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 Brynawel
Rehab – ASM 14 / Tystiolaeth gan Brynawel Rehab – ASM
14
Brynawel
House Alcohol and Drug Rehabilitation Centre response to the
National Assembly for Wales Health and Social Care Committee
inquiry into Alcohol and Substance Misuse.
-
Brynawel House
Alcohol and Drug Rehabilitation Centre, Llanharan, known as
Brynawel Rehab, is a residential substance misuse service regulated
by the Care and Social Services Inspectorate Wales, that offers a
programme of detoxification and rehabilitation to adults aged
eighteen and above (with no upper age limit), who are dependent on
alcohol or other drugs and who wish to achieve and maintain
abstinence. Brynawel Rehab is situated in Rhondda Cynon Taff but
accepts clients from all over Wales; residents of Scotland and
England also received treatment at Brynawel.
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Brynawel
offers treatment and rehabilitation to more than eighty clients a
year. It has a staff of twenty two and delivers only evidence based
psychological and psychosocial therapeutic interventions to
supports its service users to achieve and maintain recovery, the
approach through which an individual is enabled to move from
dependency on alcohol or drug use towards an alcohol or drug free
life.
- Research
commissioned by the UK government’s Department of Health
undertaken by its then lead researcher Dr David Best clearly
concludes that “The only type of formal treatment service
which was a key factor in helping drug users to stay abstinent was
residential rehabilitation. They concluded that formal long term
structured treatments (other than residential rehabilitation)
played only a peripheral role in the recovery journeys.”
(Statement by researchers Dr David Best, Jessica Loaring and
Safeena Ghufran quoted in Addiction Today 27th May
2011).
- Residential rehabilitation
placements in Brynawel Rehab are spot purchased on an individual
case by case basis by specialist local authority teams (community
care teams) following a social work “community care
assessment” to assess the needs of the person and match a
service to meet those needs. The rehabilitation programme lasts
sixteen weeks at a cost of £770 a
week.
- This method of funding a
drug and alcohol muse service is unique to residential
rehabilitation services. Services such as community based
substitute prescribing for opiate dependency or community based
services to treat alcohol dependency are funded through the global
NHS budget, in the case of NHS Community Drug and Alcohol Teams, or
by block payments as may be the case with voluntary sector
community delivered drug and alcohol treatment
services.
- This method of spot
purchasing, with its failure to guarantee income streams, means
that all the financial risk associated with delivering the service
rest solely with the board of management and trustees of Brynawel.
It is a model that inhibits growth, is not conducive to stability,
and most fundamentally undermines sustainability and contributes to
the fragility of residential rehabilitation.
- To ameliorate the
situation the Minister for Health and Social Services has
ring-fenced one million pounds of the Substance Misuse Action Fund
Budget to provide inpatient and residential rehabilitation
services. However a significant proportion of this fund is
channeled directly to Local Health Boards to deliver hospital based
detoxification. In addition the contraction of local authority
budgets has reduced the capacity of local authority social services
departments to use their community care budgets to fund placements
at Brynawel Rehab.
- Given the evidence base
for the efficacy of residential rehabilitation it is the view of
Brynawel Rehab’s board of management that to ensure the
effectiveness and efficiency of residential rehabilitation services
a planned and commissioned service should replace the system of
spot purchasing. This approach would involve the commissioning of
all treatment bed placements throughout the year on an area or
regional basis. It would require care managers, service
planners, commissioners and the service to embrace new thinking and
a new way of working to meet the challenge of delivering a planned,
sustainable recovery focused substance misuse service for
Wales.
- A sustainable recovery
service should be commissioned for at least a three year period
subject to the services continuing to meet agreed standards. In
addition to offering the most effective use of resources, this
approach would both fit with the commissioning responsibilities of
Area Health Boards and their substance misuse area planning boards
and would free residential rehabilitation services from the
vagaries of a market driven system.
- A comprehensive assessment
underpins integrated care for people who misuse drugs and alcohol
and have the most complex problems. It is also the lynchpin for
specialist staff to engage with, and offer treatment and
interventions such as residential rehabilitation.
- The aim
of the assessment is to identify the need, including the impact of
substance misuse on their physical, psychological and social
functioning. In order to recognise the treatment and interventions
required, staff that perform these assessments need to be
appropriately qualified and competent to be able to interpret the
findings of the assessment and use these to plan appropriate care
and or support. In relation to residential rehabilitation these
assessment are carried out by specialist social workers under the
umbrella of community care assessments. It is therefore an
essential prerequisite to meeting need and ensuring that there is
an integrated service planned that every locality in Wales (local
authority) is committed to offering an assessment to
identify a community care need for treatment or intervention for
drug and alcohol misuse and assessing the potential for that need
to be met by residential rehabilitation.
