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 Hywel Dda University Health Board – ASM 06 / Tystiolaeth gan Bwrdd Iechyd Prifysgol Hywel Dda – ASM 06
Response to the Health and Social Care Committee
- Inquiry into Alcohol and Substance Misuse
Impacts of Alcohol and Substance Misuse on People in Wales:
1. Patterns of drug use remain subject to change as we have seen over recent years with the increase in the use of the new psychoactive stimulants, and to more poly drug use. This is dependent on availability and trends with service users in different areas. It will remain important for drug services to be flexible in being able to respond to these changes, but fundamentally the overall approach remains consistent based on the evidence of effective intervention.
2. Alcohol continues to be the greatest presenting problem in the substance misuse field. In addition there is an increase being seen in respect of Alcohol Related Brain Damage, and this is an area that requires some consideration at an all Wales level regarding implications for the future support required for service users. Also in regard to an ageing population, use of alcohol amongst older adults is an increasing concern and it is likely we will see an increase in referrals to alcohol treatment services. There will be some particular challenges working with this older population, and currently there are limited links with the Tier 1 adult services who will have a key role to play. Links between alcohol related harm and areas of deprivation is becoming more apparent through research evidence and in respect of referrals to services. There is also a move from night time economy centred drinking to more home based and preloading patterns of use.
Effectiveness of Welsh Government Policies and Further Action Required:
3. The current Welsh Government strategy ‘Working Together to Reduce Harm’ clearly sets out the key interconnected areas of preventing harm, supporting substance misusers in their recovery, supporting and protecting families, and tackling availability and the wider community safety issues that are important in this field. This sets the frame for the local commissioning strategies and the supporting local delivery structures led by Area Planning Boards (APB’s). The APB’s provide the structure for the collective responsibility and engagement of the key agencies of police, probation, social care, health and the third sector. This is critically important in ensuring all aspects of the agenda are taken forward in a joined up approach.
4. The additional Substance Misuse Action Funding has made a significant difference to the provision and extended range of services now available locally. This funding makes up a substantial part of the investment in substance misuse services, alongside monies invested from the direct funding in statutory services. The associated performance structure is robust, and the data available via the NHS Wales Informatics Service provides useful information on the numbers accessing services, related demographic details and outcomes for service evaluation and planning purposes. The capital fund has been utilised effectively locally to support the development of shared multi agency facilities at key locations. This is particularly important in supporting joint working between specialist substance misuse agencies in being co-located, it is a cost effective use of resources and is key in supporting ease of access for service users. Recognising the pressure on budgets within statutory services, and the benefits seen from the Substance Misuse Action Fund it is key to retain the level of investment currently within both revenue and capital. It will be important to balance the use of the resources across the key areas within the strategy.
5. Welsh Government should consider promoting certain settings as ‘alcohol free zones’ and in particular we would highlight schools. The use of Temporary Event Notices [TENS] for events at schools where alcohol is served to parents whilst children are present should be avoided and the Welsh Network of Healthy Schools Schemes should be promoting this view to primary and secondary educational settings as part of the National Quality Award or other award[s]. Figures obtained from local authorities in England suggest that over 8,000 TENS were granted to primary schools in 2012 / 13. This is the equivalent of almost one in every three primary schools in England selling alcohol at events for children. As children develop future drinking habits from their parents and they are most influenced between the ages of 6-10, we believe that this practice should be discouraged in Wales.
6. Welsh Government should be encouraged to pursue national policies such as Minimum Unit Pricing [MUP] and the introduction of public health as a fifth objective under the Licensing Act 2003. There has been a strengthening of the evidence base during the past year as indicated in reports from the Advisory Panel on Substance Misuse and from Sheffield University [as commissioned by Welsh Government] which indicate that MUP if applied in Wales would save lives and reduce hospital admissions. Alongside this, the role of Health Boards in the local licensing process has developed slowly and in no small part due to the challenges of providing representations to local authority committees that relate specifically to the legislation as currently written. In practice, this has restricted the ability of health bodies to provide evidence which offers a richer context to alcohol use in a specific locality. The introduction of an additional objective to the 2003 Act in order to protect and improve public health would greatly assist Health Boards to discharge their statutory responsibility more effectively.
7. There is a national role for Welsh Government [or an appointed body like Public Health Wales] in providing leadership on the prevention / education agenda in Wales to ensure best practice is promoted by use of evidence based interventions. At the moment this agenda is fragmented, inequitable and vulnerable to budget pressures when set against the competing demands and needs of treatment services. Clarity and consistency of approach in respect of population level communication, schools based substance misuse education programmes and preventative interventions with vulnerable groups such as young offenders would be best led at a national level.
8. Welsh Government investment in areas relating to harm reduction has been very positive and these remain key priorities for service delivery. These include the roll out of Take Home Naloxone, the Blood Borne Virus [BBV] Strategy to support increased testing, vaccination and treatment, and the Drug Related Death Review process for fatal and non fatal drug overdoses. It is important to highlight that new psychoactive stimulant use has led to increase in risky behaviours around injecting with a possible consequent impact on BBV infection rates, and has been a factor in a number of drug related deaths. For these reasons we believe that the general approach taken to substance misuse policy by Welsh Government, which focuses on a harm reduction approach, is the most appropriate way to reduce risk for this client group.
