uk/uploads/medications-in-recovery-main-report3.pdf

http://www.nta.nhs.uk/uploads/commissioners-guide-to-mutual-aid.pdf


The following protected characteristics have been considered in this EIA: Disability, Racial Equality, Gender Equality, Sexual Orientation, Gender Reassignment, Age Equality, Religion and belief, Pregnancy and maternity, Marriage and civil partnership It is not anticipated that the proposals would disproportionately affect any of the above protected characteristics. On the contrary, it is envisaged that the proposals will enhance the service offer and ensure that services are better able to respond to the needs of specific groups who may be under-represented or poorly served by the current offer. It is specifically felt that these changes will enhance the service provided to young people aged 18 to 25.

Section 4 – Proposals & Mitigation

PROPOSALS & MITIGATION

The overall proposal is to redesign current substance misuse services using a transformational process.

As previously stated the current system does not work effectively and concerns continue to be raised about the accessibility of the service – particularly to Young People or first time users.

It is not anticipated that the agreed proposal will potentially have a negative impact on any protected characteristic, or that the protected characteristic group may require support to access the service.

It is intended that access to the service will be greatly enhanced via the transformation process and as such the service will be accessible to everyone in need of substance misuse services.

To ensure this is the case three core principles have been incorporated into the proposals and the service specification which specifically relate to issues of equality:

Congruent with both the needs of local people and the national strategic context.

Developed through co-design with service users, their families, and specialist local service providers.

Equipped to meet the needs of particular vulnerable groups and groups covered under the core equality strands.

Following independent consultancy, extensive dialogue with current providers, and a review of the current national clinical guidance, it is proposed that the service be put into the market as two tenders:

Substance Misuse services for Young people up to the age of 25

Substance Misuse services for adults over 25 The proposal is widely supported amongst current providers and subject specialist. It is proposed that a prime provider be sought for the tender who would manage the entire service area through a blend of direct service delivery and subcontracting. This model is broadly supported and currently being utilised in many areas of England and Wales.


Section 5 – Monitoring

MONITORING PROGRESS

Identify the officer who has overall responsibility for taking forward the policy / service.

In the box below, make a note of any ongoing issues raised by the EIA and how they will be monitored / acted upon

In conjunction with Nick Ellwood & Francine Cooper

Equality Objective

Action Target Officer

responsible By when

Any negative equalities impacts of this proposal are identified.

Tender period - Continue to monitor performance indicators to track effectiveness of the redesign and transformation process Contract Period - Undertake Contract Performance Management of any positive or adverse equality impacts of the new service.

Any negative impacts are identified and appropriate action taken to help address.

Nick Ellwood – Children’s

Francine Cooper - Adults

31 July 2014

31 July 2014

Ongoing, subject to annual performance management and verification.

NB – The version sent to Corporate Performance should be the version agreed and signed off by the relevant Senior Manager.

Sign off

Signature of Service Unit Manager Date

Signature of Assistant Executive Director / Assistant Chief Executive Date

Issue / Action Lead officer Timescale

N/A Required Required

1

Substance Misuse Services in Tameside

Transformation Paper # 1

The Case for Change Version: 4.0 FINAL Date: 10th September 2014

APPENDIX 2

2

Document Control Page Version Author(s)

Comments

Date

1.0 David Boulger

For discussion at Drug and Alcohol Transformation Task and Finish Group on 8/8/14

5/8/14

2.0 David Boulger

To reflect comments made at Drug and Alcohol Transformation Task and Finish Group on 8/8/14.

Tracked changes highlighted on pages 4, 9 and 19.

18/8/14

3.0 David Boulger

FINAL VERSION – Approved at Drug and Alcohol Transformation Task and Finish Group on 19/8/14

21/8/14

4.0 David Boulger

FINAL VERSION – Includes narrative amendments requested by DPH and Consultant in Public Health

10/9/14

Distribution List

Document Version Name Date Sent

1.0 Drug and Alcohol Transformation Task and Finish Group

5/8/14


18/8/14


22/8/14

4.0 Cllr Lynn Travis / Anna Moloney / Angela Hardman

10/9/14

3

Contents Page

Introduction 4 National Strategy Context 4 Local Context 9 The Evidence Base 12 Conclusion 19

4

The Case for Change 1. Introduction Tameside faces significant and costly challenges in relation the misuse of Drugs and Alcohol within the Borough, which affect the entire system and in particular Health, Social Care, Criminal Justice, Welfare and the local Economy. Whilst there are some pockets of good practice, including recovery-orientated provision, the current system as a whole is no longer effective, efficient, or fit for purpose. The existing system is neither congruent with the national strategic context nor the needs of local people. To tackle this systemic failure, transformational change is required to fundamentally reshape the way that Drug and Alcohol Treatment Services are delivered in Tameside. This change will result in the existence of a fully recovery-orientated system for all those who are dependent on Drugs or Alcohol, and for those whose Drug or Alcohol use is harmful or hazardous. Our aspiration is for excellence, as this is the only way we can ensure that Drug and Alcohol use ceases to cause significant harm within Tameside. 2. National Strategic Context National Drug Strategy 2010 – Reducing Demand, Restricting Supply, Building Recovery: Supporting People to live a Drug Free Life

3 Themes:

- Reducing Demand: Creating an environment where the vast majority of people who have never taken drugs continue to resist pressures to do so, and making it easier for those that do to stop.

- Restricting Supply: Making the UK an unattractive place for drug

suppliers and traffickers.

- Building Recovery in Communities: Working with people who want to tackle their dependency on Drugs and Alcohol by offering a route out of dependence and putting recovery at the heart of everything we do.

2 Overarching Aims:

- Reduce illicit and other harmful drug use.

5

- Increase the numbers recovering from dependence.

Reducing Demand:

- There is a need to establish a whole life approach to preventing and reducing demand for drugs.

- It is essential to break intergenerational paths to dependency by supporting vulnerable families.

- Information and Advice, Prevention and Early Intervention are all

vital methods of reducing demand.

- Individuals should be encouraged to take responsibility for their own health.

- Those who use Drugs and Alcohol should be supported to recover.

Building Recovery in Communities:

- The entire treatment system should be refocused towards enabling full recovery from Drug and Alcohol dependence.

- Recovery is an individual, person-centred journey which will mean

different things to different people.

- The individual should be at the heart of the system.

- Services should be commissioned which enable tailored packages of care and support.

