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 The Gwent Area Planning Board Substance Misuse Team and Provider – ASM 27 / Tystiolaeth gan Tîm a Darparwr Bwrdd Cynllunio Camddefnyddio Sylweddau Ardal Gwent – ASM 27

The Gwent Area Planning Board Substance Misuse Team and Provider response to the HSC Inquiry into Alcohol and Substance Misuse.

January 2015.

1.0 Introduction

1.1 The National Assembly for Wales Health and Care Committee inquiry into alcohol and substance misuse has requested a written response from various key partners on current alcohol and substance misuse in Wales. The HSC have particularly requested views on the following in adherence to their terms of reference:

· 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;

· the effectiveness of current Welsh Government policies on tackling alcohol and substance misuse and any further action that may be required;

· 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.

1.2 The Gwent APB covers Blaenau Gwent, Caerphilly, Monmouthshire, Newport and Torfaen and contains representatives of these five local authorities, Aneurin Bevan University Health Board (ABUHB), Gwent Police, Gwent Probation, and Prisons as well as Public Health Wales (PHW) and a representative for service users and carers.

1.3 The Gwent APB provides advice and support to responsible authorities in order to plan, commission and monitor delivery of high quality treatment and prevention services that are based on the need to improve the lives of substance misusers, families and communities.

1.4 Public Health Wales (PHW) recently conducted a regional substance misuse needs assessment on behalf of Gwent APB. The Gwent PHW team in partnership with ABUHB are responding to this inquiry separately using key messages from this needs assessment document with particular reference to the first two bullet points outlined in the terms of reference. Therefore, taking this into consideration and in order to reduce duplication this report will focus on SMAF substance misuse capacity followed by the Gwent substance misuse provider’s response to the consultation questionnaire.

2.0 Capacity

2.1 The Gwent APB currently discharges an annual regional Substance Misuse Action Fund (SMAF) budget of £4,380,943 on behalf of the 5 local authorities to provide adult and young person’s drug, alcohol and family support services within the region.

2.2 All Gwent substance misuse services operate at capacity, as demand for alcohol and substance misuses services for both adult and young people in Gwent is consistent. However, all commissioned treatment providers produce ongoing successful treatment outcomes which enable continuous access into services. This is achieved by delivering multi tiered; evidence based medical and/or psychosocial treatment modalities.

2.3 62% of all new community adult treatment referrals in Gwent during 2013-14 were for alcohol, 31% for substance misuse and 7% for family support services. Alcohol referrals are the most prevalent within Gwent for the same period of time for children and young people at 61%, followed by cannabis at 16%. However, there has been an increase in New Psychoactive Substance (NPS) misuse in both adult and young persons’ services in the last 2 years. Increasing the complex support that individuals require, particularly regarding mental health, housing and harm reduction.

3.0 Barriers

3.1 From the questionnaires provided and through commissioner’s performance management reports, reoccurring common barriers that impact on provider’s capacity and ability to access additional support services are:

· Dual diagnosis assessment and access to mental health support services

· Employment

· Access and availability of suitable accommodation

· Waiting lists- CAHMS, mental health, counselling services etc

· Availability and access to GP shared care services

· Local tier 4 aftercare services

3.2 More detailed information is provided in the appendices below.

4.0 Appendices.

4.1 Please find attached Gwent APB substance misuse service provider’s response to the consultation questionnaire; please note that these are the individual organisations comments.

Appendix A: CRI are commissioned to deliver Drug Interventions Programme (Gwent), Adult Alcohol Services (Blaenau Gwent and Caerphilly), Children and Young Persons’ Services (Blaenau Gwent and Caerphilly).

Appendix B: Drugaid are commissioned to deliver Community Open Access Adult Drug Services (Gwent with the ex. Newport) and Children and Young People Services (Monmouthshire and Torfaen).

Appendix C: Kaleidoscope who are commissioned to deliver Adult Alcohol Services (Monmouthshire, Torfaen and Newport), Adult Drug Services (Newport) and Community Prescribing (Gwent).

Appendix A

HSC Inquiry into Alcohol and Substance Misuse Gwent Provider response: CRI

Do you currently work for an organisation which works with people who misuse alcohol or other substances? If so, please state which organisation and whether we should treat your response as being on behalf of that organisation, or as a personal response from you.

CRI organisational response for Gwent.

Which client group(s) do you work with? (For example, under 18s, older persons, homeless, or female only)

CRI cover Criminal Justice Services, Community Alcohol Service, Children and Young Person’s services within Gwent.

