Working together to reduce harm : The substance misuse strategy for Wales

2008-2018

Our Strategy: Working together to reduce harm• 'Working Together to Reduce Harm' is our ten year plan to

tackle the problems caused by drugs and alcohol in Wales. Published in 2008, it sets out a clear national programme for tackling and reducing the harms associated with substance misuse.

• It is structured around four action areas:• preventing harm• supporting substance misusers• supporting families• tackling availability and protecting individuals and communities.

Preventing harm

• We want to help people resist or reduce substance misuse by providing information about the damage it can cause.

• We want to ensure that everyone understands the consequences of misusing drugs or alcohol and knows where to get support.

• We will continue to concentrate on educating children and young people. The All Wales School Liaison Core Programme (external link) is a substance misuse education and crime prevention initiative. It is jointly funded by the Welsh Government and the four Welsh Police Forces.

• We will also do more to influence attitudes across the whole population. In particular, we will place a greater focus on increasing people’s awareness of the amount of alcohol they are drinking and the associated risks.

• We want to encourage people in Wales to take responsibility for their overall consumption and follow sensible drinking guidelines.

Supporting substance misusers

• We want to improve the health of people who misuse substances, as well as supporting and maintaining their recovery.

• We provide support for substance misusers to reduce the harm they cause themselves, their families and their communities.

This includes:• basic ways of minimising harm and other advice• outreach and other services aimed at engaging individuals in

treatment• the recognised four tiers of service provision and relapse

prevention• support services aimed at helping substance misusers access

accommodation, education, employment and training• we will expand harm reduction services for drug misusers and do

more to engage priority and hard to reach groups.• we will continue to promote existing services and begin to address

gaps in provision

Supporting families

• We want to reduce the risk of harm to children and adults as a consequence of the substance misusing behaviour of a family member.

• We want substance misusing parents to have access to effective treatment, so that they can successfully parent their children.

• We also have a responsibility, in partnership with others, to ensure the child’s well being. Local authorities have a lead role to play in identifying and supporting families. However, it's important that agencies such as child and adult health and social services, as well as local police, work together.

Tackling availability

• We want to reduce the harm caused by substance misuse related crime and anti-social behaviour.

• We intend to tackle the availability of illegal drugs and the inappropriate availability of alcohol and other substances. This includes the sale of alcohol or solvents to young people.

Overall, we want:

• local partners to work more closely with local trading standards departments to tackle traders who persistently sell alcohol to children

• to make the best use of current powers and legislation• to ensure that the full range of sanctions are brought to bear

against individuals who drink irresponsibly, and licensees who continue to serve them

• partners to take a holistic approach to the management of our towns and cities during the evening and night time.

Substance Misuse Finance

• We invest almost £50m into substance misuse in Wales in 2013-14. • Substance misuse Area Planning Boards (APBs) are directly funded by

the Substance Misuse Action Fund (SMAF) and Local Health Boards (LHB) via LHB revenue allocations.

• The SMAF budget in 2013-14 is £32.55m. • £22.66m revenue and £5.07m capital of this funding is allocated to

APBs to deliver their regional substance misuse commissioning strategies and to support local capital investment.

• The remaining £4.81m of SMAF funds:-the All Wales Schools Core Liaison Programme-Operation Tarian-The Transitional Support Scheme-other centrally supported policy initiatives such as the Welsh

National Database for Substance Misuse and the free bilingual All Wales Substance Misuse Helpline, DAN 24/7. • A further £17.13m is ring fenced within the Local Health Boards

revenue allocation for substance misuse services to support prescribing services, psychosocial interventions and inpatient treatment.

Prevalence

• Increased rates of substance misuse in people with mental health problems 33-50% of those with SMI• Welsh inpatient units report 40-60% of their population

have a dual diagnosis• Alcohol misuse most common form• Drug misuse frequently co-exists with alcohol misuse• CMHTs report 8-15% of clients with dual diagnosis (higher in

inner cities)

• Services have evolved somewhat separately• Drug treatment focused upon dependence • Mental health services focused upon mental illness • Dual diagnosis high risk presentation but likelihood of falling

between the cracks• Evidence base illustrates a mutual dependence between

services

Issues

• Serial models unlikely to provide integrated care• Parallel models may also fail• Isolated dual diagnosis staff likely to burn out• pump priming vol. Orgs. to tackle issue in isolation likely to fail• One off training of little value• Specialist staff focusing on own caseload likely to be unable to

support mh & sm services more widely• Mental health strategy clarifies lead role and prescribes link

workers

Issues

Service Criteria

diagnosis orproblematic use

needsocial/medical

riskto self/to others

The Criteria trap

Substance Misuse Mental Health Problem

Highly problematicSubstance Misuse

Severe Mental Illness

Common Mental HealthProblems

Less problematicSubstance Misuse

The Criteria trap

Substance Misuse Mental Health Problem

Highly problematicSubstance Misuse

Severe Mental Illness

Common Mental HealthProblems

Less problematicSubstance Misuse

The Criteria trap

Substance Misuse Mental Health Problem

Highly problematicSubstance Misuse

Severe Mental Illness

Common Mental HealthProblems

Less problematicSubstance Misuse

Dual diagnosis –is one of the central problems facing mental health services.

1659 (27%) suicides 72 (36%) homicides

In the report were dual diagnosis cases using a restrictivedefinition, the contribution of dual diagnosis to patient suicides and homicides may be substantially more.

Previously we have recommended the development of dual Diagnosis services in all mental health trusts.

However, this is the Inquiry recommendation with the lowest take- up Rate of those we have examined.

Avoidable Deaths NCI 2006

• Definition• Preferred model of care• Service aims and Objectives• Service Standards• Linkage to CPA ( Now Statutory Care and Treatment

planning)• Special Needs Groups• Needs assessment and Service planning• Training• Development of a care pathway

The Development of a Welsh Service Framework

• Co-occurring substance use and mental health problems.• Taken together these problems give rise to significant

impairment and disability for which people affected need advice, support and services, in order to follow a more integrated life course.

• The severity and nature of a persons problems are liable to change over time.

• Each problem, however, would be significant enough to merit planned care on its own.

Framework definition

Joint liaison collaborativeapproach

The care of patients isjointly managed by bothservicesJoint working requiredbetween mental health andsubstance misuse services

Integrated

There is concurrent provision of bothpsychiatric and substance misuseinterventions by the same clinical team (designated service)

Preferred Service Models

• Agree local definition, care pathways and model using Care Programme Approach (CPA) [Care and Treatment Planning in Wales]

• Develop service standards for dual diagnosis• Need for tiered joint training programme• Need for comprehensive staff supervisory arrangements • Develop supervisory and training networks across voluntary and

statutory sector • Specialist staff to work on an outreach consultancy model• Ensure liaison with relevant generic agencies primary care,

homelessness organisations prisons A&E

Recommendations

• Implementation of Part 2 of the Measure: Holistic Care and Treatment Planning

• Development of Protocols and Care Pathways at a Local SMAB and MHPB level

• Ensure training delivered for all relevant staff• Use of the NCISH toolkit within services

Policy and Legislative requirements