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Guidance for commissioners of drug and alcohol services 1
Practical
mental health
commissioning
Guidance for commissioners of
drug and
alcohol services
Joint Commissioning Panel
for Mental Health
www.jcpmh.info
Joint Commissioning Panel
for Mental Health
Co-chaired by:
Membership:
www.jcpmh.info
2 Practical Mental Health Commissioning
Contents
Ten key messages
for commissioners
Introduction
04
What are
drug and alcohol
services?
Why are drug and
alcohol services
important to
commissioners?
06 08
What do we know
about current
drug and alcohol
services?
12
What would a
good drug and
alcohol service
look like?
14
Supporting
the delivery
of the mental
health strategy
19
References
21
Guidance for commissioners of drug and alcohol services 3
Ten key messages for commissioners
1	 Investment in drug and
alcohol services gets results.
Treatment, as part of a
co-ordinated public health
approach is proven to be cost
effective for health services
and society as a whole.
Disinvestment brings with it a
risk of reversing the progress
made over recent years.
2	 A strong evidence base
exists for the range of
interventions that are
effective in substance misuse.
Commissioning should be
based upon this evidence
using NICE quality standards.
3	 To be effective, the treatment
system should be equipped
to respond to the full range
of complexity of need
represented by those who
misuse substances.
4	 A skilled workforce, working
under appropriate supervision
and providing care within
national competence
frameworks, is key to
delivering good outcomes.
5	 Collaboration and partnership
gets results. The NHS and
voluntary sector have a
contribution to make in the
delivery of drug and alcohol
services.
6	 Commissioning of drug and
alcohol services should be
based upon accurate and up
to date information about
local needs.
7	 Commissioners should ensure
that local services have clear
leadership, both clinical and
managerial, and that services
comply with professional
and service standards.
8	 Commissioning of
drug and alcohol services
should be outcome based and
make use of available data
and information.
9	 Services should place
recovery at the centre of their
approach and commissioners
should recognise recovery as
central to their commissioning
and strategic decision making.
10	Treatment is not simply
about patients – it should
address the needs of families
and carers, and work
with patients’ wider social
networks.
The Joint Commissioning
Panel for Mental Health
(JCP-MH) (www.jcpmh.info)
is a collaboration co-chaired by
the Royal College of General
Practitioners and the Royal
College of Psychiatrists.
It brings together leading
organisations and individuals
with an interest in commissioning
for mental health and learning
disabilities. These include:
•	 People with mental health problems
•	 Carers
•	 Department of Health
•	 Association of Directors
of Adult Social Services
•	 NHS Confederation
•	 Mind
•	 Rethink Mental Illness
•	 National Survivor User Network
•	 National Involvement Partnership
•	 Royal College of Nursing
•	 British Psychological Society
•	 Representatives of the English
Strategic Health Authorities
(prior to April 2013)
•	 Mental Health Providers Forum
•	 New Savoy Partnership
•	 Representation from
Specialised Commissioning
•	 Healthcare Financial
Management Association.
Introduction
The JCP-MH is part of the implementation
arm of the government mental health
strategy No Health without Mental Health1
.
The JCP-MH has two primary aims:
•	 to bring together people with mental
health problems, carers, clinicians,
commissioners, managers and others
to work towards values-based
commissioning
•	 to integrate scientific evidence,
the experience of people with mental
health problems and carers, and
innovative service evaluations, in order
to produce the best possible advice
on commissioning the design and delivery
of high quality mental health, learning
disabilities, and public mental health
and wellbeing services.
The JCP-MH:
•	 has published Practical Mental Health
Commissioning2
, a briefing on the key
values and principles for effective mental
health commissioning
• 	has so far published seven other practical
guides on the commissioning of primary
mental health care services3
, dementia
services4
, liaison mental health services
to acute hospitals5
, transition services6
,
perinatal mental health services7
, public
mental health services8
, and rehabilitation
services9
•	 provides practical guidance and a
developing framework for mental health
•	 will support commissioners to deliver the
best possible outcomes for community
health and wellbeing.
Who is this guide for?
This guide has been written
to provide practical advice
on developing and delivering
local plans and strategies to
commission the most effective
and efficient drug and alcohol
services for adults.
Based upon clinical best practice guidance
and drawing upon the range of available
evidence, it describes what should be
expected of a modern drug and alcohol
service in terms of effectiveness, outcomes
and value for money.
The guide will be of particular use to:
•	 public health leaders who will hold
responsibility for commissioning these
services
•	 Clinical Commissioning Groups (CCGs)
•	 wider local authority commissioners
•	 and voluntary and independent sector
organisations.
This guide does not cover drug and
alcohol services for children or offenders,
whose needs may be more specific.
More information can be found in the
publication Practice Standards for Young
People with Substance Misuse Problems10
.
4 Practical Mental Health Commissioning
Guidance for commissioners of drug and alcohol services 5
HOW WILL THIS GUIDE HELP YOU?
This guide has been written
by a group of drug and alcohol
professionals, people who use
drug and alcohol services, and
carers. The content is primarily
evidence-based, but ideas
deemed to be best practice by
expert consensus have also been
included.
By the end of this guide, readers should be
better equipped to:
•	 understand what an effective range of
drug and alcohol services should look like
•	 know the sorts of interventions that
should be available
•	 understand how those interventions
can contribute to achieving recovery
and make improvements in public mental
health and wellbeing.
In doing this, the guide describes:
•	 the benefits of drug and alcohol services
•	 the desirable team configurations for
drug and alcohol services
•	 the policy context for drug and alcohol
services
•	 what good quality drug and alcohol
services look like
•	 the benefits of providing good quality
drug and alcohol services
•	 how drug and alcohol services can
make a contribution to a range of other
imperatives including those in the national
mental health strategy.
The guide draws upon, and signposts
towards, previously published guidance and
policy. Among the key documents drawn
upon are:
•	 NICE quality standards for alcohol
dependence and harmful alcohol use
(QS11)11
•	 Alcohol dependence and harmful
alcohol use CG115 (NICE)12
•	 NICE quality standards for drug use
disorders (QS23)13
•	 Drug misuse – psychosocial interventions
CG51 (NICE)14
•	 Drug misuse – opioid detoxification
CG52 (NICE)15
•	 Improving outcomes & supporting
transparency – a public health outcomes
framework for England, 2013-16
(Department of Health)16
•	 The Government’s Alcohol Strategy
(HM Government 2012)17
•	 JSNA Support Pack for Commissioners
(National Treatment Agency)18
•	 No Health without Mental Health (DH)1
•	 Medications in recovery. Re-orientating
drug dependence treatment (National
Treatment Agency 2012)19
•	 Commissioning for Recovery
(National Treatment Agency)20
•	 Drug Strategy 2010 – Reducing Demand,
Restricting Supply, Building Recovery
(HM Government)21
•	 Healthy lives, healthy people:
our strategy for public health in England
(HM Government)22
•	 the roles and competencies of doctors
working in substance misuse23
•	 Alcohol use disorders: physical
complications CG100 (NICE)24
•	 Alcohol disorders – preventing the
development of hazardous and harmful
drinking PH24 (NICE)25
.
This guide does not cover non-structured
interventions for non-dependent drinkers.
6 Practical Mental Health Commissioning
What are drug and alcohol services?
Effective treatment provides
a central means for people
dependent on drugs or alcohol
to recover from their addiction
and to live independent lives.
It can deliver a wider range of
public health and social benefits,
and can also bring about
economic savings at the local
and national level (see page 9).
Local authority-based public
health is now responsible for
commissioning drug and alcohol
prevention, treatment and
linked recovery support. This
shift will provide a platform for
a more integrated approach
to improving public health
outcomes. This approach
addresses the root causes and
wider determinants of drug
dependence and alcohol misuse,
and the harm and impact they
have on people who use drugs
or alcohol, carers, families and
communities (such as mental
health, employment, education,
crime and housing). It also
delivers the greatest gains for
individuals and the community.
There is no nationally agreed
model for the commissioning
and delivery of drug and alcohol
services. The result of this has
been a continuation of local
plans for services that attempt
to address not only local need,
but also national imperatives.
Although a locally based
approach is important it can
have the negative consequence
of different and varied
approaches across the country.
However, the existence of NICE
quality standards, the National
Drug Treatment Monitoring
System, local needs assessments,
Joint Strategic Needs Assessment
tools and the publication of
guidance such as this, means
that commissioners now have
a wide range of tools to enable
them to commission effectively.
THE SERVICES
Drug and alcohol services are
mainly provided by NHS Trusts
or voluntary sector services,
although the private sector also
plays a smaller role in provision.
In the majority of cases, patients coming
to drug and alcohol services self-refer rather
than being referred by a GP. Drug and
alcohol services employ a range of expertise
including front line doctors, psychologists,
senior nurses, and drug workers. This skill
mix makes them well equipped to conduct
complex work with a client group often
perceived as challenging.
In the past, drug and alcohol services
tended to be provided by separate drug
and alcohol teams, but recently they are
more commonly delivered from teams
that deal with both. These aim to provide
a more integrated approach, particularly
for those people who have a problematic
use of both substances. For some people
this approach has not been successful
in relation to enabling access to services
(e.g. due to the stigma associated with
particular types of substance misuse).
Most secondary care services tend to
concentrate their interventions on people
with addictions to drugs such as heroin,
crack cocaine and alcohol. However,
other substances, for example emerging
club drugs and prescribed drugs, may be
among those for which people are treated.
Given the complexity of these problems
and the range of needs, services are
required to collaborate with other parts of
the health, social care and criminal justice
systems. This is essential to the delivery of
effective high quality treatment.
This is especially the case when providing
services to those people with co-morbid
illness, (e.g. substance misuse and mental
illness, or substance misuse and physical
health needs). This is often because people
with co-morbid illness are often excluded
from general mental health services.
One of the functions of drug and alcohol
services is to work with this group.
In parts of the country where Drug &
Alcohol Action Teams (DAATs) are in
operation, these have introduced Local
Area Single Assessment and Referral
Systems (LASARS) as part of a national
pilot of drug recovery Payment by Results.
The core function of LASARS is to assess
and set a tariff, refer and in some cases
review achievement of outcome. They
may also reduce the number of assessments
that an individual has to undertake in order
to access those services26
.
WHO WORKS IN THESE SERVICES?
A wide range of people from
a number of disciplines and
specialisms work in drug and
alcohol services including:
•	 medical staff including specialist
doctors (addiction psychiatrists and
a small number of highly specialist
General Practitioners)
•	 nurses (both mental health and
general nursing)
•	 drug and alcohol support workers
•	 non-medical prescribers (especially
trained nurses or pharmacists)
•	 peer mentors
•	 pharmacists
•	 psychologists and other specialist
therapists
•	 people who are experts by experience
•	 social workers/care managers.
Those working in drug and alcohol services
are expected to work to a set of national
occupational standards and, potentially,
also the skills framework promoted by
The Substance Misuse Skills Consortium.
Alongside these are the competencies
required by specific professional
bodies, including the Royal College of
Psychiatrists, Royal College of Nursing,
Royal College of General Practitioners, and
those representing other allied health and
social care professionals.
The Substance Misuse Skills Consortium
is an independent, sector-led initiative to
harness the ideas, energy and talent within
the substance misuse treatment field, to
maximise the ability of the workforce,
and help more drug and alcohol misusers
to recover27
. Commissioners will find
helpful guidance in the Drugs and Alcohol
National Occupational Standards (DANOS)
framework described later in this guide
(page 14), but should be aware that it
does not cover all professional groups.
Guidance for commissioners of drug and alcohol services 7
Why are drug and alcohol services
important to commissioners?
Among the reasons why
drug and alcohol services are
important to commissioners are:
1	 drug and alcohol use can
have a significant and
negative impact on individuals
and wider society
2	 drug and alcohol use can also
have a public health impact
3	 considerable economic costs
are associated with drug and
alcohol use
4	 there is a relatively common
use of drugs and alcohol
among the UK population
5	 these harms, impacts and
costs can be reduced through
effective treatment, with
important economic savings.
1	SOCIAL IMPACT
The Government’s drug strategy identifies
that drug and alcohol problems not only
negatively impact on the lives of people
using these substances, but are also the
“key causes of societal harm, including
crime, family breakdown and poverty”21
.
For example:
•	 crime – there were 278,000 recorded
drug offences in the UK in 2009/1028
and
9% of the population were engaged in
illicit drug use in 2010/1129
. As a society,
although drugs cost the UK £15 billion
each year29
, investment in drug services
has been estimated at approximately
£1.3 billion per year28
. However, drug
treatment has been shown to be effective
in preventing drug-related offending,
with an estimated five million offences
being prevented in 2010-11 alone30
.
Each year, alcohol is associated with
500,000 recorded crimes in England,
125,000 instances of domestic violence
and 1,000,000 assaults31
.
•	 family difficulties – families with parental
substance misuse frequently appear in
social services statistics: around one in
five families referred to children’s social
services in the UK have a history of
alcohol or drugs problems, rising to one
in two families on the Child Protection
Register and affecting three out of four
families involved in care proceedings32
.
•	 poverty – English local authority areas
with higher levels of deprivation will
have higher numbers of problem drug
users, and higher admission rates for drug
treatment services33
. The Marmot Review
published in 2010 highlighted a range of
health inequalities and set out actions to
address them, including an approach to
substance misuse to alleviate the impact
of alcohol in particular on people living in
more deprived settings33
.