- The NHS and Community Care Act 1990 Section 47(1). imposes
a duty on local authorities to carry out an assessment of need for
community care services with people who appear to them to need such
services and then, having regard to that assessment, decide whether
those needs call for the provision by them of services. An
assessment is triggered where:
·
The person appears to be someone for whom
community care services could be provided and
·
The person's circumstances may need the provision
of some community care services
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A person with drug and alcohol dependency who
wishes to
become
abstinent has a need for community care service and the local
authority has a statutory duty to undertake an assessment. That
assessment should have regard to how that need may best be met and
should therefore include residential rehabilitation services.
Consequently no local authority should operate an access policy
that does not include residential rehabilitation in the range of
community care services available to meet assessed need and the
right of a person to access residential rehabilitation services
should the needs assessment so indicate.
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As it stands there is no general power for social
services authorities to delegate this function to other bodies.
Even if there is no hope from the resource point of view of meeting
any needs identified in the assessment, the assessment may serve a
useful purpose in identifying for the local authority unmet needs
which will help it to plan for the future. Without assessment this
could not be done.
-
It is the view of the trustees and board of
management of Brynawel Rehab that the implementation of the Social
Services and Wellbeing Act Wales in April 2016 should provided the
opportunity to strengthen and build on these provisions by not only
maintaining the obligation on the local authority but also ensuring
that assessments are undertaken by the most appropriate
professional.
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Brynawel Rehab is an
innovative service, responsive to the expressed needs of the
organisations with which it works in partnership. It is this
environment that has lead to the development of an initiative
relating to Alcohol Related Brain Damage.
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Alcohol related brain damage (ARBD) is the subject
of the report “All in the mind” produced
by Alcohol
Concern Cymru and published in March 2014. it explains that ARBD is
the term used to describe the effects of long term alcohol
consumption on the function and structure of the brain, a condition
that has a variety of related symptoms, including confusion, memory
loss, and difficulty reasoning and understanding. They are the
result of the physical damage that alcohol, as a poison does to
brain tissue, coupled with nutritional deficiencies resulting from
heavy drinking. There is considerable anecdotal evidence of
patients with ARBD being passed between services who feel reluctant
or ill-equipped to take them on. Once ARBD diagnosis is
established, the prognosis for recovery can be split broadly into
quarters:
• 25% make a complete recovery
• 25% make a significant recovery
• 25% make slight recovery
• 25% make no recovery.
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This means that, overall, 75% can make some
recovery if they are identified at an early stage and offered
appropriate treatment In all cases, research suggests that recovery
is enhanced by developing a rehabilitation programme specific and
relevant to each patient, helping them to acquire (or regain) the
skills they need to manage their own lives and their own
environment.
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A task and finish group drawn from health
and social service departments across south Wales has for the
past six months been working to shape a response to an
identified deficit in the provision of services for people with
ARBD.
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The initiative arose from the recognition by
social work specialists in Rhondda Cynon Taf of increasing numbers
of people with ARBD, a need for local services and the potential
for Brynawel Rehab to offer
a service. The initiative is timely as the Welsh Government has commissioned a
report from Public Health Wales, estimating the number of
people in Wales effected by ARBD and Alcohol Concern Cymru has
produced “ All in the Mind” with
recommendations to the Welsh Government.
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Individuals on the spectrum of Alcohol Related
Brain Damage (ARBD) have the potential for recovery. A service
should support people to move through services to greater
independence. There is continuum of need and related services
offering services from rehabilitation to continuing support in
independent living. A key
function of a service would be to support recovery and facilitate
transition between different levels of support.
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It is the view of trustees and management board
that Brynawel Rehab has the potential to be the nucleus of a
service providing accommodation initially of five beds, therapeutic
support and offering transition to independent supported living.