- The ultimate goal should be to enable individuals to become free

from their dependence and to live a drug-free life.

- Substitute prescribing and medically-assisted recovery continue to have a vital role to play, but it is not acceptable for a substitute prescription to be the end of the recovery journey. All of those on a substitute prescription should also be given the opportunity to engage in recovery-oriented activity with a view to achieving a drug-free life.

Treatment systems should focus upon building ‘recovery capital – the resources necessary to start and sustain recovery from drug and alcohol dependence.

Treatment systems should be outcomes focussed and the outcomes should be much broader than freedom from dependence on drugs and alcohol.

6

Treatment should be part of whole system approach and should engage and support families and carers.

A recovery-focussed system will require an inspirational recovery orientated workforce.

Recovery Champions, Mutual Aid, Peer Support and Recovery Communities should be an integral component of local systems.


HM Government Alcohol Strategy (2012)

“Over the last decade we have seen a culture grow where it has become acceptable to be excessively drunk in public and cause nuisance and harm to ourselves and others…a combination of irresponsibility, ignorance and poor habits led to almost 1 million alcohol-related violent crimes and 1.2 million alcohol-related hospital admissions in 2010/11 alone…alcohol is one of the three biggest lifestyle risk factors for disease and death in the United Kingdom”

4 Core Objectives:

- Turning the Tide – Challenging attitudes towards alcohol and the availability of cheap alcohol.

- Taking the Right Action Locally – Changing behaviour at a local level by changing behaviour, challenge and enforcement, Promoting rights and responsibilities, working across boundaries, and taking evidence based action on health harms.

- Shared Responsibility with Industry – Ensuring the industry plays a

core role in changing behaviour, and supporting growth amongst responsible businesses.

- Supporting Individuals to Change – Increasing people’s awareness

of the risks of excessive alcohol consumption, improving treatment and recovery, and targeting risk groups.

6 Intended Outcomes:

- A change in behaviour so that people think it is not acceptable to drink in ways that could cause harm to themselves or others.

- A reduction in alcohol-fuelled crime.

- A reduction in the number of adults drinking above the NHS guidelines.


7

- A reduction in the number of people “binge drinking”.

- A reduction in the number of alcohol-related deaths.

- A sustained reduction in both the numbers of 11-15 year olds

drinking alcohol and the amount consumed.

Taking Evidence-based action on Health Harms:

- Local Authorities and Clinical Commissioning Groups must work together to meet local needs as identified in the Joint Strategic Needs Assessment.

- The Public Health Grant should be used to commission Identification and Brief Advice for those at risk of ill health, and Specialised Treatment for those with greater needs.

- Integration across clinical pathways maximises the scope for early

interventions and secondary prevention.

- The needs of specific ‘at risk’ groups need to be approached in partnership.

Supporting Individuals to Change:

- Every opportunity should be taken to heighten the awareness of the risks associated with alcohol misuse.

- Identification and Brief Advice (IBA) should routinely be utilised in a wide range of settings, and should be the subject of further local investment.

- Alcohol Liaison Nurses should be employed by all hospitals.

- For those in need of treatment, there is an ambition to support full

recovery for those suffering from addiction, including alcohol.

- Increasing the availability of effective treatment for dependent drinkers will reduce alcohol-related harm, alcohol-related admissions, future illness and cost to the NHS.

- Alcohol Treatment should involve a whole family approach within a

whole system intervention model which recognises the wider factors which can either reinforce dependence, or enable recovery.

- There is a clear association between Mental Illness and Alcohol

Dependence and any treatment service will need to be equipped to respond effectively to this challenge.

8

- Local treatment services need to have clear pathways to the Criminal Justice System and should identify offenders as a target group for treatment.


HM Government – Putting Full Recovery First: The Recovery Road Map (2012)

There is a need for a full recovery-orientated treatment system that tackles all types of drug and alcohol use and recognises that drug and alcohol misuse is very rarely an isolated personal problem.

Whilst the current system has been successful in terms of bringing people into treatment and reducing harm, it has generated too much fatalism and waste and has left far too many people to drift into indefinite maintenance.

The existing evidence base provides the bedrock upon with to create a recovery-orientated system, but we must also challenge and build upon the evidence base.

Those entering treatment require choice and a wider range of options to support them to develop a clear pathway to recovery.

Commissioning should incorporate payment by results to incentivise providers to make the significant shift towards a recovery focussed whole system approach.


National Treatment Agency for Substance Misuse – Drug treatment in England: The Road to Recovery (2012)

Treatment should offer short-term management and long-term recovery.

Treatment for drug dependency needs to be combined with access to other health and care services that enable users to rebuilds their personal and social capital.

Drug users are more likely to complete their recovery if they have wider support to rebuild their lives.

Effective treatment programmes will cut crime and enhance safety and wellbeing.




9

Local systems require reconfiguration to enable them to deliver recovery-orientated treatment and a greater emphasis on overcoming dependency.

Every £1 invested in drug treatment saves society £2.50 in the crime and health costs of drug addiction.

http://www.nta.nhs.uk/uploads/dtie2012v1.pdf 3. Local Context Independent Consultancy (Red Quadrant) Between 1st January and 14th July 2014, Tameside Council utilised an Independent Consultancy, Red Quadrant, to undertake a wide ranging analysis of the current extent of Drug and Alcohol use in Tameside and the effectiveness of the current service provision. Their key findings were as follows: Alcohol:

Tameside continues to be disproportionately adversely impacted by Alcohol-related Harm, and has one of the highest rates of Alcohol-related and Alcohol-attributable hospital admissions in the Country.

Alcohol represents by far the most significant local Substance Misuse need, but less than 5% of current dependent drinkers in the Borough are in treatment, which is significantly less than the national average (6.9%), Department of Health guidance (10-20%), and the guidelines provided by the National Institute for Health and Clinical Excellence (NICE) (14.3%).

Drugs:

Tameside has a disproportionately high number of Opiate and Crack Cocaine Users and the current system is weighted towards managing their dependency.

There are an increasing proportion of drug service clients who have been in treatment for 4+ years (from 14% in 2005/6 to 35% in 2012/13), and an increasing proportion of this client group for whom prescribed maintenance is the primary intervention (from 44% in 2005/6 to 51% in 2012/13).