Through these services CRI work with various client groups including:

Under 18’s

NEETS

Homeless

Older Persons

Women only

Concerned others

Veterans

Sex workers,

BME

What are the main reasons why your clients take drugs or drink excessively? Please tick all that apply.

If you work with more than one client group or you feel that there are other reasons as to why your clients take drugs or drink excessively, please comment in the box below.

Peer pressure

A way to deal with stress

Client(s) already substance reliant

Mental health

Boost confidence

Relieve social anxiety

Environmental factors (for example - excessive drinking and/or drugs normalised in the home/community)

Relationship problems

Financial concerns

Self-medication

Escapism

Other (please comment below)

Comments:

· Dealing with trauma,

· Sexual abuse,

· Domestic violence,

· Habitual,

· Pressure from work

· Undiagnosed mental health

· Historic abuse including institutional

C&YP perspective:

· Service users under the age of 18 usually present with substance misuse issues relating to peer pressure. Service users also state that parents and siblings are using and therefore it becomes the norm in the family household and community where they live.

· The younger age group are usually experimental users and the older age group participating in social use with tendencies towards dependency increasing.

· Service users state that they use substances to increase their confidence and boost their self esteem

· Young people often present using substances because they like using them and like the effects. They have not yet entered problematic use. This cohort of service users are usually referred reluctantly into service and are historically difficult to engage and frequently drop out of service.

· Boredom is also another reason stated by our service users. They often state there is nothing for them to do and a lack of amenities and activities in the deprived, rural communities they live in.

· Cost and availability is another reason they use, drugs and alcohol are often cheaper and more easily accessible than cinema trips, bowling, go carting etc

Are there certain groups of people who are more likely to be affected by drugs and excessive drinking? If so, which groups might they be?

· Professionals (particularly nurses and teachers),

· Homelessness

· Mental Health

· Sex Workers

· Ex Service Men

· Vulnerable Adults

· Individuals involved within the Criminal Justice System

· Young people who are not in education, employment or training (NEET) are high risk of substance misuse and criminal activity

· Over 16 year olds whose accommodation is unsatisfactory and problematic

· In C&YP there are a high percentage of clients who are living in the Looked After System

Does a particular stage of your clients’ lives influence their likelihood of taking drugs or drinking excessively? If so, what stage might that be? (i.e. age, relationship breakdown, unemployment etc.)

In general we see a high amount of learnt behaviour from using alcohol as a coping mechanism.

· Home environment and family relationships

· Peer Pressure

· Stress/Anxiety

· Unemployment

· Social Exclusion

· Bereavement

· Historic abuse

· Being made homeless

· Young people who are not in education, employment or training (NEET) are high risk of substance misuse and criminal activity

· Over 16 year olds whose accommodation is unsatisfactory and problematic

· Looked After System

What barriers exist for your client(s) when trying to access support and services?

· Stigma within their own community of accessing services,

· Overcoming culture of normalised behaviour to use alcohol at high levels,

· Clients commonly have low self esteem and little self confidence to feel able to make changes and access support.

· Waiting times

· Confidence/low self esteem

· Trust

· Personal Finances

· Chaotic lifestyle

· Lack and cost of transport

· Lack of motivation

· Geographical barriers

· Age restrictions (particularly for C&YP services)

What barriers exist for services when trying to access support for client(s)?

· Dual diagnosis – when there is a mental health issue and an alcohol issue local mental health services decline to intervene until the client is abstinent from alcohol, which can be difficult for the client to achieve especially if they are self medicating through alcohol.

· Employment – this is often a long term goal for clients to be able to achieve employment once abstinent however it can be difficult for services to access the appropriate support for clients to achieve this.

· Inpatient detox and rehab waiting times are too long (months in most cases)

· Information Sharing

· Integrated Approach

· Waiting Times

· Suitable Accommodation

· Lack of funding for activities

· Lack of diversionary activities

· Smaller projects loosing funding and closing eg youth provisions, anger management courses

· Waiting lists eg counselling, New Pathways, CAMHS etc

What do you consider to be barriers for staff and frontline services in working with your client group(s), or substance misuse generally?

· Waiting times for alcohol inpatient detox are too long (months in most cases) and also rehab waiting times are the same. This can be difficult for staff to support a client’s motivation and prepare for inpatient detox and rehab when their physical and mental health declines further from the length of time they are waiting.

