Role The NHS new treatment landscape Annette Dale-Perera Strategic Director of Addictions and Offender Care CNWL NHS Foundation Trust

The NHS No THE Commissioners PCTs CCGs: clinical care groups Provider families GP businesses Foundation Trusts (acute, secondary, community non FTs NHS FAMILY

The NHS No THE Commissioners PCTs CCGs: clinical care groups Provider families GP businesses Foundation Trusts (acute, secondary, community non FTs Big fish eat little fish

What landscape? What needs ? Drug use in the last year (BCS) 20011/12 Change in drug trends: methadone up methamphetamine up ketamine up mephedrone up GLB/GHB up BZP, Spice etc up Heroin and crack users down…… Cocaine & cannabis use down… BUT

What landscape, what needs… Drug use in the last year (BCS) 20011/12 Some substances associated with significant harm Ketamine: kidney/renal damage Methamphetamine: psychosis & severe stimulant dependence GLB/GHB: very severe dependency & difficult detox Mephedrone: episodic psychosis Cannabis: high THC low CBD = more psychosis We don’t look for most new drugs Changing drugs use amongst yr olds, less use BUT

……….and alcohol Slightly fewer % of people now drink alcohol BUT in 2010/11 in England 198,900 primary diagnosis alcohol hospital admissions: 40% increase since 2002/3 1.17m alcohol-related hospital admissions 50% increase on 2002/3 Deaths: 2010, 6,669 deaths directly related to alcohol. 22% increase on % died from alcoholic liver disease. Major increase in need eg HMP Wormwood Scrubs; A&E liaison ……….and poly substance use….

Role of NHS in substance misuse Primary care : promoting healthier lifestyles; SM prevention and treatment; improving wider health and wellbeing Acute hospitals : SM related accidents and emergencies; treating severe illness and disease (eg related to SM); related diseases Community services : health visitors; sexual health, maternity/midwifery, dentistry etc Contracted substance misuse services: in- patient; community and Prison Teaching placements for health professionals: doctors; nurses; psychologists; pharmacists Research with universities to develop new treatments and evidence-based practice.

Shrinking NHS substance misuse service provision Re-tendering Incumbents less likely to win contracts NHS incumbents even less likely: 9% win solo, 30% win in partnership with voluntary sector WHY Resources More expensive: CIP & EBITDAR overseen by Monitor, National pay scales, information & clinical governance infrastructure costs Previously little investment to support tendering & performance data Perceptions NHS “not recovery-focussed enough” & too medical or disease model NHS “too hooked into NICE”, too many difficult Dr’s..psychiatrists NHS slow to change, all they do is `prescribe’ NARROW VIEW: ALL SERVICES VARY IN QUALITY & COMPETENCE

Does it matter if we lose NHS SMS? YES Loss of NHS staff trained in addiction, not just substance misuse services Loss university training places (& funding) for psychiatrists/psychologists Potential loss of local NHS to work with complex health needs inc mental health Potential loss of research into new substance misuse treatments Loss focus and competence on health when health needs are increasing: – Alcohol detoxification much trickier than opioids – Alcohol cognitive & health impacts are serious and need assessing & treating – Aging population of opiate and crack users with extensive health needs – emerging drug patterns require health input: eg acute health impacts eg Ketamine bladder, GHB/GBL detoxifications, – Our mental health services seriously challenged by substance misuse issues: cannabis and stimulant triggered psychosis, alcohol-related dementia in the elderly, Recovery goals around Health and Wellbeing – NHS links and competency is crucial Potential loss of system competence in health

Are we future-proofing ourselves ? Substance use and misuse is changing: it not just some drug use is going down These drug users do not come to our substance misuse services and will not unless we provide culturally relevant, targeted services and we are competent Improving health and wellbeing is likely to be of increasing importance Alcohol and some new drugs cause acute health harms – new territory Older substance misusers with chronic health and social problems: management We have a fault-line in our thinking Are we too focussed on heroin (and crack) users abstinence? The drive for recovery from dependence is wholly correct, but leads us to talk recovery at the expense of reality and what matters to public health. Lets not shoot ourselves in the head. “Not everybody can: but we can enable everybody to try” Review of international evidence (William White 2012) indicates just over 50% of those with dependence achieve recovery, with 30% doing so by total abstinence.

THE NEW LANDSCAPE Landscape is not just treatment Drug strategy: Recovery but also prevention inc new drugs Alcohol strategy: A&E & acute NHS burden, binge drinking Public health: populations, lifestyle, smoking, obesity, preventable diseases, Landscape is how to get population level lifestyle change: treatment is a small hill.……. Public health talk and think a different language The new question of balance is how to get deliver local substance misuse health and wellbeing strategies – the clue is in the name………. This not just treatment and recovery: its prevention, early intervention, dealing with acute harms etc. NHS services need to be integrally involved.