As a result, the system is ill equipped to offer a more diverse service to meet changing patterns of drug misusing behaviour.

http://www.nta.nhs.uk/uploads/dtie2012v1.pdf

10

Current Service Provision:

Whilst there are some pockets of good practice, the current system appears to be fragmented, and is weighted towards clinical intervention and maintenance in relation to Opiate and Crack Cocaine users, at the expense of Prevention, Early Intervention and Recovery.

Service Users feel that treatment options are limited and that there is little emphasis on Recovery, Dual Diagnosis and Aftercare.

There are significant gaps in service provision, particularly in relation to people with Alcohol problems.

There is a significant and long-standing issue in relation to the transition of Young People into Adult Services.

Whilst there are some examples of good practice, the current system as a whole is neither Recovery-focussed, nor Prevention-focussed.

Whilst there are some examples of good practice, the current system as a whole is not fit for purpose and is not capable of addressing the significant substance misuse challenges which exist within Tameside.

The system needs to be fundamentally refocused.

The proposal to transform the current system represents an opportunity to fundamentally reshape and rebalance the system to one which better meets the needs of some of the most vulnerable Tameside residents, and the wider Tameside community.

A full copy of the Red Quadrant Report is available on request. Tameside Joint Strategic Alcohol Needs Assessment 2014/15

The impact of alcohol misuse is widespread, inter-generational, and encompasses alcohol related illness and injuries, crime, teenage pregnancy, loss of workplace productivity, and homelessness.

The extent of alcohol use in Tameside is significant across all age groups and, in particular, young people.

There is evidence of a high prevalence of harmful and hazardous alcohol misuse.

Hospital admissions for alcohol-related conditions amongst Tameside residents have trebled over the past 10 years.

11

Tameside has disproportionately high rates of death from alcohol-related conditions.

Tameside Health and Wellbeing Strategy 2013-16

The H&W Strategy has identified drugs and alcohol as an area of challenge and recognises critical interdependencies through the adoption of its underpinning principles: - No health without mental health

- Focusing on prevention and early help

- Working together to tackle inequalities

- Value community assets

- Robust governance for health and wellbeing

Public Service Reform

Tameside, along with the rest of Greater Manchester, has embarked on an ambitious programme of reform which is intended to reshape the way in which Public Services are delivered.

In relation to Drugs and Alcohol there is a specific linkage across to workstreams relating to:

- Complex Dependency

- Early Years and Eduction

- Crime and Criminal Justice

- Work and Employment

Tameside “Care Together” Transformation

Focussed upon whole system Health and Social Care transformation and integration to: - Improve Health & Wellbeing outcomes

- Reduce health Inequalities

- Provide a better experience for Service Users

12

- Design services around the people that use them

- Focus on wellness and preventing illness

- Promote high quality, local treatment

- Provide good value for money for local taxpayers

- Ensure that people don’t have to give the same information lots of

times

- Enhance access to care when and where people need it

- Make sure that every contact counts

- Promoting health gain

- Reducing Demand

Substance Misuse is within Phase 3 and an Outline Business Case is due for submission in late September 2014.

4. The Evidence Base Advisory Council on the Misuse of Drugs – ‘Recovery from Drug and Alcohol Dependence: An Overview of the Evidence’ (2012)

‘Recovery’ from Substance Use should be the primary aim of Substance Misuse systems.

There is no consensus around the definition of ‘recovery’, but most definitions recognise that it is a process, not a single event or an end point, and that it is underpinned by 3 overarching principles:

- Wellbeing

- Citizenship

- Freedom from Dependence

The likelihood of recovery taking place is profoundly affected by:

- The substance being used;

- The severity of dependence;

- The presence or absence of ‘Recovery Capital’.

13

‘Recovery Capital’ which is defined as the breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery from substance misuse and dependency. There are 4 components to ‘Recovery Capital’:

- Social Capital: The sum of the resources that each person has as a

result of their relationships, including both support from and obligation to groups to which they belong;

- Physical Capital: Tangible assets such as property and money;

- Human Capital: Skills, health, aspirations, hopes, personal

resources, education attainment, intelligence, problem-solving abilities, interpersonal skills.

- Cultural Capital: Values, beliefs and attitudes that are linked to

levels of social conformity and the ability to fit into dominant social behaviours.

There is both an existing and emerging evidence base highlighting the links between the components of recovery capital and the likelihood of recovery

https://www.gov.uk/government/publications/acmd-recovery-from-drug-and-alcohol-dependence-an-overview-of-the-evidence-2012 Advisory Council on the Misuse of Drugs – ‘What recovery outcomes does the evidence tell us we can expect?’ (2013)

Recovery is a process which involves achieving or maintaining outcomes in a number of domains, not just overcoming dependence on drugs or alcohol;

People are unlikely to sustain drug or alcohol outcomes without having gained recovery capital in other domains such as having positive relationships, having a sense of wellbeing, meaningful occupation of their time, and adequate housing;

The evidence bases supports the focus on developing a recovery-based approach to substance misuse;

People will have a different likelihood of achieving recovery outcomes dependent on their level of recovery capital;

Recovery is highly ambitious and can require those with severe dependence and complex needs to aspire to something which is beyond what they had prior to dependence on drugs or alcohol.



14

Recovery can take years and those involved will require long term support with a wide range of issues.

Drug and Alcohol treatment services can play a critical role in the recovery journey, particularly for those with severe dependency and complex needs, but evidence shows that the quality of the service is paramount.

A high quality Drug and Alcohol treatment service should be:

- Recovery-focussed

- Person-centred

- Optimistic

- Designed to help in a number of domains and capable of enhancing recovery capital

- Well managed

- Delivered by an appropriately skilled workforce

- Capable of delivering long term treatment, utilising a range of

interventions

- Supportive of people to act responsibly and to protect themselves and others from harm

The role of recovery community organisations and mutual aid is important and the evidence indicates that they play a valuable role in recovery

Social stigma can inhibit recovery and efforts need to be made to challenge perceptions of those in Drug and Alcohol recovery.

https://www.gov.uk/government/publications/acmd-second-report-of-the-

recovery-committee-november-2013

National Institute for Health and Clinical Excellence – ‘Commissioning Guide: Services for the Identification and Treatment of Hazardous Drinking, Harmful Drinking and Alcohol Dependence in Children, Young People and Adults’ (2011)

A high quality Alcohol treatment service should include:

- Opportunistic screening and brief interventions for adults who are hazardous and harmful drinkers.