· Specialism’s with staff teams (mental health worker, housing worker)

· Partnership working and appropriate information sharing

· Paperwork

· Not enough staff

· Lack of Substance Misuse knowledge and understanding in other sectors

· Lack of Substance Misuse training

· Difference, variations and criteria between Statutory versus voluntary agencies

Where do you think efforts should be targeted to address the issue of alcohol and substance misuse in Wales?

· Greater working links and recognition between specialist alcohol and substance misuse services and mental health.

· More direct pathways set up for specialist services in alcohol to be able to refer clients directly to rehab where appropriate.

· More funding for naloxone

· More support for dual diagnosis

· Supported accommodation

· Direct access Hostels

· Night Shelter Provision all year round

· Stimulant detox

· Rehabs

· Wet House

· More funding for qualifications for staff

· Shared IT system with relevant partners

· Young Person services as a preventative measure to support the reduction of entry into adult SM services and reducing SM related illnesses and issues

· Training for statutory services e.g Social Services Health, Education

In which local authority area do you work? If you work outside of Wales, please select "Outside Wales"

CRI operate in various areas throughout Wales including South Wales and Gwent as well as outside of Wales.

However, it should please be noted that this response is from a Gwent perspective only.

If you would like to be kept updated about the progress of the Committee’s inquiry into alcohol and substance misuse in Wales, please leave your name and e-mail address below.

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Appendix B

HSC Inquiry into Alcohol and Substance Misuse Gwent Provider response: Drugaid

Drugaid. This is an organisation response.

Which client group(s) do you work with? (For example, under 18s, older persons, homeless, or female only)

Drugaid works with adults and young people (under 18’s).

This includes those using substances both alcohol and drugs, those previously using substances in addition to family members, concerned others and those affected by someone else’s substance use.

The client group includes both male and females.

Some of our client group will include homeless people and ex service personnel (veterans).

Drugaid also works with other professionals and members of the public providing training, treatment, aftercare and recovery services.

What are the main reasons why your clients take drugs or drink excessively? Please tick all that apply.

If you work with more than one client group or you feel that there are other reasons as to why your clients take drugs or drink excessively, please comment in the box below.

X Peer pressure

X A way to deal with stress

X Client(s) already substance reliant

X Mental health

X Boost confidence

X Relieve social anxiety

X Environmental factors (for example - excessive drinking and/or drugs normalised in the

home/community)

X Relationship problems

X Financial concerns

X Self-medication

X Escapism

All of the above plus:

X Boredom

X Experimentation

X Improve body image

X Homeless or accommodation issues

X Isolation

Comments:

Homelessness – we work with a large number of young people that are living in homeless hostels as well as a number of adults of no fixed abode.

Are there certain groups of people who are more likely to be affected by drugs and excessive drinking? If so, which groups might they be?

As above including

Those not in employment, training or education
Those living in deprived areas or affected by poverty or with low household income
Those part of social groups/networks using substances
Adults – with housing issues; with time on their hands e.g. retired; with access to money
Young people - living in hostels; with any social services involvement; with substance misusing parents; with access to money.

There are often a number of factors and triggers that influence substance misuse behaviour and despite commonality they will be unique to an individual and will be relevant to their own treatment journey.

We have experienced service users patterns of use as follows –

Age – younger people experimenting, trying to fit in, peer pressure, mid to late teenage years parallel with widening social network and activities. Uneducated or unaware of substance related issues. Transitional stages such as moving from Primary to Comprehensive School, Leaving school at 16, Puberty, Changes in relationships. Summer holidays with a lack of structure and routine. Also any changes out of a young persons control such as parental separation, moving home/schools, Caring for parents etc.

Age – older people who have possibly retired, no longer have routine and responsibilities e.g. parental responsibilities as children become independent or leave home
Relationship issues – breakdown of relationships or relationships of others e,g parents divorcing, isolation
Bereavement – loss of family member or friend
Employment – unable to find employment, loss of employment, change in status, unhappy with employment
Family issues – relationships, caring responsibilities
Abuse – victims of abuse including physical, emotional, neglect, financial, sexual etc. Additionally perpetrators will use substances due to guilt
Health – to cope with symptoms, pain relief etc of both physical and mental health conditions and diagnosis.
Financial issues – loss of income, living in poverty
Housing – loss of home
Other coping mechanisms

What barriers exist for your client(s) when trying to access support and services?