2	PUBLIC HEALTH IMPACT
The public health consequences of drug
and alcohol use are also significant.
The primary harms include transmission of
blood borne viruses, including Hepatitis B,
C and HIV. Estimates suggest that around
216,000 individuals are chronically infected
with hepatitis C in the UK34
.
There are also various forms of harm that
may be caused by addiction to drugs or
alcohol including acute harms:
•	 death by overdose
•	 intoxication
•	 accidental injury
•	 suicide
•	 precipitation or exacerbation of mental
illnesses such as psychosis.
Chronic harms can also occur, including:
•	 cirrhosis and other liver damage
•	 consequences of injecting – for example,
abscesses, vein damage, endocarditis
•	 sexually transmitted diseases
•	 dependence including withdrawal
symptoms
•	 hypertension
•	 stroke
•	 coronary heart disease
•	 pancreatitis
•	 depression
•	 anxiety disorders.
8 Practical Mental Health Commissioning
Guidance for commissioners of drug and alcohol services 9
BOX 1: Reasons for
drug and alcohol use
People use drugs and alcohol for a
variety of reasons. For many people
this use of substances does not turn
into what is termed misuse. It is
equally important to bear in mind
that no-one starts using substances
with the intention to develop misuse
problems. Some of the reasons why
people begin to use drugs and/or
alcohol might include: because the
initial reactions and experiences are
pleasurable; response to social or family
circumstances, such as bereavement/
loss, unemployment, relationship
difficulties, loss of accommodation;
response to peer pressure; to remove
stress or other psychological difficulties;
criminal or other antisocial antecedents.
box 2: Types of drug use36
Recreational use
Many people are able to use
psychoactive substances in a recreational
manner that causes no problems to the
individual or those around them.
This pattern of use is usually
characterised by moderate levels of
consumption and periods when the
person stops using the substance
without difficulty.
Harmful use
A pattern of psychoactive substance
use that is causing damage to health.
The damage may be physical or
psychological.
Dependent use
Dependence has both psychological
and physiological elements.
Psychological dependence involves a
need for repeated doses of the drug to
feel good, or avoid feeling bad.
Physiological dependence is associated
with tolerance, where increased doses
of the drug are required to produce the
effects originally produced by lower
doses, and development of withdrawal
syndrome when the drug is withdrawn.
Withdrawal syndrome is characterised
by physiological and psychological
symptoms that are specific to a particular
drug. The term ‘dependence’ is often
used interchangeably with ‘addiction’.
3	ECONOMIC COSTS
Alcohol
There were 1.2 million alcohol-related
hospital admissions during 2010/1117
.
Alcohol consumption has nearly trebled
since 1950 with more than seven million
people drinking at harmful or hazardous
levels and who together account for about
80% of all spending on alcoholic drink35
.
It costs the NHS in England up to
£2.7 billion a year to treat the chronic
and acute effects of drinking24
. The
Government’s alcohol strategy indicates
that alcohol-related harm is now estimated
to cost society £21 billion annually17
.
Drug use
Drug use costs the UK £15.4 billion
each year, including welfare benefit
expenditure costs of approximately
£1.6 billion per year21
.
4	PREVALENCE
Drugs
Prevalence of substance misusevaries for
different types of substances. Recent years
have shown different patterns of use, with
a trend towards an increase in the misuse
of over the counter medicines and new
substances, including those known as club
drugs such as mephedrone, ketamine and
legal highs.
10 Practical Mental Health Commissioning
box 3: Prevalence of
drug and alcohol use
•	 Estimates from the 2010/11 British
Crime Survey show that 36% of adults
aged 16-59 have used illicit drugs in
their lifetime, which equates to almost
12 million people. Among this group,
almost 9% or 2.9 million adults had
used illicit drugs in the last year29
.
•	 The National Treatment Agency
reported that in 2009-10 in England
there were 306,000 users of opiates
and/or crack cocaine corresponding to
almost 1% of the adult population (this
number represents the total number of
users, rather than those in treatment
alone). In 2011 reported use of
mephedrone in the last 12 months was
1.4% and ecstasy 1.4% among 16-59
year olds31
.
•	 Investment in drug treatment services
is widely recognised to have been a
factor in the reduction of illicit drug use.
•	 Around 200,000 people get help for
drug dependence in England every
year, with around 135,000 being
treated on any given day37
.
•	 Nearly one third of users in the last
seven years successfully completed their
treatment and did not return, which
compares favourably to international
recovery rates38
.
•	 Drug misuse in this country remains
a significant factor in poor health
outcomes, criminality and worklessness
and continues to have far reaching
effects upon individuals, families and
society as a whole.
Alcohol
•	 Alcohol consumption in the UK has
almost trebled since 1950 with more
than 7 million people drinking at harmful
or hazardous levels. Together they
account for about 80% of all spending
on alcoholic drink35
. Since 2002/03 there
has been a 40% increase in admissions
to hospital where the primary diagnosis
was attributable to the consumption of
alcohol39
.
•	 In the same period there were almost
168,000 prescription items for drugs for
the treatment of alcohol dependency
prescribed in primary care settings or
NHS hospitals and dispensed in the
community which is a 63% increase
compared to 200339
.
•	 Quantities of alcohol consumption
across the population have been rising.
Recent research shows that 24% of
adults engage in hazardous drinking
while nearly 4% engage in harmful
drinking. Almost 6% of adults are
known to be dependent on alcohol40
.
Higher consumption of alcohol is
associated with depression and the risk
of suicide is eight times higher among
those with current alcohol misuse or
dependence. Alcohol misuse by young
people is associated with a six-fold
increased risk of depression41
.
•	 The Royal College of Psychiatrists
report, Our Invisible Addicts showed
that the misuse of drugs in older people
(65 and over) is a problem that is likely
to grow and that misuse in the over-40s
has increased significantly in recent
years42
. By 2031 there is predicted
to be a 50% increase of complex
substance misuse in the over 65s (e.g.
excessive alcohol consumption as well
as inappropriate use of prescribed and
over the counter medications).
Co-morbidity
•	 The 2002 Co-morbidity of
Substance Misuse and Mental Illness
Collaborative study (COSMIC)
concluded that:
–	 75% of users of drug services and
85% of users of alcohol services were
experiencing mental health problems
–	 30% of the drug treatment
population and over 50% of those in
treatment for alcohol problems had
‘multiple morbidity’
–	 38% of drug users with a psychiatric
disorder were receiving no treatment
for their mental health problem
–	 44% of mental health service users
either reported drug use or were
assessed to have used alcohol at
hazardous or harmful levels in the
past year43
.
•	 The term ‘co-morbidity’ covers a
broad spectrum of mental health
and substance misuse problems
that an individual might experience
concurrently. The nature of the
relationship between these two
conditions is complex. Possible
mechanisms include:
–	 a primary psychiatric illness
precipitating or leading to
substance misuse
–	 substance misuse precipitating,
worsening or altering the course
of a psychiatric illness
–	 intoxication and/or substance
dependence leading to
psychological symptoms
–	 substance misuse and/or
withdrawal leading to psychiatric
symptoms or illnesses44
.
•	 The complexity of issues can make
diagnosis, care and treatment more
difficult, with service users being at
higher risk of relapse, readmission to
hospital and suicide44
.
•	 Dual diagnosis: a challenge for the
reformed NHS and for Public Health
England has reinforced the need for
commissioners to develop effective
services for dual diagnosis and that
those services are central to the
achievement of key policy objectives,
including drug recovery43
.
High risk groups
•	 There are a number of groups of
people who may be at higher risk
of misuse of drugs and alcohol.
As an example, recent research
has shown that drug use among
Lesbian Gay Bisexual and Trans-
gender groups is higher than among
their heterosexual counterparts,
irrespective of gender or the different
age distribution in the populations45
.
Guidance for commissioners of drug and alcohol services 11
5	Effective treatment can
reduce harm and increase
economic savings
Commissioners know that drug and alcohol
misuse affects an individual’s health and
impacts their local communities. The
impacts outlined in this guide should all be
of interest and importance to commissioners
as they seek to meet the health needs of
local populations, and deliver improved
public health and wellbeing.
Where provided by trained and experienced
staff, the evidence base for drug and
alcohol treatment is strong, demonstrating
the positive impact that such services can
have. From a purely economic point of
view, investment in effective treatment
and recovery services makes sense for
commissioners as they seek to ensure good
value for the public purse. The National
Institute for Health and Clinical Excellence
(NICE) produced clinical guidance for these
services in 2007, accompanied by a Costing
Report for their implementation. The
Costing Report indicates that:
•	 the total savings through implementing
the guideline attributable to healthcare
have been estimated as being almost
£4 million46
•	 an additional £37 million of savings
to society have been estimated outside of
the NHS in the criminal justice system46
•	 at an individual level research has shown
that for every £1 spent on treatment,
an estimated £2.50 is saved47
.
Good quality drug and alcohol services are
important to commissioners for more than
purely financial reasons. They can help
people to achieve their recovery potential
and as such benefit individuals directly.
Intervening early can reduce the chances
of ongoing misuse and the consequent
harms it may cause, thus reducing demand
on the use of NHS and other public services
in the future.
This can be particularly important given
the statistics in relation to co-morbidity.
Within the substance misuse treatment
sector, the prevalence of dual diagnosis has
been estimated at around 75% for those
in drug services48
, and 85% for those in
alcohol services49
. In mental health service
settings, prevalence studies50
have indicated
that around one-third of people with serious
mental health problems (such as psychosis
and bipolar disorder) have some level of
substance use problems.
Commissioning quality drug and alcohol
services will help to address the health
and well being needs of the local
population, reduce the burden on services
and help achieve improved value for money.
Drug services have developed significantly
over recent years, in part due to increased
investment and clear delivery imperatives.
The investment in drug services has led to
improved access to services coupled to a
reduction in waiting times for treatment
and support:
•	 of the approximately 204,000 clients
aged 18 and over in treatment contact
during 2010-11, just over 191,000 were
in treatment for 12 weeks or more, or
completed treatment free of dependency
before 12 weeks (93%)
•	 nearly all clients waited less than three
weeks to commence treatment (96%)51
– successful completion of treatment in
2011-12 was up by almost three times
the level seven years prior (approximately
11,000)38
.
These figures tell a story of success in
terms of improving access and outcomes
in drug services. However they do not
highlight the variation in service provision
and quality across the system. In part this
has been a consequence of the varying
priority commissioners have placed upon
investment in high quality drug and alcohol
services. We also know that some services
have found it hard to offer a comprehensive
range of interventions and to link effectively
with other services, particularly in cases of
co-morbidity and complex needs.
In terms of alcohol services, there were
just over 111,000 clients in contact with
structured treatment aged 18 and over who
cited alcohol as their primary problematic
substance in 2010-11. More than four-fifths
(82%) of all clients waited less than three
weeks to commence treatment. The number
of new treatment journeys commencing
in the year increased to almost 74,000 in
2010-11. The number and proportion of
successful completions also increased from
approximately 31,000 (48%) in 2009-10 to
nearly 36,000 (54%) in 2010-1152
.
These figures show improvement, but
the relative lack of investment in alcohol
services and minimal prioritisation of
alcohol treatment explains in part why
these services have been described as being
patchy and in some places underdeveloped.
Commissioners need to take account of the
necessity to enable providers to (a) offer
the NICE guideline approved psychological
and pharmacological treatments and
(b) plan service developments that align
with public health needs and imperatives,
as well as emerging quality standards
developed by NICE.
What do we know about current drug and alcohol services?
The last decade saw considerable
investment in the planning
and provision of drug services
in England and more people
have had access to services.
For example in drug services,
there has been a doubling in
the number of people receiving
treatment, while waiting times
have reduced significantly.
The picture is less encouraging in relation
to alcohol services. Recent reports suggest
that PCTs on average spent only 0.1% of
their budgets on alcohol services53
. The
Health Select Committee reported in 2010
that many commissioners did not have
a strategy for alcohol services and it was
acknowledged that the picture in relation
to provision was patchy35
. In the past
18 months the policy direction has shifted,
not only in respect of drug and alcohol
services but across health and social care
more broadly.
Below we set out the key areas of policy
that impact on the commissioning of drug
and alcohol services.
Government strategies: drugs,
alcohol, and mental health
•	 the Drug Strategy: ‘Reducing demand,
restricting supply, building recovery:
supporting people to live a drug-free life.’
Published in December 2010, this has an
emphasis on supporting recovery from
drug and alcohol dependence. The first
annual review of the drug strategy was
released in May 2012. www.homeoffice.
gov.uk/publications/alcohol-drugs/drugs/
drug-strategy/drug-strategy-2010
•	 the Alcohol Strategy: published in
March 2012, this sets out the
Government’s proposals to address
alcohol use. It focuses on plans to deal
with ‘binge drinking’. It also aims to
reduce alcohol related violence and
disorder and reduce the number of
people drinking to damaging levels.
www.homeoffice.gov.uk/publications/
alcohol-drugs/alcohol/alcohol-
strategy?view=Binary
•	 the mental health outcomes strategy
for people of all ages: ‘No Health
without Mental Health’ makes a
commitment to ‘parity of esteem between
mental and physical health services’,
and has a clear objective to improve the
physical health of those with a mental
disorder54
. The strategy is now supported
by an Implementation Framework.
www.dh.gov.uk/prod_consum_dh/
groups/dh_digitalassets/documents/
digitalasset/dh_124058.pdf
NHS reforms
A range of changes to the way in which
services are commissioned and delivered
are contained in the Health and Social
Care Act. They include:
•	 Clinical Commissioning Groups: hold
the local budget for health care and are
responsible for deciding what services
should be delivered and by whom. They
will be accountable to NHS England.