15

- Diagnosis, assessment and management of harmful drinking and

alcohol dependence in adults, in specialist services

- Services for children and young people who are vulnerable to alcohol-related harm

- Whole-system commissioning of high-quality alcohol services

A high quality Alcohol treatment service should aspire to achieve the following outcomes:

- Improving people’s health, wellbeing and relationships

- Reducing alcohol-related harm, morbidity and mortality

- Improving quality of life for the community

- Reducing the need for alcohol-related hospital admissions

- Promoting long-term recovery

- Improving peoples experience of the system

As a minimum, opportunistic screening and brief interventions for adults who are hazardous and harmful drinkers should include:

- Health and Social Care staff opportunistically carrying out screening

and brief interventions for hazardous and harmful drinking as an integral part of practice.

- Local availability of validated Structured Brief Advice and Extended

Brief Interventions such as Motivational Interviewing and Motivational Enhancement Therapy.

- Targeted delivery of screening and brief interventions to selected

populations at appropriate times and in appropriate settings.

- Clear identification methods and referral pathways for those who require more specialist interventions.

As a minimum, the diagnosis, assessment and management of harmful drinking and alcohol dependence in adults in specialist services should include:

- An integrated approach involving a multi-disciplinary team;

- Ease of access at the point at which treatment is required;

- Clear pathways and consistent thresholds;

16

- A Care Co-ordination and Case Management approach;

- Involvement of families and carers and the provision of relevant

family support and interventions;

- High quality and comprehensive assessments which are delivered by appropriately trained and competent specialist staff, and which include a motivational intervention;

- Recovery-focused Care Plans;

- The availability of a wide range of evidence-based interventions,

including Psychosocial Interventions and Pharmacological interventions, which are delivered by appropriately trained and competent specialist staff;

- Regular treatment outcome reviews which are used to plan

subsequent care;

- Availability of both community-based and residential medically-assisted alcohol withdrawal;

- Long term aftercare and holistic reintegration support, including

ongoing Case Management for the highest risk cases;

- Access to credible and meaningful peer support and mutual aid for adults who misuse alcohol and their families;

- A clear and robust approach to the prevention, identification and

response to individuals at risk of, or presenting with, Wernicke’s encephalopathy and Wernicke’s-Korsakoff syndrome.

As a minimum, services for children and young people who are vulnerable to alcohol-related harm should include:

- A whole family approach to managing and reducing risk taking

behaviours;

- A distinct approach to those who pose a lower risk of alcohol-related harm which incorporates tailored empathy, counselling or short interventions delivered by trained professionals within targeted universal and specialist partner agencies;

- A distinct approach to those who pose a higher risk of alcohol-

related harm, which is delivered by a specialist drug and alcohol treatment service;

17

- A wider definition of children and young people to include those aged 18 to 25 who often struggle to make the transition into Adult treatment services;

- High quality and comprehensive assessments for those accessing

specialist services, which are delivered by appropriately trained and competent specialist staff, and which are rooted in existing assessment approaches such as the Common Assessment framework (CAF);

- The availability of behavioural interventions such as Cognitive

Behavioural Therapy for those accessing specialist services;

- The availability of multi-component programmes of care including family or systems therapy, for those how have additional co-morbidities or wider complex needs;

- Clear and readily accessible links into specialist Mental Health

services and a clear protocol for managing co-morbidity / dual diagnosis;

- A clear transitional pathway into Adult Services;

As a minimum, whole-system commissioning of high-quality alcohol services should include:

- A clear and up to date understanding of the prevalence and nature

of alcohol use within the local area;

- Widespread availability of Alcohol Awareness training;

- Well-trained staff across agencies who can identify alcohol-related harm and promote the respectful and non-judgemental care who people who misuse alcohol;

- Shared governance, policies and procedures;

- The active involvement of a wide range of partners who can enable

long-term recovery;

- Service user engagement and involvement. https://www.nice.org.uk/guidance/cmg38 National Treatment Agency for Substance Misuse – ‘Commissioning for Recovery: Drug Treatment, Reintegration and Recovery in the Community and Prisons’ (2010)

https://www.nice.org.uk/guidance/cmg38

18

The components of an effectively commissioned recovery-focussed Drug treatment model are:

- A clear and up to date understanding of the prevalence and nature

of drug use at a local level;

- Strong local leadership;

- Meaningful engagement with service users, their families, carers and the public;

- A collaborative approach across partners, including input from

clinicians;

- A wide range or relevant, effective and evidence-based treatment interventions;

- The availability of long-term aftercare and mutual aid;

- The availability of abstinence-based services;

- Robust monitoring and evaluation, and a clear understanding of

desired outcomes.


National Treatment Agency for Substance Misuse – ‘Medications in Recovery: Re-orientating Drug Dependence Treatment’ (2012)

Not everyone who comes into treatment will break free of their dependence and so any treatment system needs to offer a wide range of treatment and intervention options including Opioid Substitution Treatment (OST);

Opioid Substitution Treatment (OST) has achieved significant harm reduction goals;

A recovery focussed Drug treatment system should continue to recognise the value of OST for some people, and should ensure it has an important role within recovery-orientated systems of care;

It is not acceptable to leave people on OST without actively supporting long-term recovery and the increase in recovery capital amongst those in treatment as part of a phased and layered approach to intervention;

Nor is it acceptable or safe to impose time-limits on OST to coerce service users to adopt a different approach.




19

Public Health England – ‘Improving Access to Mutual Aid: A Brief Guide for Commissioners’ (2014)

A wide range of international, peer-reviewed evidence demonstrates the efficacy and effectiveness of mutual aid and its potential role in improving service users’ community integration, their social networks and recovery outcomes, along with the health and wellbeing of their families and carers;

At a local level, Mutual Aid should be fully integrated into recovery-focussed drug and alcohol services;

Mutual Aid is not homogenous and people in treatment should have access to a range of peer-based recovery options including 12 step, SMART Recovery and other community-based recovery organisations;

http://www.nta.nhs.uk/uploads/commissioners-guide-to-mutual-aid.pdf 5. Conclusion It is clear that the current Drug and Alcohol Treatment system within Tameside is no longer fit for purpose and requires transformational redesign. The local approach to reducing drug dependency is rooted in a bygone era and is ill-equipped to respond to changing patterns of drug misuse and associated risks. The local approach to reducing alcohol dependency is insufficient to tackle the scale of the issue and is limited in scope. Whilst there are some pockets of good practice, the current treatment system is fragmented and lacks a meaningful and coherent focus on recovery, prevention or early intervention. Overall, the current Drug and Alcohol Treatment System in Tameside does not meet the needs of the Tameside Community. As a result, the costs of substance misuse related harm have increased exponentially over the past decade and will continue to do so unless remedial action is taken. Tameside is not alone in experiencing these challenges, but the level of harm that currently exists within Tameside is disproportionately high.