Brynawel could offer a five bedroom ensuite facility, in a safe
environment. A range of psychosocial activity based therapy such as
horticulture: social therapeutic programmes outdoor activities as
well as psychological interventions: physical health and
nutritional support and the introduction of new therapeutic
treatment models tailored to individual clients, which are evidence
based, all would involve new and additional staff. However there
are major obstacles to be overcome in developing and implementing
such a service. A residential rehabilitation service needs a whole
system approach. It is insufficient to establish a free standing,
residential rehabilitation resource without the
associated architecture of community based health social care
services and supported living services focussed on delivering
services to people with ARBD. This may not require a new, discrete
service but community based health and social care services would
need to be strengthened to ensure that they have the capacity to
deliver a service. Any service and in particular the rehabilitative
residential component of the service cannot be created on the
financially unsustainable basis of spot purchasing. If appropriate
facilities are to be developed they must be on the basis
of centrally funded start up costs with the costs of
the ongoing service met through the process of long term
commissioning of places.
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The timely diagnosis of, and response to ARBD is
critical if the prospect of recovery is to be realised and
significant social and economic costs averted. To ensure timely
diagnosis health and social care professionals need to have the
skills and knowledge to identify people with ARBD and
comprehensive, assessment and reassessments need to be carried out
by health and social care staff competent in assessing and care
managing ARBD.
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In order to illustrate the impact of ARBD on
people and the health and social care responses
currently available to people with ARBD four case examples drawn
from local authority social work teams in Wales are included
at annex A.
Annex A
Case examples
Mr. A
- Mr A is a 54 year old
divorced man who lived alone in the community for several years,
moving from public house to public house until a referral was made
to the substance misuse team as part of a hospital discharge
referral. He had a long history of alcohol dependence, self
neglect, was homeless, was quite isolated in the community and did
not have contact with his remaining family. He was also dependent
on diazepam, had peripheral neuropathy and had poor independent
living skills.
- Mr A was placed in Bed and
Breakfast accommodation whilst suitable housing was found.
Eventually he moved into a 1 bedroom ground floor local authority
flat.
- The local authority
attempted to support Mr A in his own home in the community for a
few years; however, it became apparent that his needs were
substantial and complex and that the local authority was no longer
able to meet them in the community.
- The significant issues
were his mental capacity and possible ARBD with memory loss, marked
confabulation; peripheral neuropathy which affected his mobility
and Mr. A subsequently experienced pressure sores to buttocks:
double incontinence and pressure sores: low mood :misuse of
diazepam resulting in frequent calls for emergency services
by neighbours due to him experiencing diazepam withdrawal:
increased dietary neglect including hiding food: vulnerable adult
concerns regarding possible financial abuse despite the local
authority having appointeeship in relation to his
finances.
- Mr A was eventually
admitted to hospital suffering from a twisted bowel. Whilst as an
in-patient a request was made for a mental capacity assessment and
assessment for ARBD. Problems arose attempting to establish a
diagnosis as medical staff was unable to agree whether the Older
Persons Mental Health or Adult Mental Health Services were most
appropriate to assess his needs.
- Mr. A was transferred to
another hospital for rehabilitation and assessments including a
continuing health care assessment. After 18 months in hospitals, Mr
A was moved to a local nursing home, whilst it was appreciated that
this did not entirely meet his needs, it was preferable to
remaining in hospital. Both the hospital and residential care
setting had limited scope for rehabilitation of his physical and
cognitive health issues. Mr A would have been a candidate for
assessment at a local Alcohol Related Brain damage facility;
however, this was not available at this time.
- Further referrals were
made to the adult mental health services for an assessment of Mr
A’s mental health; however, despite vulnerable adult concerns
with his behaviour impacting on other residents both Adult Mental
Health and Older Persons Mental Health services were unable to
agree which service should take this assessment forward. Both
the Health Board and Local authority Social Services Department
shared the cost of the a residential placement whilst financial
responsibility was disputed, a dispute that has now been resolved
and Mr. A’s care is being met from the continuing health care
budget
Mr.
B
- Mr B is a sixty two years
of age, separated from his wife. He has three adult children, two
of whom have a “tense, strained” relationship with him.
Mr B worked all his life, retiring two years ago years ago. He had
many active interests including gardening, ‘foraging’,
metal detecting and darts.
- Mr B drank alcohol all his
life and said that this was never a problem. However, his estranged
family provided a conflicting opinion. It appears that alcohol use
increased at the time of retirement and significantly following his
separation from his wife.
- Following the separation
Mr B lived in sheltered accommodation. Following a fall
approximately a year after moving into the accommodation, he was
admitted to the District General Hospital. It appeared that he was
malnourished on admission to hospital and quickly became confused
and agitated and, it appeared that his short term memory was
impaired.