•	 NHS England: will support and regulate
the CCGs, and it will have a limited
commissioning function in respect of
specific national services.
•	 ‘Any Qualified Provider’: the market
environment in the NHS and social
care has expanded to admit a wider
range of independent and voluntary
sector providers.
•	 Health and Wellbeing Boards (HWBs):
The aim of HWBs is to consider how
prioritising health improvement
and prevention will best deliver benefits
for the health and wellbeing of the
local population.
•	 Public Health England (PHE): PHE
will take on the responsibility for the
monitoring of drug treatment through its
Knowledge and Information Directorate55
.
Directors of Public Health will be located
within local authorities, which will have
responsibility for health improvement
within their areas.
•	 outcomes: Improving outcomes &
supporting transparency – A public
health outcomes framework for England,
2013-16 was published in early 2012.
It sets out two outcome measures to
improve and protect the nation’s health
and wellbeing, and improve the health of
the poorest fastest:
–	 outcome one: increased life expectancy,
i.e. taking account of the health quality
as well as the length of life
–	 outcome two: reduced differences
in life expectancy and healthy life
expectancy between communities
(through greater improvements in more
disadvantaged communities).
The outcomes have four domains and a
set of indicators. Table 1 (overleaf) sets
out the outcomes that are of relevance to
drugs and alcohol services.
12 Practical Mental Health Commissioning
Guidance for commissioners of drug and alcohol services 13
The drug strategy: ‘Reducing
demand, restricting supply, building
recovery: supporting people to live
a drug-free life’
Commissioning which leads to good
drug and alcohol services as described
in this guide will support the delivery
of the national drug strategy. By
commissioning for outcomes and
recovery, commissioners can enable
services to:
•	enable people to be free from
dependence on drugs or alcohol
•	prevent/reduce drug related deaths
and blood borne viruses
•	improve mental and physical health
and wellbeing
•	contribute to a reduction in crime and
re-offending
•	improve the ability of patients
to access and sustain suitable
accommodation
•	improve the ability of patients to
gain and maintain appropriate
employment and/or training as part
of their recovery
•	provide accurate information on
drugs and alcohol through substance
misuse education.
These are among some of the central
elements that the drug strategy seeks
to deliver.
The Government’s alcohol strategy
Effective alcohol services will support
the delivery of the objectives described
in the Government’s alcohol strategy.
Commissioners should commission
services that will:
•	contribute to a reduction in the
number of alcohol-related deaths
•	a reduction in the number of adults
drinking above the NHS guidelines.
These are among some of the central
elements that the alcohol strategy seeks
to deliver that specialist alcohol services
can contribute to.
NICE guidelines
Drug and alcohol services should
be commissioned to provide a
range of interventions, including
those recommended by NICE. Of
particular importance is the need for
commissioners to ensure services
will deliver NICE guideline TA114 in
respect of the management of opioid
dependence56
and NICE Guideline
CG51 in respect of psychosocial
interventions for drug misuse14
.
Drug and alcohol services should
also be able to demonstrate adherence
to the NICE quality standards (boxes
6 and 7).
table 1
Domains Improving the wider
determinants of health
Health improvement Health protection Healthcare public health
and preventing premature
mortality
Indicators People with mental illness
or disability in settled
accommodation
Hospital admissions caused
as a result of self-harm
People presenting with HIV
at a late stage of infection
Mortality from causes
considered preventable
Re-offending Successful completion of
drug treatment
Public sector organisations
with board-approved
sustainable development
management plans
Mortality from liver disease
Employment for those
with a long-term health
condition including those
with a learning difficulty/
disability or mental illness
People entering prison
with substance misuse
issues who are previously
not known to community
treatment
Mortality from
communicable diseases
Domestic abuse Alcohol related admissions
to hospital
Suicide
Violent crime (including
sexual violence)
Self reported wellbeing Excess under 75 mortality
in adults with serious
mental illness
Statutory homelessness
What would a good drug and alcohol service look like?
A good drug and alcohol
service should be comprised
of a number of elements.
This section sets out some of
the key issues for commissioners
to think about.
Key components of a good
quality service
A comprehensive drug and alcohol service
will have the following features:
Assessment of patients’ needs
•	 the provision of comprehensive
assessment of need, including risk
assessment using recognised tools
•	 ensuring that assessment of need includes
not only the needs that arise from their
substance use, but identifies the recovery
goals and outcomes the service will seek
to achieve with the patient
•	 taking account of the physical needs of
the patient including the harms associated
with substance misuse, including blood
borne virus screening
•	 taking account of the psychiatric and
psychological needs of the patient,
including psychosis, depression, cognitive
impairment and broader issues of health
and wellbeing
•	 taking account of social factors including
housing and homelessness, employment
and social and family networks.
The provision of a range of interventions,
which may include:
•	 structured psychological and psycho-
social interventions – commissioners
should refer to NICE guidance and quality
standards for more information about
specific interventions
•	 appropriate and timely access to
prescribing including opioid substitution
therapy including methadone,
buprenorphine, giving access to injectable
treatments where this is clinically indicated
•	 medically assisted withdrawal for alcohol,
opioids and other drugs
•	 access to appropriate in-patient beds for
those people who require a period of
admission
•	 peer led support – where people provide
knowledge, experience, emotional, social
or practical help to each other (peer
support relies on the assets, skills and
knowledge in the community, and the
recognition that local people can offer
help in ways that are sometimes more
effective than professional help)55
•	 a directory of all local services should be
available to both professionals and the
public – commissioners should ensure that
such a directory exists in a range of ways
that enable easy access to information
•	 signposting to other services, such as
needle exchange, sexual health, housing,
employment, mental health services
including talking therapies
•	 be a source of information and advice
to other services, including colleagues
in primary care, general hospitals, adult
social care and children’s services
•	 fulfil responsibilities relating to
child protection and adult and child
safeguarding
•	 the provision of support for families and
carers, including the conducting of carer
assessments to identify support needs.
Workforce standards
Commissioners will need to commission
drug and alcohol services that can
demonstrate that they meet the necessary
statutory standards as set out by the
relevant professional regulatory bodies.
Individual professionals working in drug
and alcohol services should be able to
demonstrate and meet a range of core
standards and competencies.
There are a number of other advisory and
regulatory bodies including NICE, CQC
and Royal Colleges of Psychiatrists and
General Practitioners, Nursing & Midwifery
Council, General Medical Council, British
Pharmaceutical Association, British
Psychological Society, the Health Care
Professions Council, and British Association
of Social Workers.
This guide has described the range of
professionals that are often employed in
drug and alcohol services. To be able to
provide the right range of interventions
and services, commissioners and providers
will need to ensure there is a mix of
appropriately qualified and skilled staff
working within the service.
The Drugs and Alcohol National
Occupational Standards (DANOS) specify
the standards of performance that people
in the drugs and alcohol field should
be working to. They also describe the
knowledge and skills workers need in
order to perform to the required standard.
DANOS can be used to ensure that services
have a competent workforce and that
everyone has the knowledge and skills
to deliver services to the required quality
standards27
.
14 Practical Mental Health Commissioning
Guidance for commissioners of drug and alcohol services 15
A good drug and alcohol service will
usually function best as a specialist,
integrated team that includes a range
of professional health and social care
staff, under single management.
Commissioners and patients should
expect any services to have at its core
the aim of providing a holistic and
personalised care package for patients
that is both tailored to their specific
needs and which is focused on recovery.
The Expert Reference Group that has
developed this guide, has produced the
set of core principles described below to
assist commissioners. These state that a
good drug and alcohol service should be:
•	 commissioned on the basis of local
need and recognise the motivations
that underpin drug and alcohol use
•	 staffed by an appropriately
qualified and skilled group of staff
working within agreed standards of
competence with the necessary levels
of supervision and support – there
should be sufficient staff to ensure
there is the capacity to maintain the
service
•	 able to manage the full range of
complexity of need, including being
able to address the issues of co-
morbidity including mental and
associated physical health needs
•	 providing interventions that are
evidence based and should implement
the relevant NICE guidance
•	 providing a therapeutic environment for
patients that is non-judgmental where
they can expect to receive a good
quality assessment of their needs and a
range of evidence based treatments
•	 working with patients to enhance
their recovery potential and address
not only their substance dependence
but also the other factors impacted by
that dependence, including housing,
employment and social and family
networks
•	 providing continuity of care in
supporting people in recovery
•	 establishing, maintaining and building
on good links with other services,
including mental health services and
have a good knowledge of other local
resources
•	 using data and information to enable
regular and accurate performance
monitoring and review of effectiveness
and outcomes
•	 providing value for money to
commissioners and the public purse.
The DANOS standards are applicable to a
range of professionals working in substance
misuse services including commissioners of
substance misuse services, drugs and alcohol
workers, psychiatrists, psychotherapists,
social workers and probation officers who
regularly work with substance misusers27
.
The sorts of skills that should be expected to
be present within drug and alcohol services
should include:
•	 assessment of substance misuse
•	 risk assessment and management
•	 care planning
•	 knowledge of the law in respect of drugs
and alcohol
•	 knowledge of other relevant legislation
including the Mental Health Act, the
Mental Capacity Act and Safeguarding
•	 knowledge of other local services and
agencies including the criminal justice
system, housing, adult social care,
children’s services.
Commissioners and providers should also be
able to ensure that the workforce is suitably
equipped to meet the quality standards
described by NICE for the delivery of specific
intervention in drug and alcohol services.
Outcomes
There is increasing emphasis on the delivery
of outcomes in health services, not just in
terms of the wider public health outcomes
described earlier in this guide, but more
specifically those that apply to the service
provided and the outcomes experienced by
the patient. Commissioners may apply their
own outcomes at local level, in partnership
with providers, as part of their planning and
review processes.
The NICE Quality Standards for drug and
alcohol services provide a comprehensive
range of outcomes that commissioners
should ensure their local services are
delivering against. The quality standards can
be found in boxes 6 and 7.
Commissioners will be able to review
performance by using data from the
National Drug Treatment Monitoring
System (NDTMS) and use other NHS and
social care national outcome frameworks
to ensure delivery of improved outcomes.
box 4: Model of service delivery and core principles
16 Practical Mental Health Commissioning
Commissioning process
The commissioning process has been
well described in a range of JCP-MH
guides, including Practical Mental Health
Commissioning, published in March 20112
.
The National Treatment Agency has
also developed specific guidance for the
commissioning of recovery focused drug
and alcohol services with a set of resources
to support the Joint Strategic Needs
Assessment process18
.
Both documents provide commissioners
with helpful information about the
commissioning process and are
recommended for further reference.
Alongside those documents, the top-tips
in box 5 should help commissioners in
their thinking when commissioning a
drug and alcohol service.
What would a good drug and alcohol service look like? (continued)
•	 the commissioning process is a
continuous cycle through three key
stages: strategic planning, procuring
services and monitoring and
evaluation2
– commissioning should
be a dynamic process that is about
identifying and prioritising need
and apportioning resources to meet
those needs and achieve positive
outcomes in a spiral of continuous
improvement2
•	 examine the current services,
statutory, independent and voluntary
sector to determine what exists now
and what might be needed in the
future – understand the drug and
alcohol treatment system locally,
and address recovery challenges20
•	 the Joint Strategic Needs Assessment
process should be used to establish
local patterns of need and in
partnership with other stakeholders
agree local priorities for investment and
development and decommissioning
where necessary – taking account of
service re-design, changing service
models and practice, and ensuring the
provision of an appropriately skilled
and experienced workforce
•	 ensure that service providers are able
to deliver a range of services, with
an appropriate mix of staff that will
effectively address the complexity
of issues that those with addiction
present – this should include co-
morbidity with mental health and
physical health problems
•	 ensure there is an appropriate
range of services that are able to
meet demand and secure required
clinical treatment, reintegration and
recovery outcomes20
, and decide
which provider(s) will best meet the
local needs and procure clinically
effective services. In doing so
commissioners should be particularly
mindful of issues of quality and
patient safety, and where appropriate
commissioners should stimulate the
local market to ensure the value for
money, the right range of provision
and improved outcomes
•	 use the national benchmarks as
a guide for quality and standards
including NICE guidance for
drug and alcohol services and
interventions, CQC standards and
relevant good practice guidance.
Work in partnership with providers
to ensure contract compliance and
continuous improvements in quality
and outcomes20
, and ensure linkage
to clinical and corporate governance
requirements and monitor delivery,
effectiveness, outcomes and costs.
box 5: commissioning principles
Guidance for commissioners of drug and alcohol services 17
Statement 1
Health and social care staff receive
alcohol awareness training that
promotes respectful, non-judgmental
care of people who misuse alcohol.
Statement 2
Health and social care staff
opportunistically carry out screening
and brief interventions for hazardous
and harmful drinking as an integral
part of practice.