http://www.nta.nhs.uk/uploads/commissioners-guide-to-mutual-aid.pdf

20

At a local level, the current system could not sufficiently meet the aspirations of the Health and Wellbeing Board or Care Together. The national strategic environment, with a renewed emphasis on Recovery and Whole System reform, provides an opportunity to adopt a transformational approach to redesigning Substance Misuse services in Tameside. At present, the Tameside approach is not congruent with the expectations that exist at a national level, but there is no reason why this cannot be remedied. The emerging evidence base in relation to Recovery-focussed treatment is highly encouraging, but is not fully utilised within Tameside. This provides real optimism that transformational redesign could lead to significantly better outcomes. The change required is substantial, and implementing it will be hugely ambitious. However, the outcomes could be equally significant as we strive to significantly improve the wellbeing of local people, and reduce the financial drain that substance misuse currently places upon public services and the local economy.

1



A Pathway to Change Version: FINAL Date: 8th October 2014

APPENDIX 3

2

Document Control Page Version Author(s)

Comments

Date

1.0 David Boulger

For discussion at Drugs and Alcohol Transformation Task and Finish Group on 8/8/14

5/8/14

2.0 David Boulger

Includes changes as a result of Drugs and Alcohol Transformation Task and Finish Group on 8/8/14 and greater clarity in relation to financial envelope.

Tracked changes highlighted in document

18/8/14

3.0 David Boulger

Includes changes as a result of Drugs and Alcohol Transformation Task and Finish Group on 19/8/14 and 26/8/14 and changes to financial envelope

3/9/14

4.0 David Boulger

Final proposals following discussions with Director of Public Health and Consultant in Public Health

10/9/14

5.0 David Boulger

Final proposals separating out hospital based services as part of a separate review, and reflecting amended financial figures.

15/9/14

FINAL David Boulger

Final proposals following discussions with TMBC Legal Dept.

8/10/14

Distribution List


1.0 Drugs and Alcohol Transformation Task and Finish Group

5/8/14


18/8/14

3.0 DPH, Consultant in Public Health, Executive Member - Health

10/9/14


11/9/14

5.0 TMBC Legal Services, Finance and Democratic Services.

17/9/14

FINAL TMBC Legal Services, Commissioning Support, Finance, Democratic Services, Director of Public Health and Executive Member - Health and Communities.

8/10/14

3

Contents Page

Introduction 4 Our Shared Vision 4 Our Shared Aims 4 Intended Outcomes 5 Scope and Scale 6 Current Providers 7 Contract Length 7 Finance 9 Investing to Save 10 Achieving financial efficiencies whilst improving outcomes 12 Shifting Investment 13 From a Vicious Cycle to a Virtuous Cycle 13 The Beneficiaries 15 Approach to Tendering 15

4

1. Introduction Tameside faces significant and costly challenges in relation the misuse of Drugs and Alcohol within the Borough, which affect the entire system and in particular Health, Social Care, Criminal Justice, Welfare and the local Economy. The current system is no longer effective, efficient, or fit for purpose. The existing system is neither congruent with the national strategic context nor the needs of local people. Transformational change is required to fundamentally reshape the way that Drug and Alcohol Treatment Services are delivered in Tameside. This change will see the emergence of a fully recovery-orientated system for all those who are dependent on Drugs or Alcohol, and for those whose Drug or Alcohol use is harmful or hazardous. Our aspiration is for excellence, as this is the only way we can ensure that Drug and Alcohol use ceases to be such a significant issue within Tameside. The proposals within this report have been co-designed with a wide range of partners through a Drug and Alcohol Transformation Task and Finish Group. The approach that is articulated within this report is attracting attention from representatives of the Advisory Council on the Misuse of Drugs (ACMD), National Drug and Alcohol charities and lobby groups, and other Local Authority areas as a promising model and one which has the potential to represent a national exemplar of best practice. 2. Our Shared Vision The following shared vision has been developed and agreed by the Drug and Alcohol Transformation Group: “Providing person-centred, holistic and recovery-focussed Alcohol and Drug treatment services which are easy to access and navigate, responsive to the needs of local people, focussed upon Prevention and Early Intervention, and which achieve exceptional, meaningful and sustained outcomes.” 3. Our Shared Aims We aspire to undertake a whole service redesign of Drug and Alcohol Services within Tameside and to develop an excellent service which is:

- Recovery-orientated, whilst maintaining high quality clinical services which reduce harm.

5

- Easy to access and simple to navigate

- Effective, efficient and flexible.

- Individual and Person-Centred

- Evidence-based and Sequential, whilst creating space for

Innovation and Creativity.

- Congruent with both the needs of local people and the national strategic context.

- Developed through co-design with service users, their families, and

specialist local service providers.

- Underpinned by a range of pathways which enhance the development of recovery capital.

- Committed to the growth of Mutual Aid, Peer Support and User

Participation.

- Able to identify those who are reluctant to engage in treatment and work with them to increase their motivation to change.

- Embedded within the wider Public Service Reform agenda with a

focus on Whole Family Approaches, Integration and the development of a Whole System Response.

- Equipped to meet the needs of particular vulnerable groups and

groups covered under the core equality strands.

- Focussed upon maximising the role played by Primary Care

providers in managing both complex and non-complex treatment plans.

- Capable of providing Value for Money, and delivering medium to

long term cost savings through Prevention / Early Intervention and Demand Reduction within the most costly parts of the system.

- Focussed upon achieving a smaller number of core outcomes.

The current service provision within Tameside does not meet these aspirations and requires fundamental transformation. 4. Intended Outcomes The following outcomes have been devised by the Multi-Agency Drug and Alcohol Transformation Task and Finish Group:

6

a. To increase the number of people accessing treatment and the number

of people who move onto long-term sustained recovery.

b. To reduce alcohol-related harm and drug-related harm.

c. To maximise the opportunities for integration and collaboration by adopting a whole system approach to Drug and Alcohol treatment.

d. To contribute to a whole system approach which reduces the demand

for Specialist and Targeted services, through enhanced Early Intervention and Prevention.

e. To become a national exemplar of best practice.

