Substance misuse services: Lancashire Chris Lee Public Health Lancashire County Council

History of substance misuse in Lancashire Difficult history, under spends, poor services Lacked design, no clear system, inequitable provision, unacceptable waiting times Difficult commissioner/provider relationships Varied performance Lack of political support Block contracts (substance misuse tied up with mental health) Alcohol: Historically little funding, Long waiting lists, Very little performance data

Modernisation of adult treatment system 2008 – North Lancs – Integrated substance misuse services 2009 – East Lancs follows North and adds CJ 2009 – Central follows East adds IDTS 2011-13 – further redesign in North and Central Integrated prison and community Recovery orientated, asset based, 5 Ways to Health and Wellbeing Includes prison based therapeutic communities (2 of 4 nationally)

Present day Alcohol fully embedded in substance misuse services Use all budgets as substance misuse System designed to meet the needs of the population – not just opiate/alcohol (cannabis/stimulants/NPS) Applied drug targets where alcohol target missing eg waiting times Significantly improved performance: Successful completions growing, waiting times very low, improvement in wider outcomes – housing, employment, reducing injecting, growth in detox etc

Alcohol now equates to approx 2/3 of all referrals Case loads still opiate dominated Shorter ‘in treatment’ period for alcohol 89% of alcohol users in treatment 12 months or less (opiates – 34.4% 2 years or less; 28.8% 6 years plus) Majority of community and inpatient detox = alcohol Almost half of alcohol users living with children (less than 10% for opiate users)

AUDIT-C (3 questions) Where individual scores below 7, no further action required Where individual scores 7+, ask remaining 7 AUDIT questions for total score AUDIT Score 0-7 AUDIT Score 8 -15 AUDIT Score 16+ Congratulate and reinforce benefits of lower risk drinking. Complete Brief Assessment and Deliver ‘Brief Advice’ Signpost - groups/SMART/mutual aid/peer mentors Open Access as per Strength based assessment Pathway For Abstinent Service Users assessment sessions to be completed then refer directly to DEAP To all who score AUDIT 16+PLUS offer: Welcome group, 1 x 1-2-1 Recovery plan session, 3 x 1-2-1 sessions or delivered as 3 group work sessions, 1 exit session SADQ score 20+ also refer to Alcohol Detox Team regarding medically assisted withdrawal and pre-detox group SADQ 30+ offer above as appropriate and consider referral to Tier 4 as per pathway seek advice from Alcohol Detox Team regarding medically assisted withdrawal Those who score Audit 16+ who require community alcohol detox will be encouraged to work on the alcohol sessions and attend pre-detox group, RAMP or Intuitive Recovery. A referral to DEAP will be made where identified in the recovery plan. People who cannot undertake the Sessions, or who work, can still access community detox: related clinical need will drive this journey

Issues Professional resistance to joining drug and alcohol together (not from service users) Dual diagnosis: DD is the norm, not a rare event Often present as CJ issues Homeless/housing need History of service disengagement Alcohol and cannabis (largest cohort) MH issues What appears to be a fragmented service response from MH SM services commissioned to work with partners – will adapt to changes in partner providers etc Sm services offer an inclusive approach MH services commissioned differently Exclusive approach, different teams with differing criteria, more fragmented Liaison model difficult when one side commits and the other disengages. Would be great to include SM providers and commissioners in MH redesign to ensure effective care pathways.

Thank you - Any questions?