Statement 3
People who may benefit from specialist
assessment or treatment for alcohol
misuse are offered referral to specialist
alcohol services and are able to access
specialist alcohol treatment.
Statement 4
People accessing specialist alcohol
services receive assessments and
interventions delivered by appropriately
trained and competent specialist staff.
Statement 5
Adults accessing specialist alcohol
services for alcohol misuse receive
a comprehensive assessment that
includes the use of validated measures.
Statement 6
Children and young people accessing
specialist services for alcohol use
receive a comprehensive assessment
that includes the use of validated
measures.
Statement 7
Families and carers of people who
misuse alcohol have their own needs
identified, including those associated
with risk of harm, and are offered
information and support.
Statement 8
People needing medically assisted
alcohol withdrawal are offered
treatment within the setting most
appropriate to their age, the severity
of alcohol dependence, their social
support and the presence of any
physical or psychiatric co-morbidities.
Statement 9
People needing medically assisted
alcohol withdrawal receive medication
using drug regimens appropriate to
the setting in which the withdrawal
is managed in accordance with NICE
guidance.
Statement 10
People with suspected, or at high
risk of developing, Wernicke’s
encephalopathy are offered thiamine
in accordance with NICE guidance.
Statement 11
Adults who misuse alcohol are
offered evidence-based psychological
interventions, and those with alcohol
dependence that is moderate or
severe can in addition access relapse
prevention medication in accordance
with NICE guidance.
Statement 12
Children and young people accessing
specialist services for alcohol use are
offered individual cognitive behavioural
therapy, or if they have significant
comorbidities or limited social support,
a multi component programme of care
including family or systems therapy.
Statement 13
People receiving specialist treatment for
alcohol misuse have regular treatment
outcome reviews, which are used to
plan subsequent care.
box 6: NICE Quality Standards for Alcohol Dependence and Harmful Use11
18 Practical Mental Health Commissioning
The quality standard
describes markers of high-
quality, cost-effective
care that, when delivered
collectively, should
contribute to improving the
effectiveness, safety and
experience of care for people
with drug use disorders.
Statement 1
People who inject drugs have access
to needle and syringe programmes
in accordance with NICE guidance.
Statement 2
People in drug treatment are offered
a comprehensive assessment.
Statement 3
Families and carers of people with
drug use disorders are offered an
assessment of their needs.
Statement 4
People accessing drug treatment
services are offered testing and referral
for treatment for hepatitis B, hepatitis C
and HIV and vaccination for hepatitis B.
Statement 5
People in drug treatment are given
information and advice about the
following treatment options: harm-
reduction, maintenance, detoxification
and abstinence.
Statement 6
People in drug treatment are offered
appropriate psychosocial interventions
by their keyworker.
Statement 7
People in drug treatment are offered
support to access services that promote
recovery and reintegration including
housing, education, employment,
personal finance, healthcare and
mutual aid.
Statement 8
People in drug treatment are offered
appropriate formal psychosocial
interventions and/or psychological
treatments.
Statement 9
People who have achieved abstinence
are offered continued treatment or
support for at least six months.
Statement 10
People in drug treatment are given
information and advice on the NICE
eligibility criteria for residential
rehabilitative treatment.
box 7: NICE quality standard for drug use disorders13
What would a good drug and alcohol service look like? (continued)
Supporting the delivery of the mental health strategy
The JCP-MH believes that commissioning
which leads to good drug and alcohol
services as described in this guide will
support the delivery of No Health without
Mental Health.
Shared objective 1:
More people will have
good mental health.
Commissioning effective drug and alcohol
services will enable the identification of
associated mental health problems and
ensure access to appropriate assessment,
diagnosis treatment and support.
Shared objective 2:
more people with mental
health problems will recover.
Many people with drug and alcohol
problems have co-morbidity, therefore
effective services will be able to jointly
work with people, alongside mental health
services utilising a recovery oriented
approach that enables them to achieve
greater independence and enhance their
prospects of sustained recovery.
Shared objective 3:
more people with mental
health problems will have
good physical health.
Ensuring the provision of effective drug
and alcohol services will enable those
people who have co-morbid mental health
problems to have their physical health
needs properly assessed and treated.
The identification of these needs and
action to address them will result in
improved physical health.
Shared objective 4:
more people will have a positive
experience of care and support.
Addressing drug and alcohol dependency
alongside mental health problems (where
they are present) can improve the chances
of the patient experiencing a more holistic
service that should have a positive impact
on their health and wellbeing. A joined-
up approach is more likely to improve a
person’s experience of services. The use
of peer support and mutual aid can be a
helpful means through which to engage
those who use services in a contribution,
not only to recovery, but to building a
positive experience of care and treatment
for others57
.
Shared objective 5:
fewer people will suffer
avoidable harm.
Assessing the risk of harm and providing
a service that will have as one of its aims
an objective to reduce it should help to
reduce the incidence of harm, reduce
the need for future intervention such as
hospital admission and ongoing treatment,
and provide patients with strategies for
remaining free from both harm and
dependence on drugs and/or alcohol.
Shared objective 6:
fewer people will experience
stigma and discrimination.
By commissioning services that recognise
the connections and linkages between
drug and alcohol misuse and mental health
problems, commissioners will be actively
addressing the stigma and discrimination
that many people experience as a
consequence of their addiction and/or
mental health needs.
Guidance for commissioners of drug and alcohol services 19
20 Practical Mental Health Commissioning
Drug and Alcohol
Expert Reference Group Members
•	 Owen Bowden-Jones
(ERG Chair)
Consultant Psychiatrist and Lead
Clinician for Club Drug Clinic
Central and North West London NHS
Foundation Trust
•	 Andre Geel
Chartered & Consultant
Clinical Psychologist
Central and North West London
NHS Foundation Trust
•	 Chris Fitch
Research and Policy Fellow
Royal College of Psychiatrists
•	 Diane Goslar
Service user consultant
•	 Emily Finch
Clinical Director
South London and Maudsley NHS
Foundation Trust
•	 Ellie Gordon
Clinical and Transformational Lead
for NHS Continuing Healthcare
North Yorkshire and Humber
Commissioning Support Unit
Development process
This guide has been written by a group
of drug and alcohol service experts,
in consultation with patients and carers.
Each member of the Joint Commissioning
Panel for Mental Health received drafts
of the guide for review and revision, and
advice was sought from external partner
organisations and individual experts. Final
revisions to the guide were made by the
Chair of the Expert Reference Group in
collaboration with the JCP’s Editorial Board
(comprised of the two co-chairs of the
JCP-MH, one user representative, one
carer representative, and technical and
project management support staff).
Acknowledgements
This guide was led and written by
Steve Appleton, Owen Bowden Jones,
and Chris Fitch.
Steve Appleton
Steve Appleton is the Managing Director
of Contact Consulting, a specialist
consultancy and research practice working
at the intersection of health, housing and
social care. He has held operational and
strategic posts in local authorities and
the NHS, with a specialist interest in the
health, housing and social care needs
of people with mental health problems,
substance misuse needs, learning disability,
older people and offender health
•	 Jonathan Campion
Director for Public Mental Health
and Consultant Psychiatrist
South London and Maudsley
NHS Foundation Trust
•	 Kostas Agath
Medical Director
Addaction
•	 Lesley Andrews
Head of Service
Kent Drug and Alcohol Action Team
•	 Martin Barnes
Chief Executive
Drug Scope
•	 Mick Davies
Regional Manager
Huntercombe Group
•	 Nuzhat Anjum
Head of Public Health Commissioning
NHS Redbridge
•	 Pete Burkinshaw (Observer)
Skills and Development Manager
National Treatment Agency
•	 William Butler
Chair (at time of guide development)
Substance Misuse Skills Consortium
Guidance for commissioners of drug and alcohol services 21
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22 Practical Mental Health Commissioning
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NICE PHB6. www.publications.nice.org.
uk/alcohol-phb6
32 Action for Children (2009) Neglect:
research evidence to inform practice.
www.actionforchildren.org.uk/
media/143188/neglectc_research_
evidence_to_inform_practice.pdf
33 Strategic Review of Health Inequalities
in England Commission (2010) Fair Society,
Healthy Lives. The Marmot Review
February. www.instituteofhealthequity.org/
34 Health Protection Agency (2011)
Hepatitis C in the UK
www.hpa.org.uk/webc/HPAwebFile/
HPAweb_C/1309969906418
35 Health Select Committee
http://bit.ly/8i5Hvq
36 British Medical Association (2013).
Drugs of dependence. The role of
medical professionals. http://bma.org.uk/
news-views-analysis/in-depth-drugs-of-
dependence/full-report
37 National Treatment Agency for
Substance Misuse (2012) From Access
to Recovery: Analysing six years of drug
treatment data. www.nta.nhs.uk/uploads/
six-yearstudy.pdf
38 National Treatment Agency for
Substance Misuse (2012) Drug treatment
2012: the progress made, the challenges
ahead. www.nta.nhs.uk/uploads/
commentaryfinal%5B0%5D.pdf
39 The NHS Information Centre Statistics
on Alcohol www.ic.nhs.uk/pubs/alcohol11
40 NHS Information Centre for Health
and Social Care (2009) Adult Psychiatric
Morbidity in England, 2007: Results of a
Household Survey. www.ic.nhs.uk/pubs/
psychiatricmorbidity07
41 World Health Organization (2008).
Global burden of disease report. WHO.
42 Royal College of Psychiatrists (2011).
Our Invisible Addicts. CR165. London:
RCPsych CR165. www.rcpsych.ac.uk/
publications/collegereports/cr/cr165.aspx
43 Centre for Mental Health, DrugScope,
and the UK Drug Policy Commission
(2012) Dual diagnosis: a challenge for
the reformed NHS and for Public Health
England. www.ukdpc.org.uk/publication/
dual-diagnosis-challenge-reformed-nhs/
44 Department of Health (2002). Mental
Health Policy Implementation Guide
http://webarchive.nationalarchives.
gov.uk/+/www.dh.gov.uk/en/
Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/
DH_4009350
45 UK Drug Policy Commission (2010).
Drugs and Diversity: Lesbian, gay, bisexual
and transgender (LGBT) communities.
Learning from the evidence. www.ukdpc.
org.uk/wp-content/uploads/Policy%20
report%20-%20Drugs%20and%20
diversity_%20LGBT%20groups%20
%28policy%20briefing%29.pdf
46 Wellbeing Enterprises CIC/NTA/NHS
Nottinghamshire. http://bit.ly/VlnZHn
and http://bit.ly/V9U9r1
47 Home Office (2009) The Drug
Treatment Outcomes Research Study: Cost
Effectiveness Analysis. www.dtors.org.uk/
reports/DTORS_CostEffect_Main.pdf
48 Weaver T, Charles V, Madden P,
and Renton A. (2002) A study of the
Prevalence and Management of Co-
Morbidity amongst Adult Substance
Misuse & Mental Health Treatment
Populations. London: Imperial College.
http://dmri.lshtm.ac.uk/docs/weaver_
es.pdf
49 Saunders B & Robinson S (2002)
Co-occurring mental health and drug
dependency: workforce development
challenges for the AOD field. Drug and
Alcohol Review, 21, 231-237.
50 Menezes PR, Johnson S, Thornicroft G
et al (1996) Drug and alcohol problems
among individuals with severe mental
illness in south London. British Journal of
Psychiatry, 168: 612-619.
Guidance for commissioners of drug and alcohol services 23
51 National Treatment Agency for
Substance Misuse (2011). Statistics from
the National Drug Treatment Monitoring
System (NDTMS) 1 April 2010– 31
March 2011. www.nta.nhs.uk/uploads/
statisticsfromndtms201011vol1
thenumbers.pdf
52 National Treatment Agency for
Substance Misuse (2012). Statistics from
the National Drug Treatment Monitoring
System (NDTMS) 1 April 2010– 31
March 2011. www.nta.nhs.uk/uploads/
natmsannualstatisticsreport2010-11.pdf
53 Alcohol Concern (2011) Making
alcohol a health priority. Opportunities
to reduce alcohol harms and rising costs.
www.alcoholconcern.org.uk/assets/
files/Publications/2011/Making%20
alcohol%20a%20health%20priority-
opportunities%20to%20curb%20
alcohol%20harms%20and%20
reduce%20rising%20costs.pdf
54 Royal College of Psychiatrists (2012)
Achieving parity of esteem between
mental and physical health. Executive
summary. www.rcpsych.ac.uk/pdf/
Parity%20of%20Esteem%20briefing%20
Feb%202012.pdf
55 Department of Health (2012) Structure
of Public Health England. Factsheet.
www.rcpsych.ac.uk/pdf/Structure%20
of%20Public%20Health%20England.pdf
56 National Institute for Health and
Clinical Excellence (2007). Drug misuse
- methadone and buprenorphine. NICE
TA114. www.nice.org.uk/TA114
57 Alcohol Concern (2010) Developing
choice in peer-support. How alcohol
services can support SMART Recovery.
www.alcoholconcern.org.uk/assets/files/
Publications/Developing%20choice%20
in%20peer%20support%281%29.pdf
A large print version of this document is available from
www.jcpmh.info
Published May 2013
Produced by Raffertys

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Guidance for commissioners of drug and alcohol services

  • 1. Guidance for commissioners of drug and alcohol services 1 Practical mental health commissioning Guidance for commissioners of drug and alcohol services Joint Commissioning Panel for Mental Health www.jcpmh.info
  • 2. Joint Commissioning Panel for Mental Health Co-chaired by: Membership: www.jcpmh.info
  • 3. 2 Practical Mental Health Commissioning Contents Ten key messages for commissioners Introduction 04 What are drug and alcohol services? Why are drug and alcohol services important to commissioners? 06 08 What do we know about current drug and alcohol services? 12 What would a good drug and alcohol service look like? 14 Supporting the delivery of the mental health strategy 19 References 21
  • 4. Guidance for commissioners of drug and alcohol services 3 Ten key messages for commissioners 1 Investment in drug and alcohol services gets results. Treatment, as part of a co-ordinated public health approach is proven to be cost effective for health services and society as a whole. Disinvestment brings with it a risk of reversing the progress made over recent years. 2 A strong evidence base exists for the range of interventions that are effective in substance misuse. Commissioning should be based upon this evidence using NICE quality standards. 3 To be effective, the treatment system should be equipped to respond to the full range of complexity of need represented by those who misuse substances. 4 A skilled workforce, working under appropriate supervision and providing care within national competence frameworks, is key to delivering good outcomes. 5 Collaboration and partnership gets results. The NHS and voluntary sector have a contribution to make in the delivery of drug and alcohol services. 6 Commissioning of drug and alcohol services should be based upon accurate and up to date information about local needs. 7 Commissioners should ensure that local services have clear leadership, both clinical and managerial, and that services comply with professional and service standards. 8 Commissioning of drug and alcohol services should be outcome based and make use of available data and information. 9 Services should place recovery at the centre of their approach and commissioners should recognise recovery as central to their commissioning and strategic decision making. 10 Treatment is not simply about patients – it should address the needs of families and carers, and work with patients’ wider social networks.