5. Scope and Scale At present, the Drug and Alcohol Treatment System within Tameside is not fit for purpose and requires whole system redesign. As a result, all existing treatment services commissioned by Tameside Council are in scope. This includes:

All Tier 2 and 3 Drug and Alcohol Treatment and Harm Reduction

All Tier 4 Residential Rehabilitation and Inpatient Detoxification

Drug Intervention Programme

Through the Gate Criminal Justice Interventions

Assertive Outreach

Mutual Aid and Peer Support

Shared Care and Primary Care support provided by GP’s and Pharmacies

Drugs and Alcohol Training and Development There are a small number of local mutual aid providers, primarily those delivering SMART Recovery and 12 Step Recovery approaches, who are not funded by Tameside Council and are therefore out of scope of this proposal. There are a number of services delivered from Tameside General Hospital and funded primarily by the Clinical Commissioning Group, such as the Hospital Alcohol Liaison Service (HALS) and an under-18 Alcohol-related admission practitioner. The funding associated within this is not in scope of these proposals, but acute and hospital based investments will be considered

7

as part of the broader Care Together Outline Business Case, with a focus on establishing greater clarity and integration. Finally, the Rapid Assessment, Interface and Discharge (RAID) Alcohol Liaison Service, based at Tameside General Hospital and delivered by Pennine Care is also out of scope of these proposals, but will be considered as part of the broader Care Together Outline Business Case, with a focus on establishing greater clarity and integration. Whilst these projects are not specifically in scope of this transformation, the service redesign provides an opportunity to enhance the level of engagement with these providers to maximise the role they play and to ensure that the resource they provide is considered within a whole system model. 6. Current Providers The above ‘in scope’ services are currently delivered by a number of providers including:

Pennine Care

Addiction Dependency Solutions (ADS)

Acorn

Community Led Initiatives (CLI)

Lifeline

Tier 4 Approved Provider List

Probation Community Rehabilitation Company

Primary Care (GP’s; Pharmacies)

Tameside and Glossop Clinical Commissioning Group (Drug and Alcohol Clinical Leads; Medicines Management function)

Extensive consultation and engagement has clearly identified that most current providers fully understand the limitations of the current system, are open to transformational change and will be a part of co-designing the proposed new service. There is clear anxiety amongst providers about the potential implications for their organisations and their staff which will need to be carefully managed to ensure that current service quality is not compromised during this period of change and that current providers and their staff are supported during this challenging time.

8

7. Contract Length Fundamentally transforming Substance Misuse services in a manner which achieves exceptional outcomes, whilst maximising financial savings requires a long term approach delivered in incremental phases. It is proposed, and strongly supported by independent experts, current service providers, and the multi-agency task and finish group, that a 10 year contract be awarded. A 10 year approach is proposed for the following reasons:

- The scale of the challenge is significant, complex and inter-generational and reforming the system to meet it will require a long term approach.

- Creating a recovery-orientated system which enables meaningful

and sustained long-term recovery requires the establishment of enhanced pathways which promote the attainment and retention of recovery capital over a significant timeframe.

- The budget proposals include a frontloading of additional investment, followed by long term budget reduction. A shorter contract would serve as a disincentive for the provider to undertake the required transformational changes as they would not necessarily be expected to manage the long term budget reductions. This could jeopardise the overall project and the likelihood of the Council maximising the long term savings opportunities.

- A long term contract will maximise the opportunities for a prime

provider to bring in additional investment which adds value to the contract allocation and will equip the provider with the impetus and confidence to deliver truly transformational change.

- Shifting resources away from the maintenance and management of

a long term cohort of individuals with complex needs takes time to ensure that ethical, clinical and service needs are met.

- The transformation of treatment services alone is not sufficient and

is only one element of a long term strategy which will also focus upon universal provision / wellness, social norming and cultural acceptability of harmful alcohol use, public service reform / complex dependency, removing the stigma associated with treatment and recovery, disrupting the supply chain for illegal drugs and illicit alcohol, and reducing the demand for drugs through an increased awareness of risk.

9

The risks associated with a 10 year contract will be mitigated through the following measures:

- Robust contract and performance management against a basket of meaningful outcomes set out in (4);

- The inclusion of a 12 month no fault contract termination clause;

- The use of an innovative variation on Payment by Results which will financially incentivize changes to working practices and the modelling of approaches which are commensurate with the principles identified in (3).

- The inclusion of a clause within the contract highlighting that the

budget is indicative and subject to annual review. 8. Finance The 2014/15 budget for community Drugs and Alcohol treatment in Tameside is £4.292 million. The planned 2015/16 Drugs and Alcohol budget is £3.843 million. The reduction in funding between 2014/15 and 2015/16 is due to the cessation of providing Drug and Alcohol treatment services to Glossop residents, and the cessation of a number of non-recurrent in year projects. Transforming the system to maximise medium and long term financial gains, whilst maintaining short-term treatment integrity and clinical safety, is a balancing act which requires careful management and creative thinking. This shift requires a period where the previous delivery model is given space to change, whilst the new model is embedded and gradually becomes the dominant cultural approach. To enable this to happen, an initial uplift in investment will be allocated to create and model the new operating model, parallel to the maintenance of the existing model before a shift in approach. Over time, this additional investment will reduce, and will then move into an overall long term reduction in the financial commitment as follows:

10

Year Budget £million

Comparison to Baseline £million

2015/16 (Original Budget) 3.843 N/A 2015/16 (Proposed Budget) 4.043 + 0.200 2016/17 4.043 + 0.200 2017/18 3.843 0 2018/19 3.843 0 2019/20 3.643 - 0.200 2020/21 3.643 - 0.200 2021/22 3.443 - 0.400 2022/23 3.443 - 0.400 2023/24 3.343 - 0.500 2024/25 3.343 - 0.500

Total 36.630 - 1.800

If the original baseline 2015/16 budget were to remain ‘as is’ for the next 10 years, the total investment would be £38.430 million. If the 2014/15 budget was to remain ‘as is’ for the next 10 years, the total investment would be £42.921 million. Under these proposals, the total investment will be £36.630 million. This represents:

- A total 10 year reduction in expenditure of £1.800 million or 4.7% against a continuation of the original 2015/16 budget.