- Mr. B spent several months
on a rehabilitation whilst there he received an appropriate diet,
hydration, medication, physiotherapy and occupational
therapy. Though his memory improved significantly whilst on
the ward however, there remains some residual memory loss, he also
reports dizziness when he moves about which affects his confidents
in mobilising and managing some tasks of independent living and
increases anxiety – this is thought to be due to damage to
his cerebral cortex.
- As Mr B had been in
hospital for approximately 6 months with little activity, there has
been some atrophy to the legs, which also impacted upon his
confidence to move around. At this point in Mr B’s
rehabilitation, he would have been a good candidate for placement
at a specialist Alcohol Related Brain Damage unit to build on
independent living skills. However this type of facility is not
available in the local area as a result Mr B was placed in
residential care home and remains in long term care
Mr.
C
-
Mr. C is forty six years old and had been homeless
and in the early stages of ARBD He was hospitalised with acute
cirrhosis, ascites and was gravely ill. His parents could not face
him sleeping rough but could not cope with his illness and were
very distressed by his condition. Mr. C reacted with understandable
fear expressed as aggression borne of confusion at his
situation.
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Mr. C was referred to the Community Drug and
Alcohol Social Work Team. The Social Worker conducted her
assessment and intervention over a sustained period in order to
gain his trust in her. Mr. C accepted that he could not drink again
and after working with the Social Worker. However the appropriate
service to meet Mr. C’s needs on discharge from hospital
simply did not exist.
-
Mr.C was eventually placed in the local
authority’s supported accommodation. The manager of the
accommodation was anxious about accepting the Mr. C because of the
degree of his health and social need. Since the placement Mr.
C’s health has improved dramatically though there is the
occasional fluctuation because of the damage to his liver. He is
now in regular contact with his children and parents.
Mr. D
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Mr. D was a 53 year old man referred, by his
anxious relatives, to the local authority’s Community Drug
and Alcohol Social Work Team Mr. D lived alone but was wealthy. His
circumstances meant that he could do as he pleased and it pleased
him to drink a bottle of vodka during the day.
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Mr. D was a gregarious person well known for his
generosity and spirited company. As he grew older use of
alcohol became dependent and by slow degrees his temperament
changed, relationships disappeared, his wife left him, he became
estranged from his children and his dependency on alcohol grew
until only those few remaining close relatives sustained him. When
the social worker visited it was immediately evident that Mr. D
needed hospital admission, detoxification and residential
rehabilitation. He had been seen by NHS general medical staff but
they had not referred him the specialist team at that time. Mr. D
was by now consuming 75cl bottle vodka and 2 bottles of red wine a
day. His intoxication was unusually profound so that he lacked any
capacity His cerebellum had atrophied and he had lost the use of
his legs.
-
Mr. D was referred to the specialist team and his
faculties returned with detoxification. He could not access the
steps to his own privately rented flat and he was accommodated in
unsuitable bed and breakfast accommodation with a very caring and
generous owner who looked after him more than one would normally
expect. Mr. D relapsed to a slightly less dangerous pattern of
drinking but dangerous nonetheless. Following an episode of Deep
Vein Thrombosis brought on by immobility and smoking and very badly
managed by general medical services he was referred to
Physiotherapy services at the local hospital saw him but rejected
the referral on the grounds that he had been drinking and any work
with him would be “pointless.” This may be seen as is
typical of the multiple oppressions endured by people with problems
of substance misuse.
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Mr. D was referred to Brynawel who were
sympathetic to his physical and mental health needs and after an
interview offered him a place. Unfortunately Mr. D could not be
persuaded to take the place because of his resistance to counseling
and anything he would perceive as therapy. The social worker,
consultant psychiatrist and the specialist nurse all tried their
utmost to persuade Mr. D to accept residential rehabilitation. In
desperation the social worker suggested that he forgot the therapy
and suggested that he needed, at very least, a sustained break from
alcohol. Mr. D remained convinced that he could win his battle with
alcohol and that one day he would walk again. Sadly he passed away
after a seizure and a fall.
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The social worker wrote “ I remain convinced
that if Mr. D could have accessed an abstinence based service for
people with ARBD immediately after detoxification he would have
done well. He often said that he regarded me as a friend rather
than a social worker and friendly professionals have the power to
give people like Mr. D the support that not even a caring relative
can. It is not true to say that Mr. D was a great drain on health
or social care resources for the year and a half that he lived
following detoxification because he could not access them. Social
Workers work with marginalised and oppressed people - presently it
is difficult to think of any group so marginalized that they do not
have a module in the Treatment Framework for
Wales”.