  • 5. The Joint Commissioning Panel for Mental Health (JCP-MH) (www.jcpmh.info) is a collaboration co-chaired by the Royal College of General Practitioners and the Royal College of Psychiatrists. It brings together leading organisations and individuals with an interest in commissioning for mental health and learning disabilities. These include: • People with mental health problems • Carers • Department of Health • Association of Directors of Adult Social Services • NHS Confederation • Mind • Rethink Mental Illness • National Survivor User Network • National Involvement Partnership • Royal College of Nursing • British Psychological Society • Representatives of the English Strategic Health Authorities (prior to April 2013) • Mental Health Providers Forum • New Savoy Partnership • Representation from Specialised Commissioning • Healthcare Financial Management Association. Introduction The JCP-MH is part of the implementation arm of the government mental health strategy No Health without Mental Health1 . The JCP-MH has two primary aims: • to bring together people with mental health problems, carers, clinicians, commissioners, managers and others to work towards values-based commissioning • to integrate scientific evidence, the experience of people with mental health problems and carers, and innovative service evaluations, in order to produce the best possible advice on commissioning the design and delivery of high quality mental health, learning disabilities, and public mental health and wellbeing services. The JCP-MH: • has published Practical Mental Health Commissioning2 , a briefing on the key values and principles for effective mental health commissioning • has so far published seven other practical guides on the commissioning of primary mental health care services3 , dementia services4 , liaison mental health services to acute hospitals5 , transition services6 , perinatal mental health services7 , public mental health services8 , and rehabilitation services9 • provides practical guidance and a developing framework for mental health • will support commissioners to deliver the best possible outcomes for community health and wellbeing. Who is this guide for? This guide has been written to provide practical advice on developing and delivering local plans and strategies to commission the most effective and efficient drug and alcohol services for adults. Based upon clinical best practice guidance and drawing upon the range of available evidence, it describes what should be expected of a modern drug and alcohol service in terms of effectiveness, outcomes and value for money. The guide will be of particular use to: • public health leaders who will hold responsibility for commissioning these services • Clinical Commissioning Groups (CCGs) • wider local authority commissioners • and voluntary and independent sector organisations. This guide does not cover drug and alcohol services for children or offenders, whose needs may be more specific. More information can be found in the publication Practice Standards for Young People with Substance Misuse Problems10 . 4 Practical Mental Health Commissioning
  • 6. Guidance for commissioners of drug and alcohol services 5 HOW WILL THIS GUIDE HELP YOU? This guide has been written by a group of drug and alcohol professionals, people who use drug and alcohol services, and carers. The content is primarily evidence-based, but ideas deemed to be best practice by expert consensus have also been included. By the end of this guide, readers should be better equipped to: • understand what an effective range of drug and alcohol services should look like • know the sorts of interventions that should be available • understand how those interventions can contribute to achieving recovery and make improvements in public mental health and wellbeing. In doing this, the guide describes: • the benefits of drug and alcohol services • the desirable team configurations for drug and alcohol services • the policy context for drug and alcohol services • what good quality drug and alcohol services look like • the benefits of providing good quality drug and alcohol services • how drug and alcohol services can make a contribution to a range of other imperatives including those in the national mental health strategy. The guide draws upon, and signposts towards, previously published guidance and policy. Among the key documents drawn upon are: • NICE quality standards for alcohol dependence and harmful alcohol use (QS11)11 • Alcohol dependence and harmful alcohol use CG115 (NICE)12 • NICE quality standards for drug use disorders (QS23)13 • Drug misuse – psychosocial interventions CG51 (NICE)14 • Drug misuse – opioid detoxification CG52 (NICE)15 • Improving outcomes & supporting transparency – a public health outcomes framework for England, 2013-16 (Department of Health)16 • The Government’s Alcohol Strategy (HM Government 2012)17 • JSNA Support Pack for Commissioners (National Treatment Agency)18 • No Health without Mental Health (DH)1 • Medications in recovery. Re-orientating drug dependence treatment (National Treatment Agency 2012)19 • Commissioning for Recovery (National Treatment Agency)20 • Drug Strategy 2010 – Reducing Demand, Restricting Supply, Building Recovery (HM Government)21 • Healthy lives, healthy people: our strategy for public health in England (HM Government)22 • the roles and competencies of doctors working in substance misuse23 • Alcohol use disorders: physical complications CG100 (NICE)24 • Alcohol disorders – preventing the development of hazardous and harmful drinking PH24 (NICE)25 . This guide does not cover non-structured interventions for non-dependent drinkers.
  • 7. 6 Practical Mental Health Commissioning What are drug and alcohol services? Effective treatment provides a central means for people dependent on drugs or alcohol to recover from their addiction and to live independent lives. It can deliver a wider range of public health and social benefits, and can also bring about economic savings at the local and national level (see page 9). Local authority-based public health is now responsible for commissioning drug and alcohol prevention, treatment and linked recovery support. This shift will provide a platform for a more integrated approach to improving public health outcomes. This approach addresses the root causes and wider determinants of drug dependence and alcohol misuse, and the harm and impact they have on people who use drugs or alcohol, carers, families and communities (such as mental health, employment, education, crime and housing). It also delivers the greatest gains for individuals and the community. There is no nationally agreed model for the commissioning and delivery of drug and alcohol services. The result of this has been a continuation of local plans for services that attempt to address not only local need, but also national imperatives. Although a locally based approach is important it can have the negative consequence of different and varied approaches across the country. However, the existence of NICE quality standards, the National Drug Treatment Monitoring System, local needs assessments, Joint Strategic Needs Assessment tools and the publication of guidance such as this, means that commissioners now have a wide range of tools to enable them to commission effectively. THE SERVICES
  • 8. Drug and alcohol services are mainly provided by NHS Trusts or voluntary sector services, although the private sector also plays a smaller role in provision. In the majority of cases, patients coming to drug and alcohol services self-refer rather than being referred by a GP. Drug and alcohol services employ a range of expertise including front line doctors, psychologists, senior nurses, and drug workers. This skill mix makes them well equipped to conduct complex work with a client group often perceived as challenging. In the past, drug and alcohol services tended to be provided by separate drug and alcohol teams, but recently they are more commonly delivered from teams that deal with both. These aim to provide a more integrated approach, particularly for those people who have a problematic use of both substances. For some people this approach has not been successful in relation to enabling access to services (e.g. due to the stigma associated with particular types of substance misuse). Most secondary care services tend to concentrate their interventions on people with addictions to drugs such as heroin, crack cocaine and alcohol. However, other substances, for example emerging club drugs and prescribed drugs, may be among those for which people are treated. Given the complexity of these problems and the range of needs, services are required to collaborate with other parts of the health, social care and criminal justice systems. This is essential to the delivery of effective high quality treatment. This is especially the case when providing services to those people with co-morbid illness, (e.g. substance misuse and mental illness, or substance misuse and physical health needs). This is often because people with co-morbid illness are often excluded from general mental health services. One of the functions of drug and alcohol services is to work with this group. In parts of the country where Drug & Alcohol Action Teams (DAATs) are in operation, these have introduced Local Area Single Assessment and Referral Systems (LASARS) as part of a national pilot of drug recovery Payment by Results. The core function of LASARS is to assess and set a tariff, refer and in some cases review achievement of outcome. They may also reduce the number of assessments that an individual has to undertake in order to access those services26 . WHO WORKS IN THESE SERVICES? A wide range of people from a number of disciplines and specialisms work in drug and alcohol services including: • medical staff including specialist doctors (addiction psychiatrists and a small number of highly specialist General Practitioners) • nurses (both mental health and general nursing) • drug and alcohol support workers • non-medical prescribers (especially trained nurses or pharmacists) • peer mentors • pharmacists • psychologists and other specialist therapists • people who are experts by experience • social workers/care managers. Those working in drug and alcohol services are expected to work to a set of national occupational standards and, potentially, also the skills framework promoted by The Substance Misuse Skills Consortium. Alongside these are the competencies required by specific professional bodies, including the Royal College of Psychiatrists, Royal College of Nursing, Royal College of General Practitioners, and those representing other allied health and social care professionals. The Substance Misuse Skills Consortium is an independent, sector-led initiative to harness the ideas, energy and talent within the substance misuse treatment field, to maximise the ability of the workforce, and help more drug and alcohol misusers to recover27 . Commissioners will find helpful guidance in the Drugs and Alcohol National Occupational Standards (DANOS) framework described later in this guide (page 14), but should be aware that it does not cover all professional groups. Guidance for commissioners of drug and alcohol services 7
  • 9. Why are drug and alcohol services important to commissioners? Among the reasons why drug and alcohol services are important to commissioners are: 1 drug and alcohol use can have a significant and negative impact on individuals and wider society 2 drug and alcohol use can also have a public health impact 3 considerable economic costs are associated with drug and alcohol use 4 there is a relatively common use of drugs and alcohol among the UK population 5 these harms, impacts and costs can be reduced through effective treatment, with important economic savings. 1 SOCIAL IMPACT The Government’s drug strategy identifies that drug and alcohol problems not only negatively impact on the lives of people using these substances, but are also the “key causes of societal harm, including crime, family breakdown and poverty”21 . For example: • crime – there were 278,000 recorded drug offences in the UK in 2009/1028 and 9% of the population were engaged in illicit drug use in 2010/1129 . As a society, although drugs cost the UK £15 billion each year29 , investment in drug services has been estimated at approximately £1.3 billion per year28 . However, drug treatment has been shown to be effective in preventing drug-related offending, with an estimated five million offences being prevented in 2010-11 alone30 . Each year, alcohol is associated with 500,000 recorded crimes in England, 125,000 instances of domestic violence and 1,000,000 assaults31 . • family difficulties – families with parental substance misuse frequently appear in social services statistics: around one in five families referred to children’s social services in the UK have a history of alcohol or drugs problems, rising to one in two families on the Child Protection Register and affecting three out of four families involved in care proceedings32 . • poverty – English local authority areas with higher levels of deprivation will have higher numbers of problem drug users, and higher admission rates for drug treatment services33 . The Marmot Review published in 2010 highlighted a range of health inequalities and set out actions to address them, including an approach to substance misuse to alleviate the impact of alcohol in particular on people living in more deprived settings33 . 2 PUBLIC HEALTH IMPACT The public health consequences of drug and alcohol use are also significant. The primary harms include transmission of blood borne viruses, including Hepatitis B, C and HIV. Estimates suggest that around 216,000 individuals are chronically infected with hepatitis C in the UK34 . There are also various forms of harm that may be caused by addiction to drugs or alcohol including acute harms: • death by overdose • intoxication • accidental injury • suicide • precipitation or exacerbation of mental illnesses such as psychosis. Chronic harms can also occur, including: • cirrhosis and other liver damage • consequences of injecting – for example, abscesses, vein damage, endocarditis • sexually transmitted diseases • dependence including withdrawal symptoms • hypertension • stroke • coronary heart disease • pancreatitis • depression • anxiety disorders. 8 Practical Mental Health Commissioning
  • 10. Guidance for commissioners of drug and alcohol services 9 BOX 1: Reasons for drug and alcohol use People use drugs and alcohol for a variety of reasons. For many people this use of substances does not turn into what is termed misuse. It is equally important to bear in mind that no-one starts using substances with the intention to develop misuse problems. Some of the reasons why people begin to use drugs and/or alcohol might include: because the initial reactions and experiences are pleasurable; response to social or family circumstances, such as bereavement/ loss, unemployment, relationship difficulties, loss of accommodation; response to peer pressure; to remove stress or other psychological difficulties; criminal or other antisocial antecedents. box 2: Types of drug use36 Recreational use Many people are able to use psychoactive substances in a recreational manner that causes no problems to the individual or those around them. This pattern of use is usually characterised by moderate levels of consumption and periods when the person stops using the substance without difficulty. Harmful use A pattern of psychoactive substance use that is causing damage to health. The damage may be physical or psychological. Dependent use Dependence has both psychological and physiological elements. Psychological dependence involves a need for repeated doses of the drug to feel good, or avoid feeling bad. Physiological dependence is associated with tolerance, where increased doses of the drug are required to produce the effects originally produced by lower doses, and development of withdrawal syndrome when the drug is withdrawn. Withdrawal syndrome is characterised by physiological and psychological symptoms that are specific to a particular drug. The term ‘dependence’ is often used interchangeably with ‘addiction’. 3 ECONOMIC COSTS Alcohol There were 1.2 million alcohol-related hospital admissions during 2010/1117 . Alcohol consumption has nearly trebled since 1950 with more than seven million people drinking at harmful or hazardous levels and who together account for about 80% of all spending on alcoholic drink35 . It costs the NHS in England up to £2.7 billion a year to treat the chronic and acute effects of drinking24 . The Government’s alcohol strategy indicates that alcohol-related harm is now estimated to cost society £21 billion annually17 . Drug use Drug use costs the UK £15.4 billion each year, including welfare benefit expenditure costs of approximately £1.6 billion per year21 . 4 PREVALENCE Drugs Prevalence of substance misusevaries for different types of substances. Recent years have shown different patterns of use, with a trend towards an increase in the misuse of over the counter medicines and new substances, including those known as club drugs such as mephedrone, ketamine and legal highs.