- A total 10 year reduction in expenditure of £6.292 million or 14.7% against a continuation of the 2014/15 budget.

The initial increase in funding is essential for the following reasons:

- The current Alcohol Treatment system is insufficient to meet the level of need that exists in Tameside. At present an average of 679 individuals are in treatment, which represents 4.8% of the likely dependent population (14,200 adults aged 16+). The national average is 6.9%, the Department of Health advises between 10 and 20%, and the National Institute for Health and Clinical Excellence (NICE) Guidelines suggests it should be 14.3%. To reach the national average, the Tameside system would need to work with 295 extra clients at any given time. To reach the NICE guidance threshold it would need to work with an extra 1352 clients at any given time. Both represent a significant increase against current service capacity.

- The current Drug Treatment system is primarily geared towards managing the needs of a cohort of opiate dependent users who have been in treatment for a considerable period of time, and for

11

whom the primary treatment is pharmacological maintenance. There is a need to continue to meet the clinical needs of this group whilst also broadening the scope of the Drug Treatment system to more effectively capture a wider range of drug misusing behaviour, and to increase the Drug Treatment population to include more non-Opiate users (including Cannabis users and those using New Psychoactive Substances – “Legal Highs”), and to embed a wider range of effective evidence-based treatments, interventions and practices.

9. Investing to Save Investment in Drug and Alcohol is primarily a decision underpinned by ‘invest to save’ principles. The financial modelling in (8) does not take into consideration the potential associated cost savings and reductions in demand that a high performing Drug and Alcohol Treatment System could generate in relation to Health, Social Care, Welfare and Criminal Justice, and the potential positive impact upon the wider local economy. Reducing expenditure on Drug and Alcohol Treatment either too quickly, or without accompanying service transformation, could be financially counter-productive and highly risky. There is a robust evidence base, accepted by the National Audit Office, which highlights the value for money provided by investment in Drug and Alcohol Treatment. Key facts are as follows:

- The annual cost of alcohol-related harm to society is £21 billion.

- The annual cost of drug addiction to society is £15.4 billion, and in 2011 alone the cost of deaths linked to drug misuse was £2.4 billion.

- Every £1 spent on Drug Treatment saves £2.50 in wider costs to

society.

- Every £1 spent on Alcohol Treatments saves £5 in wider costs to society.

- Every £1 spent on Young People’s Drug and Alcohol Treatment and Interventions brings a benefit of between £5 and £8.

- Drug treatment prevents an estimated 4.9 million crimes per year,

saving an estimated £960 million to the Public, Businesses, Health and Criminal Justice.

12

- For every £1 taken out of the Treatment System, there is likely to be a £1.80 increase in the Cost of Drug-related Crime.

http://www.nta.nhs.uk/uploads/whyinvest2014.pdf http://www.nta.nhs.uk/uploads/whyinvest2final.pdf http://www.nta.nhs.uk/uploads/vfm2012.pdf The wider international evidence base also highlights the following cost-benefit implications of Drug and Alcohol Treatment:

- A UK based review of Drug and Alcohol Treatment identified a total net benefit of £6,527 per client when the costs of treatment are offset against reduced costs linked to other health and social care use, and reduced offending.

- A US government research summary concluded that every

£100,000 spent on drug and alcohol treatment led to the avoidance of £487,000 in healthcare costs and £700,000 in crime costs.

- A literature review of US and European alcohol treatment found

compelling evidence of the benefits of investment in alcohol treatment with research findings identifying cost benefit ratios ranging from 1:1.89 to 1:39.00

http://www.dtors.org.uk/reports/DTORS_CostEffect_Main.pdf https://www.samhsa-gpra.samhsa.gov/CSAT/view/docs/SAIS_GPRA_CostOffsetSubstanceAbuse.pdf http://www.researchgate.net/publication/51640718_A_literature_review_of_cost-benefit_analyses_for_the_treatment_of_alcohol_dependence These are important considerations when placing Drug and Alcohol treatment in the context of wider Public Service Reform, understanding the potential savings generated across the Health, Social Care, Criminal Justice and Welfare Systems, and recognising the potential unintended negative consequences of reducing funding for Drug and Alcohol Treatment. 10. Achieving financial efficiencies whilst improving outcomes The proposed transformational approach and financial modelling enables significant medium to long term direct cost savings and likely wider financial benefits across the public sector and the wider economy. However, this will not be at the expense of service quality.

http://www.nta.nhs.uk/uploads/whyinvest2014.pdf

http://www.nta.nhs.uk/uploads/whyinvest2final.pdf

http://www.nta.nhs.uk/uploads/vfm2012.pdf

http://www.dtors.org.uk/reports/DTORS_CostEffect_Main.pdf

https://www.samhsa-gpra.samhsa.gov/CSAT/view/docs/SAIS_GPRA_CostOffsetSubstanceAbuse.pdf



http://www.researchgate.net/publication/51640718_A_literature_review_of_cost-benefit_analyses_for_the_treatment_of_alcohol_dependence

http://www.researchgate.net/publication/51640718_A_literature_review_of_cost-benefit_analyses_for_the_treatment_of_alcohol_dependence

13

Adopting a long term approach and sensible budget modelling allows for the medium to long term savings to be achieved by:

Increasing operational effectiveness and efficiency;

Reducing ‘failure demand’ through high quality service provision;

Increasing the role played by communities and volunteers through peer-led support and mutual aid;

Enhancing the use of evidence-based interventions and ceasing activity which is ineffective or counter-productive;

Reducing the need for costly targeted and specialist services and shifting over time towards a model underpinned by prevention and early intervention;

Reducing the prescribing costs associated with a long-term pharmacological maintenance approach by adopting an approach focussed upon meaningful and sustained recovery;

Increasing the contribution of Drug and Alcohol treatment to the wider work around Troubled Families and Complex Dependency to tackle inter-generational drug and alcohol use.

11. Shifting Investment Reducing the long term investment in Drug and Alcohol Treatment Services allows for the realignment of resources to other service areas which contribute to the long term reduction in Drug and Alcohol Related harm in Tameside such as:

Universal and Preventative services for Children and Young People

Family Support

Early Help and Early Intervention

Wellbeing Offer

Asset-based Community Development

12. From a Vicious Cycle to a Virtuous Cycle This transformation project advocates a process of change that requires short term increased investment to enable the implementation of new working practices and a new delivery culture, whilst not undermining the clinical integrity of existing service delivery at too early a stage on the transformational journey.