Capacity and Availability of Local Services to Deal with the Impact of Substance Misuse:
9. An area we consider important locally and have been very successful with is partnership working across the specialist substance misuse agencies. This has been underpinned by us working within an agreed model for service delivery based on a tiered intervention approach - to ensure that the level of intervention is at the minimum level appropriate which is in line with prudent healthcare principles. The model is provided by both the third and statutory sector, and has a clear integrated pathway with a single point of contact, and weekly multi agency case management meetings. It has been supported by the development of joint working agreements, joint training programmes, and information sharing agreements between services. It has resulted in good response times for assessment and treatment, effective joint working with service users and being able to move service users through services effectively. A key element is that the statutory services work with those with more complex needs and who require case management, and the third sector services work with those with less complex needs. There is joint working also where appropriate, and mechanisms for advice and consultation between services - this supports a flexible approach to service delivery and the best use of available resources.
10. The move towards a more community reintegration and recovery focussed approach remains key, and the need to ensure that the range of services is available both in regard to specialist and mainstream. This applies both to aftercare and wraparound services, but also to ensure that there are therapeutic services available to enable service users to address any underlying psychological issues. There has been collaborative working locally with the Psychological Therapies strategy, where the needs of service users who misuse substances are being taken into account. There is evidence locally of an increase move through of primary drug service users who have successfully completed treatment. The key developments in Peer Mentoring, and Coastal were important in supporting this. Projects that support service users to develop skills so that they can return to the labour market have played a valuable role in aiding recovery and have enabled treatment services to refer onwards in the knowledge that their generic support needs will be met by such projects. However there have been gaps left with the loss of these EU funded aftercare projects that had made a significant difference to the lives of service users, and supported treatment services in moving towards a more recovery orientated approach. Whilst these services will be coming back on line in a revised format the gap that has been left has had a detrimental effect on service users recovery journey and a slow down in moving service users through treatment services. The shift towards more of a recovery orientated approach has been quite a challenging one to make particularly for drug services, and service users who have been with services for long periods of time. Progress is however being made, and the role of SMART recovery and other peer led psychosocial interventions plays a key part in this. However it is important to also ensure that access to opiate substitute prescribing remains as an effective treatment intervention, whilst being set in the context of the recovery journey. Service users who have be unable to progress fully within community based services continue to access Tier 4, and we have a robust assessment, preparation and aftercare process supporting these individuals. Tier 4 services remain a key part of the overall treatment service, and where appropriate placements are made within services in Wales.
11. There is an increasing range of medication interventions for primary alcohol users becoming available and it will be important to bed them into the treatment options available, and to review their effectiveness. Access to such medications needs to be carefully monitored in order to ensure both value for money for the health service in Wales and also the best treatment outcomes.
12. Initiatives such as the Integrated Family Support Teams have been very positive in working with parents who misuse substances, aiming to reduce the impact on them and their children. This intervention can only be welcomed in addressing intergenerational substance misuse that we see often, and assists with collaboratively working across adult and children services, and mainstream and substance misuse services.
13. In regard to working with those involved with the criminal justice system we have worked well locally with the roll out of the Integrated Offender Management Service. This has ensured effective joint working and risk management with service users coming out of prison, and in the community across substance misuse and criminal justice agencies. There has been agreement locally to bring together the funding for this client group and progress with an integrated model of provision for mainstream and criminal justice services users.
14. Co-produced responses to identified substance misuse concerns at a community level should be encouraged as these have been highlighted as a key principle of a prudent healthcare approach. Alcohol Concern Cymru is currently leading a community development project in the Fishguard and Goodwick area of Pembrokeshire identifying residents concerns in respect of alcohol use and misuse using an asset based approach which helps local communities to identify their own strengths and talents and their own capacity to effect positive change.
15. It should be noted that the all Wales Police schools programme is currently the only educational intervention that is applied consistently across Wales. Our understanding is that the programme received a budget cut last year which it was able to absorb. However, any continued reduction in central funding from Welsh Government will significantly affect its ability to deliver on the ground.
16. A key challenge with this field of work is that substance misuse cuts across so many areas of life and service provision. Specialist substance misuse services have a place in delivering treatment services, and in supporting and advising on wider service / practice developments. However there is a lot of work required in skilling up Tier 1 services to identity and where appropriate intervene or joint work with those with substance misuse issues. It is important that it is seen as everyone’s business and that there is a joined up agenda and commitment to address associated issues. An example where this has worked well is the ‘Have a Word’ programme of training [as delivered by Public Health Wales nationally] on the use of alcohol screening and brief interventions should be noted. Over 600 health and social care professionals in the Hywel Dda area have received training in delivery of evidence based approaches to screening and brief interventions. This is a useful tool in engaging people in a conversation about their alcohol use but it should be noted that this will uncover hitherto unseen levels of hazardous or harmful drinking amongst the population and as a result of this there may well be additional pressures placed on treatment services who will have to assess and intervene with these increased referrals.
17. Inevitably there is always a place for further resources however the principles of the strategy remain sound, and the supporting framework and resources remain a key part in taking this forward robustly. The strategy is due for review in 2018. It is important to have mechanisms in place to share good practice across Wales, and to ensure that we review the strategic direction and local practice in line with the current thinking and evidence base on an ongoing basis. There is limited opportunity to do this currently across commissioners and provider agencies and this is an area that would benefit from some consideration. It will be important to maintain an overview of the changing patterns of substance misuse and the impact on treatment services, but to ensure that there is appropriate investment and actions across the key interconnected areas of the strategy.