  • 11. 10 Practical Mental Health Commissioning box 3: Prevalence of drug and alcohol use • Estimates from the 2010/11 British Crime Survey show that 36% of adults aged 16-59 have used illicit drugs in their lifetime, which equates to almost 12 million people. Among this group, almost 9% or 2.9 million adults had used illicit drugs in the last year29 . • The National Treatment Agency reported that in 2009-10 in England there were 306,000 users of opiates and/or crack cocaine corresponding to almost 1% of the adult population (this number represents the total number of users, rather than those in treatment alone). In 2011 reported use of mephedrone in the last 12 months was 1.4% and ecstasy 1.4% among 16-59 year olds31 . • Investment in drug treatment services is widely recognised to have been a factor in the reduction of illicit drug use. • Around 200,000 people get help for drug dependence in England every year, with around 135,000 being treated on any given day37 . • Nearly one third of users in the last seven years successfully completed their treatment and did not return, which compares favourably to international recovery rates38 . • Drug misuse in this country remains a significant factor in poor health outcomes, criminality and worklessness and continues to have far reaching effects upon individuals, families and society as a whole. Alcohol • Alcohol consumption in the UK has almost trebled since 1950 with more than 7 million people drinking at harmful or hazardous levels. Together they account for about 80% of all spending on alcoholic drink35 . Since 2002/03 there has been a 40% increase in admissions to hospital where the primary diagnosis was attributable to the consumption of alcohol39 . • In the same period there were almost 168,000 prescription items for drugs for the treatment of alcohol dependency prescribed in primary care settings or NHS hospitals and dispensed in the community which is a 63% increase compared to 200339 . • Quantities of alcohol consumption across the population have been rising. Recent research shows that 24% of adults engage in hazardous drinking while nearly 4% engage in harmful drinking. Almost 6% of adults are known to be dependent on alcohol40 . Higher consumption of alcohol is associated with depression and the risk of suicide is eight times higher among those with current alcohol misuse or dependence. Alcohol misuse by young people is associated with a six-fold increased risk of depression41 . • The Royal College of Psychiatrists report, Our Invisible Addicts showed that the misuse of drugs in older people (65 and over) is a problem that is likely to grow and that misuse in the over-40s has increased significantly in recent years42 . By 2031 there is predicted to be a 50% increase of complex substance misuse in the over 65s (e.g. excessive alcohol consumption as well as inappropriate use of prescribed and over the counter medications). Co-morbidity • The 2002 Co-morbidity of Substance Misuse and Mental Illness Collaborative study (COSMIC) concluded that: – 75% of users of drug services and 85% of users of alcohol services were experiencing mental health problems – 30% of the drug treatment population and over 50% of those in treatment for alcohol problems had ‘multiple morbidity’ – 38% of drug users with a psychiatric disorder were receiving no treatment for their mental health problem – 44% of mental health service users either reported drug use or were assessed to have used alcohol at hazardous or harmful levels in the past year43 . • The term ‘co-morbidity’ covers a broad spectrum of mental health and substance misuse problems that an individual might experience concurrently. The nature of the relationship between these two conditions is complex. Possible mechanisms include: – a primary psychiatric illness precipitating or leading to substance misuse – substance misuse precipitating, worsening or altering the course of a psychiatric illness – intoxication and/or substance dependence leading to psychological symptoms – substance misuse and/or withdrawal leading to psychiatric symptoms or illnesses44 . • The complexity of issues can make diagnosis, care and treatment more difficult, with service users being at higher risk of relapse, readmission to hospital and suicide44 . • Dual diagnosis: a challenge for the reformed NHS and for Public Health England has reinforced the need for commissioners to develop effective services for dual diagnosis and that those services are central to the achievement of key policy objectives, including drug recovery43 . High risk groups • There are a number of groups of people who may be at higher risk of misuse of drugs and alcohol. As an example, recent research has shown that drug use among Lesbian Gay Bisexual and Trans- gender groups is higher than among their heterosexual counterparts, irrespective of gender or the different age distribution in the populations45 .
  • 12. Guidance for commissioners of drug and alcohol services 11 5 Effective treatment can reduce harm and increase economic savings Commissioners know that drug and alcohol misuse affects an individual’s health and impacts their local communities. The impacts outlined in this guide should all be of interest and importance to commissioners as they seek to meet the health needs of local populations, and deliver improved public health and wellbeing. Where provided by trained and experienced staff, the evidence base for drug and alcohol treatment is strong, demonstrating the positive impact that such services can have. From a purely economic point of view, investment in effective treatment and recovery services makes sense for commissioners as they seek to ensure good value for the public purse. The National Institute for Health and Clinical Excellence (NICE) produced clinical guidance for these services in 2007, accompanied by a Costing Report for their implementation. The Costing Report indicates that: • the total savings through implementing the guideline attributable to healthcare have been estimated as being almost £4 million46 • an additional £37 million of savings to society have been estimated outside of the NHS in the criminal justice system46 • at an individual level research has shown that for every £1 spent on treatment, an estimated £2.50 is saved47 . Good quality drug and alcohol services are important to commissioners for more than purely financial reasons. They can help people to achieve their recovery potential and as such benefit individuals directly. Intervening early can reduce the chances of ongoing misuse and the consequent harms it may cause, thus reducing demand on the use of NHS and other public services in the future. This can be particularly important given the statistics in relation to co-morbidity. Within the substance misuse treatment sector, the prevalence of dual diagnosis has been estimated at around 75% for those in drug services48 , and 85% for those in alcohol services49 . In mental health service settings, prevalence studies50 have indicated that around one-third of people with serious mental health problems (such as psychosis and bipolar disorder) have some level of substance use problems. Commissioning quality drug and alcohol services will help to address the health and well being needs of the local population, reduce the burden on services and help achieve improved value for money. Drug services have developed significantly over recent years, in part due to increased investment and clear delivery imperatives. The investment in drug services has led to improved access to services coupled to a reduction in waiting times for treatment and support: • of the approximately 204,000 clients aged 18 and over in treatment contact during 2010-11, just over 191,000 were in treatment for 12 weeks or more, or completed treatment free of dependency before 12 weeks (93%) • nearly all clients waited less than three weeks to commence treatment (96%)51 – successful completion of treatment in 2011-12 was up by almost three times the level seven years prior (approximately 11,000)38 . These figures tell a story of success in terms of improving access and outcomes in drug services. However they do not highlight the variation in service provision and quality across the system. In part this has been a consequence of the varying priority commissioners have placed upon investment in high quality drug and alcohol services. We also know that some services have found it hard to offer a comprehensive range of interventions and to link effectively with other services, particularly in cases of co-morbidity and complex needs. In terms of alcohol services, there were just over 111,000 clients in contact with structured treatment aged 18 and over who cited alcohol as their primary problematic substance in 2010-11. More than four-fifths (82%) of all clients waited less than three weeks to commence treatment. The number of new treatment journeys commencing in the year increased to almost 74,000 in 2010-11. The number and proportion of successful completions also increased from approximately 31,000 (48%) in 2009-10 to nearly 36,000 (54%) in 2010-1152 . These figures show improvement, but the relative lack of investment in alcohol services and minimal prioritisation of alcohol treatment explains in part why these services have been described as being patchy and in some places underdeveloped. Commissioners need to take account of the necessity to enable providers to (a) offer the NICE guideline approved psychological and pharmacological treatments and (b) plan service developments that align with public health needs and imperatives, as well as emerging quality standards developed by NICE.
  • 13. What do we know about current drug and alcohol services? The last decade saw considerable investment in the planning and provision of drug services in England and more people have had access to services. For example in drug services, there has been a doubling in the number of people receiving treatment, while waiting times have reduced significantly. The picture is less encouraging in relation to alcohol services. Recent reports suggest that PCTs on average spent only 0.1% of their budgets on alcohol services53 . The Health Select Committee reported in 2010 that many commissioners did not have a strategy for alcohol services and it was acknowledged that the picture in relation to provision was patchy35 . In the past 18 months the policy direction has shifted, not only in respect of drug and alcohol services but across health and social care more broadly. Below we set out the key areas of policy that impact on the commissioning of drug and alcohol services. Government strategies: drugs, alcohol, and mental health • the Drug Strategy: ‘Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life.’ Published in December 2010, this has an emphasis on supporting recovery from drug and alcohol dependence. The first annual review of the drug strategy was released in May 2012. www.homeoffice. gov.uk/publications/alcohol-drugs/drugs/ drug-strategy/drug-strategy-2010 • the Alcohol Strategy: published in March 2012, this sets out the Government’s proposals to address alcohol use. It focuses on plans to deal with ‘binge drinking’. It also aims to reduce alcohol related violence and disorder and reduce the number of people drinking to damaging levels. www.homeoffice.gov.uk/publications/ alcohol-drugs/alcohol/alcohol- strategy?view=Binary • the mental health outcomes strategy for people of all ages: ‘No Health without Mental Health’ makes a commitment to ‘parity of esteem between mental and physical health services’, and has a clear objective to improve the physical health of those with a mental disorder54 . The strategy is now supported by an Implementation Framework. www.dh.gov.uk/prod_consum_dh/ groups/dh_digitalassets/documents/ digitalasset/dh_124058.pdf NHS reforms A range of changes to the way in which services are commissioned and delivered are contained in the Health and Social Care Act. They include: • Clinical Commissioning Groups: hold the local budget for health care and are responsible for deciding what services should be delivered and by whom. They will be accountable to NHS England. • NHS England: will support and regulate the CCGs, and it will have a limited commissioning function in respect of specific national services. • ‘Any Qualified Provider’: the market environment in the NHS and social care has expanded to admit a wider range of independent and voluntary sector providers. • Health and Wellbeing Boards (HWBs): The aim of HWBs is to consider how prioritising health improvement and prevention will best deliver benefits for the health and wellbeing of the local population. • Public Health England (PHE): PHE will take on the responsibility for the monitoring of drug treatment through its Knowledge and Information Directorate55 . Directors of Public Health will be located within local authorities, which will have responsibility for health improvement within their areas. • outcomes: Improving outcomes & supporting transparency – A public health outcomes framework for England, 2013-16 was published in early 2012. It sets out two outcome measures to improve and protect the nation’s health and wellbeing, and improve the health of the poorest fastest: – outcome one: increased life expectancy, i.e. taking account of the health quality as well as the length of life – outcome two: reduced differences in life expectancy and healthy life expectancy between communities (through greater improvements in more disadvantaged communities). The outcomes have four domains and a set of indicators. Table 1 (overleaf) sets out the outcomes that are of relevance to drugs and alcohol services. 12 Practical Mental Health Commissioning
  • 14. Guidance for commissioners of drug and alcohol services 13 The drug strategy: ‘Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life’ Commissioning which leads to good drug and alcohol services as described in this guide will support the delivery of the national drug strategy. By commissioning for outcomes and recovery, commissioners can enable services to: • enable people to be free from dependence on drugs or alcohol • prevent/reduce drug related deaths and blood borne viruses • improve mental and physical health and wellbeing • contribute to a reduction in crime and re-offending • improve the ability of patients to access and sustain suitable accommodation • improve the ability of patients to gain and maintain appropriate employment and/or training as part of their recovery • provide accurate information on drugs and alcohol through substance misuse education. These are among some of the central elements that the drug strategy seeks to deliver. The Government’s alcohol strategy Effective alcohol services will support the delivery of the objectives described in the Government’s alcohol strategy. Commissioners should commission services that will: • contribute to a reduction in the number of alcohol-related deaths • a reduction in the number of adults drinking above the NHS guidelines. These are among some of the central elements that the alcohol strategy seeks to deliver that specialist alcohol services can contribute to. NICE guidelines Drug and alcohol services should be commissioned to provide a range of interventions, including those recommended by NICE. Of particular importance is the need for commissioners to ensure services will deliver NICE guideline TA114 in respect of the management of opioid dependence56 and NICE Guideline CG51 in respect of psychosocial interventions for drug misuse14 . Drug and alcohol services should also be able to demonstrate adherence to the NICE quality standards (boxes 6 and 7). table 1 Domains Improving the wider determinants of health Health improvement Health protection Healthcare public health and preventing premature mortality Indicators People with mental illness or disability in settled accommodation Hospital admissions caused as a result of self-harm People presenting with HIV at a late stage of infection Mortality from causes considered preventable Re-offending Successful completion of drug treatment Public sector organisations with board-approved sustainable development management plans Mortality from liver disease Employment for those with a long-term health condition including those with a learning difficulty/ disability or mental illness People entering prison with substance misuse issues who are previously not known to community treatment Mortality from communicable diseases Domestic abuse Alcohol related admissions to hospital Suicide Violent crime (including sexual violence) Self reported wellbeing Excess under 75 mortality in adults with serious mental illness Statutory homelessness
