National Assembly for Wales / Cynulliad Cenedlaethol Cymru
Health and Social Care Committee / Y Pwyllgor Iechyd a Gofal Cymdeithasol

Inquiry into alcohol and substance misuse / Ymchwiliad i gamddefnyddio alcohol a sylweddau

Evidence from Abertawe Bro Morgannwg University Health Board – ASM 01 / Tystiolaeth gan Bwrdd Iechyd Prifysgol Abertawe Bro Morgannwg – ASM 01

Abertawe Bro Morgannwg University Health Board

Response to the National Assembly for Wales Health and Social Care Committee inquiry into alcohol and substance misuse.

1.0 The ABM University Heath Board welcomes the terms of reference for this consultation, which are apposite. ABM University Health Board currently provides tier 3 addiction services. Tier 3 services are described by the National Treatment Agency (NTA) in ‘Models of care for treatment of adult drug misusers’ as ‘structured community based drug treatment services.’ They suggest that the drug or alcohol misuser attending will normally have agreed to a structured programme of care, which places certain requirements on attendance and behaviour. Tier 3 services often tend to work with complex cases, which require multi disciplinary intervention and where there is often a medical component. In this context CDAT is defined as a ‘Tier 3 service.’

1.1 In addition to three Community Drug and Alcohol Teams the service provides a five bedded in patient unit and access to residential rehabilitation. These services are deemed to be tier 4 services, defined as, ‘Tier 4 interventions include provision of residential specialised drug treatment, which is care planned and care coordinated to ensure continuity of care and aftercare.

2.0 The impacts of alcohol and substance misuse on people in Wales, including young people and university students; older people; homeless people; and people in police custody or prisons.

2.1 Historically there has been a lack of national and international research regarding the efficacy of preventative and educational interventions for children and young people. The healthy schools programme requires revision and consideration of emerging international research regarding the most effective way of educating and raising awareness amongst young people.

2.2 Higher education establishments need to be engaged and supported in tackling the use of substances by the student population, particularly alcohol and new and emerging novel substances. There also needs to legislation to ameliorate ploys to encourage risky and unsafe drinking habits developing; for example, the promotions available in fresher’s week that encourage and enable students to drink alcohol in excessive amounts.

2.3 There needs to be greater engagement with parents, particularly regarding alcohol and new and emerging novel substances, and how they can talk with their children regarding these areas to the best effect. There is emerging evidence that children who drink alcohol when under age are accessing alcohol via their parents, either via their drink cabinet or via their parents purchasing alcohol at their child’s request.

2.4 Older people are not proportionately represented in those referred to specialist agencies. The Welsh core standards for substance misuse services could be used to encourage agencies to adopt flexible and creative ways of engaging with this age group. Primary care is ideally placed to screen, assess and sign post this age group but there is no incentive for primary care to participate in this area.

2.5 There has been an unhelpful legacy from the policy ‘disconnect’ caused by the separate commissioning processes for services provided across the regional service footprint and those services commissioned via the Home Office, now via Police Crime Commissioners, in terms of Integrated Offender Intervention Services. We would welcome this funding being devolved to a local level to ensure more effective integration of care pathways.

2.6 Our view is that custodial health care provision should mirror those interventions available in the community and that, in the same way adult mental health services are commissioned, community addiction teams should provide in reach services for the prison population. Additional resource would be required by those health boards covering prison estate.

2.7 Specialist substance misuse services for the homeless are variable, particularly outside of cities. Given the increasing rate of alcohol related brain injury being observed in this population it is essential that substance misuse and particularly alcohol is included in locally enhanced service contracts with primary care.

3.0 The effectiveness of current Welsh Government policies on tackling alcohol and substance misuse and any further action that may be required.

3.1 The priority actions identified against each of the substance misuse strategy’s four key area

3.2 The increasing focus on alcohol and legislation such as proposed minimum unit pricing legislation is very welcome.

3.3 The roll out of the take home Naloxone scheme has been particularly beneficial in areas where there have historically been high rates of drug related deaths, including Swansea.

3.4 The increased involvement of service users and carers has been particularly evident in the planning and design of local specialist services.

3.5 There is concern regarding the additional capacity that will be required by services if tasked with the identification and review of alcohol related deaths, particularly as the review of drug related deaths has been devolved by Welsh Government to a local level.

3.6 We would welcome acceleration of the provision of LARC via specialist services and the expansion of initial work completed by Public Health Wales with local resource to train staff to deliver this intervention.

3.7 Whilst the increasing emergence of peer recovery led groups has been welcome there needs to be evidenced appropriate governance structures in place for any organisations receiving funding via local commissioning arrangements.

4.0 The capacity and availability of local services across Wales to raise awareness and deal with the impact of the harms associated with alcohol and substance misuse.

4.1 Within the health community there is often a lack of ‘whole systems’ approach to this client population. Services have developed in a manner that does not reflect the most natural sequence of engagement with progressive tiers of provision. Service models have been developed in an everted fashion, with most areas taking clients requiring detoxification or prescribing into a secondary care service, before transferring them to primary care – where primary care exists. There is a distinct lack of capacity in terms of services in primary care.

4.2 Models of service that exist in primary care are disparate, and in many areas non existent, resulting in secondary care services becoming congested with clients who could be treated in primary care.

4.3 Often enhanced service contracts in primary care provide solely for opiate users requiring long term substitute prescribing. This does not address the emerging issue and more commonplace presentation of hazardous and dependent alcohol use. Primary care is ideally placed to screen, assess, sign post and treat these clients but there is no financial or nationally agreed target incentive for General Practitioners to engage in this work.

4.4 Of great concern are those members of the public who are at risk of acquiring an alcohol related brain injury due to nutritional depletion, particularly of thiamine. Presentation of Wernicke Korsakoff syndrome is increasing. There needs to be an increased focus on raising awareness of this and the presenting signs and symptoms, as intra muscular vitamin replacement can be easily administered at primary care level. Again, primary care will not participate in treating this issue and the resulting damage and long term health and social care that is needed by these individuals is substantial.

4.5 Residential rehabilitation services for those diagnosed with Wernicke Korsakoff syndrome need to be developed across Wales. There is only one small unit on the Welsh border and this does not serve to meet the needs of those with alcohol related brain injury who may make moderate to significant recovery when comprehensively assessed and rehabilitated.

4.6 Residential rehabilitation needs to be offered to service users as part of the menu of treatment options at an early stage in their contact with services. Research shows that rehabilitation of this nature works well for service users early on, or at the end stages, of their substance misuse, and should not be offered merely for clients who have tried and not succeeded in all other treatment elements.

Sue Stone

Service Manager

Addictions Services.