14

This approach will enable a shift from a vicious cycle and towards a virtuous cycle as follows: Current Challenge – “Vicious Cycle”

Future Opportunity – Virtuous Cycle

Increased Demand for High Cost Targeted and

Specialist Treatment Services

Increased Cost of Targeted and


Reduced opportunities for investment in Prevention, Early

Intervention and Asset Based Community

Development

Reduced Demand for High Costs Targeted and


Reduced Cost of Targeted and


Increased opportunities for investment in Prevention, Early

Intervention and Asset Based Community

Development

15

This shift is only feasible in the presence of the right pre-conditions underpinned by an appropriate transformational change journey. 13. The Beneficiaries Transforming the Tameside Drug and Alcohol Treatment System will have significant benefits for Service Users and their Families, and the wider Tameside Community. However, it will also create a robust platform from which to provide both operational and financial benefits for a range of partners through:

Reductions in Crime and Anti-Social Behaviour

Reductions in Acute presentations, admissions and long term complex healthcare.

Reductions in under-18 conceptions rates and the prevalence of Sexually transmitted diseases.

Reductions in Domestic Abuse.

Reductions in the need for Children’s and Adult Social Care.

Reductions in Welfare Costs.

Increased contribution to the local economy and a reduction in Economic Inactivity

Reductions in Accidental Dwelling House fires

Increased volunteering, participation and active citizenship/

14. Approach to Tendering Following independent consultancy, extensive dialogue with current providers, and a review of the current national clinical guidance, it is proposed that the service be put into the market as a single tender to provide 2 services:

Substance Misuse Services for Young People up to age 25

Substance Misuse Services for Adults aged over 25 This proposal is widely supported amongst current providers and subject specialists.

16

It is proposed that a Prime provider be sought who would manage the entire service through a blend of direct service delivery and sub-contracting. This approach is broadly supported by current providers, and is the model currently being progressed by a number of areas of England and Wales. It is proposed that the tender timescales are as follows:

Commencement of Tender Process – November 2014

Award of Contract – March 2015

Go Live – August 2015

END

1

APPENDIX 4



Risk Register Version: v4.0 Date: 5th September 2014

2

APPENDIX 4

Document Control Page

Version Author(s)

Comments

Date

1.0 David Boulger

Blank template for population at Drug and Alcohol Transformation Task and Finish Group on 19.8.14

18.8.14

2.0 David Boulger

Partially completed template for discussion at Drug and Alcohol Transformation Task and Finish Group on 19.8.14

22.8.14

3.0 David Boulger

Amended with owners following discussion at Drug and Alcohol Transformation Task and Finish Group on 19.8.14. Still needs mitigating actions from group members

27.8.14

4.0 David Boulger

Amended by FC to include her mitigating actions

5.9.14

Distribution List



18.8.14


22.8.14

3.0

3

APPENDIX 4

Impact 1

2

3

4

5

Likelihood Insignificant

Low

Moderate

Major

Catastrophic

5 Almost Certain (80 - 100%)

Low Risk

Moderate Risk

High Risk

Very High Risk

Very High Risk

4 Highly Likely (60-80%)

Minimal Risk

Low Risk

Moderate Risk

High Risk

Very High Risk

3 Likely (40-60%)

Minimal Risk

Low Risk

Moderate Risk

High Risk

High Risk

2 Unlikely (20-40%)

Minimal Risk

Low Risk

Low Risk

Moderate Risk

High Risk

1 Highly Unlikely (0-20%)

Minimal Risk

Minimal Risk

Low Risk

Moderate Risk

High Risk

4

APPENDIX 4

Key Risks Category Likelihood Impact Risk Score (L x I)

Owner Mitigating Actions

R1: Demotivation and resistance amongst current service providers

Operational 4 4 16

(High)

DB Service Managers

Engagement as per Stakeholder Engagement Plan

R2: Failure to secure the future funding that has been requested.

Operational Financial

4

3

12

(High)

DB Development of coherent and compelling business case Direct engagement with key interested and influential parties as per Stakeholder Engagement Plan

R3: Destabilisation of existing client group

Operational Reputational

3 4 12

(High)

DB Current Providers

Engagement as per Stakeholder Engagement Plan

R4: Resistance amongst key influential and interested stakeholders

Operational Financial Reputational

3 4 12

(High)

DB Engagement as per Stakeholder Engagement Plan

R5: Legal challenge in relation to contract award

Operational Financial Legal Reputational

3 4 12

(High)

FC NE

Compliance with PSOs, Financial Regulations, EU regulations and current legislation.

R6: Requested to make 18% Care Together Savings Target


2 4 8

(Moderate)

DB Development of coherent and compelling business case Direct engagement with key interested and influential parties as per Stakeholder Engagement Plan

R7: Proposals not agreed by Operational 2 4 8 DB Development of coherent and

5

APPENDIX 4

Council

Reputational Financial

(Moderate)

compelling business case Direct engagement with key interested and influential parties as per Stakeholder Engagement Plan Early engagement with Legal, Democratic Services and Finance.

R8: Proposals not agreed by Care Together Executive

Operational Reputational Financial Partnership

2 4 8

(Moderate)

DB Development of coherent and compelling business case Direct engagement with key interested and influential parties as per Stakeholder Engagement Plan Early engagement with Care Together Integration Lead

R9: Missing the timescale for going out to tender


2 4 8

(Moderate)

DB As R7 and R8 + Development of appropriate papers and business cases in a timely manner

R10: Failure to deliver a robust and fair tender process

Financial Reputational Legal

1 4 4

(Moderate)

FC NE

As R5 and in addition; FC & NE within JC&PM Team follow audit approved commissioning procedures. Tender procedures are designed to be open, fair and equitable.

R11: Failure to develop a new service that it clinically sound and grounded in a robust evidence base.

Operational Reputational Legal

1 4 4

(Moderate)

DB KB

Appointment of suitably qualified and experienced clinical advisor. Appointment of suitably qualified and

6

APPENDIX 4

experienced academic advisor.

R12: Failure to award contract Operational Financial Reputational

1 4 4

(Moderate)

DB Ensure appropriate service specification is in place and suitable budget envelope is secured.

item no: 6 · treatment services within tameside are commissioned and delivered. 1.6 further...

Documents