  • 15. What would a good drug and alcohol service look like? A good drug and alcohol service should be comprised of a number of elements. This section sets out some of the key issues for commissioners to think about. Key components of a good quality service A comprehensive drug and alcohol service will have the following features: Assessment of patients’ needs • the provision of comprehensive assessment of need, including risk assessment using recognised tools • ensuring that assessment of need includes not only the needs that arise from their substance use, but identifies the recovery goals and outcomes the service will seek to achieve with the patient • taking account of the physical needs of the patient including the harms associated with substance misuse, including blood borne virus screening • taking account of the psychiatric and psychological needs of the patient, including psychosis, depression, cognitive impairment and broader issues of health and wellbeing • taking account of social factors including housing and homelessness, employment and social and family networks. The provision of a range of interventions, which may include: • structured psychological and psycho- social interventions – commissioners should refer to NICE guidance and quality standards for more information about specific interventions • appropriate and timely access to prescribing including opioid substitution therapy including methadone, buprenorphine, giving access to injectable treatments where this is clinically indicated • medically assisted withdrawal for alcohol, opioids and other drugs • access to appropriate in-patient beds for those people who require a period of admission • peer led support – where people provide knowledge, experience, emotional, social or practical help to each other (peer support relies on the assets, skills and knowledge in the community, and the recognition that local people can offer help in ways that are sometimes more effective than professional help)55 • a directory of all local services should be available to both professionals and the public – commissioners should ensure that such a directory exists in a range of ways that enable easy access to information • signposting to other services, such as needle exchange, sexual health, housing, employment, mental health services including talking therapies • be a source of information and advice to other services, including colleagues in primary care, general hospitals, adult social care and children’s services • fulfil responsibilities relating to child protection and adult and child safeguarding • the provision of support for families and carers, including the conducting of carer assessments to identify support needs. Workforce standards Commissioners will need to commission drug and alcohol services that can demonstrate that they meet the necessary statutory standards as set out by the relevant professional regulatory bodies. Individual professionals working in drug and alcohol services should be able to demonstrate and meet a range of core standards and competencies. There are a number of other advisory and regulatory bodies including NICE, CQC and Royal Colleges of Psychiatrists and General Practitioners, Nursing & Midwifery Council, General Medical Council, British Pharmaceutical Association, British Psychological Society, the Health Care Professions Council, and British Association of Social Workers. This guide has described the range of professionals that are often employed in drug and alcohol services. To be able to provide the right range of interventions and services, commissioners and providers will need to ensure there is a mix of appropriately qualified and skilled staff working within the service. The Drugs and Alcohol National Occupational Standards (DANOS) specify the standards of performance that people in the drugs and alcohol field should be working to. They also describe the knowledge and skills workers need in order to perform to the required standard. DANOS can be used to ensure that services have a competent workforce and that everyone has the knowledge and skills to deliver services to the required quality standards27 . 14 Practical Mental Health Commissioning
  • 16. Guidance for commissioners of drug and alcohol services 15 A good drug and alcohol service will usually function best as a specialist, integrated team that includes a range of professional health and social care staff, under single management. Commissioners and patients should expect any services to have at its core the aim of providing a holistic and personalised care package for patients that is both tailored to their specific needs and which is focused on recovery. The Expert Reference Group that has developed this guide, has produced the set of core principles described below to assist commissioners. These state that a good drug and alcohol service should be: • commissioned on the basis of local need and recognise the motivations that underpin drug and alcohol use • staffed by an appropriately qualified and skilled group of staff working within agreed standards of competence with the necessary levels of supervision and support – there should be sufficient staff to ensure there is the capacity to maintain the service • able to manage the full range of complexity of need, including being able to address the issues of co- morbidity including mental and associated physical health needs • providing interventions that are evidence based and should implement the relevant NICE guidance • providing a therapeutic environment for patients that is non-judgmental where they can expect to receive a good quality assessment of their needs and a range of evidence based treatments • working with patients to enhance their recovery potential and address not only their substance dependence but also the other factors impacted by that dependence, including housing, employment and social and family networks • providing continuity of care in supporting people in recovery • establishing, maintaining and building on good links with other services, including mental health services and have a good knowledge of other local resources • using data and information to enable regular and accurate performance monitoring and review of effectiveness and outcomes • providing value for money to commissioners and the public purse. The DANOS standards are applicable to a range of professionals working in substance misuse services including commissioners of substance misuse services, drugs and alcohol workers, psychiatrists, psychotherapists, social workers and probation officers who regularly work with substance misusers27 . The sorts of skills that should be expected to be present within drug and alcohol services should include: • assessment of substance misuse • risk assessment and management • care planning • knowledge of the law in respect of drugs and alcohol • knowledge of other relevant legislation including the Mental Health Act, the Mental Capacity Act and Safeguarding • knowledge of other local services and agencies including the criminal justice system, housing, adult social care, children’s services. Commissioners and providers should also be able to ensure that the workforce is suitably equipped to meet the quality standards described by NICE for the delivery of specific intervention in drug and alcohol services. Outcomes There is increasing emphasis on the delivery of outcomes in health services, not just in terms of the wider public health outcomes described earlier in this guide, but more specifically those that apply to the service provided and the outcomes experienced by the patient. Commissioners may apply their own outcomes at local level, in partnership with providers, as part of their planning and review processes. The NICE Quality Standards for drug and alcohol services provide a comprehensive range of outcomes that commissioners should ensure their local services are delivering against. The quality standards can be found in boxes 6 and 7. Commissioners will be able to review performance by using data from the National Drug Treatment Monitoring System (NDTMS) and use other NHS and social care national outcome frameworks to ensure delivery of improved outcomes. box 4: Model of service delivery and core principles
  • 17. 16 Practical Mental Health Commissioning Commissioning process The commissioning process has been well described in a range of JCP-MH guides, including Practical Mental Health Commissioning, published in March 20112 . The National Treatment Agency has also developed specific guidance for the commissioning of recovery focused drug and alcohol services with a set of resources to support the Joint Strategic Needs Assessment process18 . Both documents provide commissioners with helpful information about the commissioning process and are recommended for further reference. Alongside those documents, the top-tips in box 5 should help commissioners in their thinking when commissioning a drug and alcohol service. What would a good drug and alcohol service look like? (continued) • the commissioning process is a continuous cycle through three key stages: strategic planning, procuring services and monitoring and evaluation2 – commissioning should be a dynamic process that is about identifying and prioritising need and apportioning resources to meet those needs and achieve positive outcomes in a spiral of continuous improvement2 • examine the current services, statutory, independent and voluntary sector to determine what exists now and what might be needed in the future – understand the drug and alcohol treatment system locally, and address recovery challenges20 • the Joint Strategic Needs Assessment process should be used to establish local patterns of need and in partnership with other stakeholders agree local priorities for investment and development and decommissioning where necessary – taking account of service re-design, changing service models and practice, and ensuring the provision of an appropriately skilled and experienced workforce • ensure that service providers are able to deliver a range of services, with an appropriate mix of staff that will effectively address the complexity of issues that those with addiction present – this should include co- morbidity with mental health and physical health problems • ensure there is an appropriate range of services that are able to meet demand and secure required clinical treatment, reintegration and recovery outcomes20 , and decide which provider(s) will best meet the local needs and procure clinically effective services. In doing so commissioners should be particularly mindful of issues of quality and patient safety, and where appropriate commissioners should stimulate the local market to ensure the value for money, the right range of provision and improved outcomes • use the national benchmarks as a guide for quality and standards including NICE guidance for drug and alcohol services and interventions, CQC standards and relevant good practice guidance. Work in partnership with providers to ensure contract compliance and continuous improvements in quality and outcomes20 , and ensure linkage to clinical and corporate governance requirements and monitor delivery, effectiveness, outcomes and costs. box 5: commissioning principles
  • 18. Guidance for commissioners of drug and alcohol services 17 Statement 1 Health and social care staff receive alcohol awareness training that promotes respectful, non-judgmental care of people who misuse alcohol. Statement 2 Health and social care staff opportunistically carry out screening and brief interventions for hazardous and harmful drinking as an integral part of practice. Statement 3 People who may benefit from specialist assessment or treatment for alcohol misuse are offered referral to specialist alcohol services and are able to access specialist alcohol treatment. Statement 4 People accessing specialist alcohol services receive assessments and interventions delivered by appropriately trained and competent specialist staff. Statement 5 Adults accessing specialist alcohol services for alcohol misuse receive a comprehensive assessment that includes the use of validated measures. Statement 6 Children and young people accessing specialist services for alcohol use receive a comprehensive assessment that includes the use of validated measures. Statement 7 Families and carers of people who misuse alcohol have their own needs identified, including those associated with risk of harm, and are offered information and support. Statement 8 People needing medically assisted alcohol withdrawal are offered treatment within the setting most appropriate to their age, the severity of alcohol dependence, their social support and the presence of any physical or psychiatric co-morbidities. Statement 9 People needing medically assisted alcohol withdrawal receive medication using drug regimens appropriate to the setting in which the withdrawal is managed in accordance with NICE guidance. Statement 10 People with suspected, or at high risk of developing, Wernicke’s encephalopathy are offered thiamine in accordance with NICE guidance. Statement 11 Adults who misuse alcohol are offered evidence-based psychological interventions, and those with alcohol dependence that is moderate or severe can in addition access relapse prevention medication in accordance with NICE guidance. Statement 12 Children and young people accessing specialist services for alcohol use are offered individual cognitive behavioural therapy, or if they have significant comorbidities or limited social support, a multi component programme of care including family or systems therapy. Statement 13 People receiving specialist treatment for alcohol misuse have regular treatment outcome reviews, which are used to plan subsequent care. box 6: NICE Quality Standards for Alcohol Dependence and Harmful Use11
  • 19. 18 Practical Mental Health Commissioning The quality standard describes markers of high- quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for people with drug use disorders. Statement 1 People who inject drugs have access to needle and syringe programmes in accordance with NICE guidance. Statement 2 People in drug treatment are offered a comprehensive assessment. Statement 3 Families and carers of people with drug use disorders are offered an assessment of their needs. Statement 4 People accessing drug treatment services are offered testing and referral for treatment for hepatitis B, hepatitis C and HIV and vaccination for hepatitis B. Statement 5 People in drug treatment are given information and advice about the following treatment options: harm- reduction, maintenance, detoxification and abstinence. Statement 6 People in drug treatment are offered appropriate psychosocial interventions by their keyworker. Statement 7 People in drug treatment are offered support to access services that promote recovery and reintegration including housing, education, employment, personal finance, healthcare and mutual aid. Statement 8 People in drug treatment are offered appropriate formal psychosocial interventions and/or psychological treatments. Statement 9 People who have achieved abstinence are offered continued treatment or support for at least six months. Statement 10 People in drug treatment are given information and advice on the NICE eligibility criteria for residential rehabilitative treatment. box 7: NICE quality standard for drug use disorders13 What would a good drug and alcohol service look like? (continued)
  • 20. Supporting the delivery of the mental health strategy The JCP-MH believes that commissioning which leads to good drug and alcohol services as described in this guide will support the delivery of No Health without Mental Health. Shared objective 1: More people will have good mental health. Commissioning effective drug and alcohol services will enable the identification of associated mental health problems and ensure access to appropriate assessment, diagnosis treatment and support. Shared objective 2: more people with mental health problems will recover. Many people with drug and alcohol problems have co-morbidity, therefore effective services will be able to jointly work with people, alongside mental health services utilising a recovery oriented approach that enables them to achieve greater independence and enhance their prospects of sustained recovery. Shared objective 3: more people with mental health problems will have good physical health. Ensuring the provision of effective drug and alcohol services will enable those people who have co-morbid mental health problems to have their physical health needs properly assessed and treated. The identification of these needs and action to address them will result in improved physical health. Shared objective 4: more people will have a positive experience of care and support. Addressing drug and alcohol dependency alongside mental health problems (where they are present) can improve the chances of the patient experiencing a more holistic service that should have a positive impact on their health and wellbeing. A joined- up approach is more likely to improve a person’s experience of services. The use of peer support and mutual aid can be a helpful means through which to engage those who use services in a contribution, not only to recovery, but to building a positive experience of care and treatment for others57 . Shared objective 5: fewer people will suffer avoidable harm. Assessing the risk of harm and providing a service that will have as one of its aims an objective to reduce it should help to reduce the incidence of harm, reduce the need for future intervention such as hospital admission and ongoing treatment, and provide patients with strategies for remaining free from both harm and dependence on drugs and/or alcohol. Shared objective 6: fewer people will experience stigma and discrimination. By commissioning services that recognise the connections and linkages between drug and alcohol misuse and mental health problems, commissioners will be actively addressing the stigma and discrimination that many people experience as a consequence of their addiction and/or mental health needs. Guidance for commissioners of drug and alcohol services 19
  • 21. 20 Practical Mental Health Commissioning Drug and Alcohol Expert Reference Group Members • Owen Bowden-Jones (ERG Chair) Consultant Psychiatrist and Lead Clinician for Club Drug Clinic Central and North West London NHS Foundation Trust • Andre Geel Chartered & Consultant Clinical Psychologist Central and North West London NHS Foundation Trust • Chris Fitch Research and Policy Fellow Royal College of Psychiatrists • Diane Goslar Service user consultant • Emily Finch Clinical Director South London and Maudsley NHS Foundation Trust • Ellie Gordon Clinical and Transformational Lead for NHS Continuing Healthcare North Yorkshire and Humber Commissioning Support Unit Development process This guide has been written by a group of drug and alcohol service experts, in consultation with patients and carers. Each member of the Joint Commissioning Panel for Mental Health received drafts of the guide for review and revision, and advice was sought from external partner organisations and individual experts. Final revisions to the guide were made by the Chair of the Expert Reference Group in collaboration with the JCP’s Editorial Board (comprised of the two co-chairs of the JCP-MH, one user representative, one carer representative, and technical and project management support staff). Acknowledgements This guide was led and written by Steve Appleton, Owen Bowden Jones, and Chris Fitch. Steve Appleton Steve Appleton is the Managing Director of Contact Consulting, a specialist consultancy and research practice working at the intersection of health, housing and social care. He has held operational and strategic posts in local authorities and the NHS, with a specialist interest in the health, housing and social care needs of people with mental health problems, substance misuse needs, learning disability, older people and offender health • Jonathan Campion Director for Public Mental Health and Consultant Psychiatrist South London and Maudsley NHS Foundation Trust • Kostas Agath Medical Director Addaction • Lesley Andrews Head of Service Kent Drug and Alcohol Action Team • Martin Barnes Chief Executive Drug Scope • Mick Davies Regional Manager Huntercombe Group • Nuzhat Anjum Head of Public Health Commissioning NHS Redbridge • Pete Burkinshaw (Observer) Skills and Development Manager National Treatment Agency • William Butler Chair (at time of guide development) Substance Misuse Skills Consortium
  • 22. Guidance for commissioners of drug and alcohol services 21 References 1 Department of Health (2011a) No Health Without Mental Health; a cross government mental health outcomes strategy for people of all ages. www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/documents/digitalasset/ dh_124058.pdf 2 Bennett, A., Appleton, S., Jackson,C. (eds) (2011) Practical mental health commissioning. London: JCP-MH. 3 Joint Commissioning Panel for Mental Health (2012) Guidance for commissioners of primary mental health services. London: JCP-MH. 4 Joint Commissioning Panel for Mental Health (2012) Guidance for commissioners of dementia services. London: JCP-MH. 5 Joint Commissioning Panel for Mental Health (2012) Guidance for commissioners of liaison mental health services to acute hospitals. London: JCP-MH. 6 Joint Commissioning Panel for Mental Health (2012) Guidance for commissioners of mental health services for young people making the transition from child and adolescent to adult services. London: JCP-MH. 7 Joint Commissioning Panel for Mental Health (2012) Guidance for commissioners of perinatal mental health services. London: JCP-MH. 8 Joint Commissioning Panel for Mental Health (2012) Guidance for commissioners of public mental health services. London: JCP-MH. 9 Joint Commissioning Panel for Mental Health (2012) Guidance for commissioners of rehabilitation services for people with complex mental health needs. London: JCP-MH. 10 College Centre for Quality Improvement (2012) Practice standards for young people with substance misuse problems. London: Royal College of Psychiatrists. www.rcpsych.ac.uk/pdf/ Practice%20standards%20for%20 young%20people%20with%20 substance%20misuse%20problems.pdf 11 National Institute for Health and Clinical Excellence (2011) Alcohol dependence and harmful alcohol use quality standard. NICE Quality Standard 11. http://guidance.nice.org.uk/QS11 12 National Institute for Health and Clinical Excellence (2011) Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. NICE clinical guideline 115. www.nice.org.uk/guidance/ index.jsp?action=byID&o=13337 13 National Institute for Health and Clinical Excellence (2011) Quality standard for drug use disorders. NICE Quality Standard 23. http://guidance.nice.org.uk/ QS23 14 National Institute for Health and Clinical Excellence (2007) Drug misuse. Psychosocial interventions. NICE clinical guideline 51. www.nice.org.uk/cg51 15 National Institute for Health and Clinical Excellence (2007) Drug misuse. Opiod detoxification. NICE clinical guideline 52. www.nice.org.uk/cg52 16 Department of Health (2012) Improving outcomes & supporting transparency. Part 1: a public health outcomes framework for England, 2013-16. www.dh.gov.uk/en/ Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/ DH_132358 17 HM Government (2012) The Government’s Alcohol Strategy. London: Home Office. www.homeoffice.gov. uk/publications/alcohol-drugs/alcohol/ alcohol-strategy 18 National Treatment Agency for Substance Misuse (2013) JSNA Support Pack for Commissioners of Recovery in Communities. www.nta.nhs.uk/ healthcare-JSNA.aspx 19 National Treatment Agency for Substance Misuse (2012) Medications in recovery. Re-orientating drug dependence treatment. www.nta.nhs.uk/uploads/ medications-in-recovery-main-report3.pdf 20 National Treatment Agency (2010) Commissioning for Recovery. Drug treatment, reintegration and recovery in the community and prisons: a guide for drug partnerships. www.nta.nhs.uk/ c4r.aspx 21 HM Government (2010) Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life. www.homeoffice.gov.uk/ drugs/drug-strategy-2010/ 22 HM Government (2010) Healthy lives, healthy people: our strategy for public health in England. London: Stationary Office. www.dh.gov.uk/health/tag/ healthy-lives-healthy-people/ 23 Royal College of Psychiatrists (2010). Delivering Quality Care for Drug and Alcohol Users: the Roles and Competencies of Doctors. CR173. London: RCPsych www.rcpsych.ac.uk/usefulresources/ publications/collegereports/cr/cr173.aspx 24 National Institute for Health and Clinical Excellence (2010) Alcohol- use disorders: Diagnosis and clinical management of alcohol-related physical complications. NICE CG 100. www.nice.org.uk/CG100 25 National Institute for Health and Clinical Excellence (2010) Alcohol use disorders: preventing harmful drinking. NICE public health guidance 24. www.nice.org.uk/nicemedia/ live/13001/48984/48984.pdf
  • 23. 22 Practical Mental Health Commissioning References (continued) 26 Department of Health (2012) From our pilots – West Kent, A LASARS http://recoverypbr.dh.gov. uk/2012/07/12/wkent2/ 27 Skills for Health (2008) Drugs and Alcohol National Occupational Standards (DANOS). www.skillsforhealth.org. uk/about-us/resource-library/doc_ download/130-ad-danos-guide.html 28 Department of Health (2010) UK Drug situation. UK Focal Point on Drugs. Annual Report to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). 29 Drug Misuse Declared: Findings from the 2010/11 British Crime Survey, Home Office Statistical Bulletin July 2011. 30 National Treatment Agency for Substance Misuse (2012). Estimating the crime reduction benefits of drug treatment and recovery. www.nta.nhs.uk/ uploads/vfm2012.pdf 31 National Institute for Health and Care Excellence (2012). Alcohol. Local government public health briefings. NICE PHB6. www.publications.nice.org. uk/alcohol-phb6 32 Action for Children (2009) Neglect: research evidence to inform practice. www.actionforchildren.org.uk/ media/143188/neglectc_research_ evidence_to_inform_practice.pdf 33 Strategic Review of Health Inequalities in England Commission (2010) Fair Society, Healthy Lives. The Marmot Review February. www.instituteofhealthequity.org/ 34 Health Protection Agency (2011) Hepatitis C in the UK www.hpa.org.uk/webc/HPAwebFile/ HPAweb_C/1309969906418 35 Health Select Committee http://bit.ly/8i5Hvq 36 British Medical Association (2013). Drugs of dependence. The role of medical professionals. http://bma.org.uk/ news-views-analysis/in-depth-drugs-of- dependence/full-report 37 National Treatment Agency for Substance Misuse (2012) From Access to Recovery: Analysing six years of drug treatment data. www.nta.nhs.uk/uploads/ six-yearstudy.pdf 38 National Treatment Agency for Substance Misuse (2012) Drug treatment 2012: the progress made, the challenges ahead. www.nta.nhs.uk/uploads/ commentaryfinal%5B0%5D.pdf 39 The NHS Information Centre Statistics on Alcohol www.ic.nhs.uk/pubs/alcohol11 40 NHS Information Centre for Health and Social Care (2009) Adult Psychiatric Morbidity in England, 2007: Results of a Household Survey. www.ic.nhs.uk/pubs/ psychiatricmorbidity07 41 World Health Organization (2008). Global burden of disease report. WHO. 42 Royal College of Psychiatrists (2011). Our Invisible Addicts. CR165. London: RCPsych CR165. www.rcpsych.ac.uk/ publications/collegereports/cr/cr165.aspx 43 Centre for Mental Health, DrugScope, and the UK Drug Policy Commission (2012) Dual diagnosis: a challenge for the reformed NHS and for Public Health England. www.ukdpc.org.uk/publication/ dual-diagnosis-challenge-reformed-nhs/ 44 Department of Health (2002). Mental Health Policy Implementation Guide http://webarchive.nationalarchives. gov.uk/+/www.dh.gov.uk/en/ Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/ DH_4009350 45 UK Drug Policy Commission (2010). Drugs and Diversity: Lesbian, gay, bisexual and transgender (LGBT) communities. Learning from the evidence. www.ukdpc. org.uk/wp-content/uploads/Policy%20 report%20-%20Drugs%20and%20 diversity_%20LGBT%20groups%20 %28policy%20briefing%29.pdf 46 Wellbeing Enterprises CIC/NTA/NHS Nottinghamshire. http://bit.ly/VlnZHn and http://bit.ly/V9U9r1 47 Home Office (2009) The Drug Treatment Outcomes Research Study: Cost Effectiveness Analysis. www.dtors.org.uk/ reports/DTORS_CostEffect_Main.pdf 48 Weaver T, Charles V, Madden P, and Renton A. (2002) A study of the Prevalence and Management of Co- Morbidity amongst Adult Substance Misuse & Mental Health Treatment Populations. London: Imperial College. http://dmri.lshtm.ac.uk/docs/weaver_ es.pdf 49 Saunders B & Robinson S (2002) Co-occurring mental health and drug dependency: workforce development challenges for the AOD field. Drug and Alcohol Review, 21, 231-237. 50 Menezes PR, Johnson S, Thornicroft G et al (1996) Drug and alcohol problems among individuals with severe mental illness in south London. British Journal of Psychiatry, 168: 612-619.
  • 24. Guidance for commissioners of drug and alcohol services 23 51 National Treatment Agency for Substance Misuse (2011). Statistics from the National Drug Treatment Monitoring System (NDTMS) 1 April 2010– 31 March 2011. www.nta.nhs.uk/uploads/ statisticsfromndtms201011vol1 thenumbers.pdf 52 National Treatment Agency for Substance Misuse (2012). Statistics from the National Drug Treatment Monitoring System (NDTMS) 1 April 2010– 31 March 2011. www.nta.nhs.uk/uploads/ natmsannualstatisticsreport2010-11.pdf 53 Alcohol Concern (2011) Making alcohol a health priority. Opportunities to reduce alcohol harms and rising costs. www.alcoholconcern.org.uk/assets/ files/Publications/2011/Making%20 alcohol%20a%20health%20priority- opportunities%20to%20curb%20 alcohol%20harms%20and%20 reduce%20rising%20costs.pdf 54 Royal College of Psychiatrists (2012) Achieving parity of esteem between mental and physical health. Executive summary. www.rcpsych.ac.uk/pdf/ Parity%20of%20Esteem%20briefing%20 Feb%202012.pdf 55 Department of Health (2012) Structure of Public Health England. Factsheet. www.rcpsych.ac.uk/pdf/Structure%20 of%20Public%20Health%20England.pdf 56 National Institute for Health and Clinical Excellence (2007). Drug misuse - methadone and buprenorphine. NICE TA114. www.nice.org.uk/TA114 57 Alcohol Concern (2010) Developing choice in peer-support. How alcohol services can support SMART Recovery. www.alcoholconcern.org.uk/assets/files/ Publications/Developing%20choice%20 in%20peer%20support%281%29.pdf
  • 25. A large print version of this document is available from www.jcpmh.info Published May 2013 Produced by Raffertys