Lack of awareness and understanding of services available
Uncertainty how to access or refer into service
Lack of continuity between services – no clear care pathway
Inconsistency of services across areas or projects
Stigma – embarrassment, shame, feeling of failure asking for help, not wanting family members or concerned others to be aware of their use.
Transport – unable to get to places of assessment and ongoing support
Opening Hours – times of appointments and services opening hours may not be convenient to client eg individual may be working or child care responsibilities
Location – as per transport. Some rural areas and valleys locations do not have substance misuse bases.
Lack of motivation to change
Peer group influences
Young people having to access locations/venues that are predominantly for 18+

What barriers exist for services when trying to access support for client(s)?

Waiting lists, capacity issues, demand outstripping supply (e.g. counselling)
Lack of understanding of other services
Limited access for some other core services eg mental health support
Locality – being able to see service users in a location close to or convenient for them
Good services only provided for short term contracts due to funding
Inconsistency in age requirements for access to services – some are under 18 some are under 25
Inconsistencies with agencies across areas e.g. social services support
Lack of referrals from health care professionals eg. GPs’

What do you consider to be barriers for staff and frontline services in working with your client group(s), or substance misuse generally?

Capacity – high caseloads and workloads ( only in some areas and generally for adult services)
Client expectations too high e.g. some service users might expect a substitute opiate prescription immediately on presenting to services
Multiple needs – substance misuse clients generally present with more than one need and if that need cannot be met by our service the overriding reason for someone using may remain
Inconsistencies in service delivery across areas e.g. Some receive funding for recreational counselling whereas others don’t
Lack of young person specific service buildings to use e.g. to offer drop in sessions
Limited resources to do more assertive outreach work
Restrictions with job role/remits
Joined up working and integrated care
Third sector working more closely with statutory service and ensure mutual trust and respect

Where do you think efforts should be targeted to address the issue of alcohol and substance misuse in Wales?

Outreach – a greater outreach provision to provide equality of services especially to redress geographical disparities
More consistent Harm reduction service provision, this would include needle exchange, BBV testing, Naloxone prescribing and brief interventions
Aftercare and Recovery services
Access to mutual aid groups eg NA, AA and Smart recovery
Peer mentoring services
Services to include mental health/substance misuse specialists including those for young people
More appropriate housing for homeless people and more specialist supported housing including for young persons
Young person’s services to have the option to work up to 25 where appropriate
More drop in venues including young people specific
Compulsory training for schools and other services on substance misuse education
More engagement and consultation with service users
More engagement with primary care and local community provision
More opportunities for individual to build recovery capital in the community
Fostering a sense of hope throughout the treatment system
More communication about the issues and the services in Wales
More work targeting specific communities in Wales e.g. LGBT community and travelling community, non-English speaking migrant community

In which local authority area do you work? If you work outside of Wales, please select "Outside Wales"

Gwent
Cwm Taf
Dyfed

If you would like to be kept updated about the progress of the Committee’s inquiry into alcohol and substance misuse in Wales, please leave your name and e-mail address below.

Caroline Phipps

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Appendix C

HSC Inquiry into Alcohol and Substance Misuse Gwent Provider response: Kaleidoscope

Kaleidoscope Gwent (all services)

Which client group(s) do you work with? (For example, under 18s, older persons, homeless, or female only)

Adult Substance misuse (Over 18’s) including alcohol.

What are the main reasons why your clients take drugs or drink excessively? Please tick all that apply.

If you work with more than one client group or you feel that there are other reasons as to why your clients take drugs or drink excessively, please comment in the box below.

Peer pressure

A way to deal with stress

Client(s) already substance reliant

Mental health

Boost confidence

Relieve social anxiety

Environmental factors (for example - excessive drinking and/or drugs normalised in the home/community)

Relationship problems

Financial concerns

Self-medication

Escapism

Other (please comment)

Comments:

· Bereavement

· Relationship breakdown

· Redundancy / unemployment

· Domestic / sexual abuse

· Post traumatic stress

Are there certain groups of people who are more likely to be affected by drugs and excessive drinking? If so, which groups might they be?

· Family History of Substance misuse

· Lower economic background and environment

· Service users with mental health issues

· Alcohol misuse does not discriminate for gender, class, or ethnic background.

There are many factors and triggers that can be associated with influencing the likelihood of substance misuse. Research suggests that alcohol misuse can develop in early years from experimental use. Or can develop in later years after periods of recreational use that has caused no long term negative effects. Alcohol misuse can increase due to dependence, or through negative life experiences such as bereavement, homelessness, financial insecurity, domestic abuse, sexual abuse, relationship breakdown, pain relief / other health concerns, loss of social or family support through moving area or lifestyle change eg loneliness, isolation particularly in old age.

What barriers exist for your client(s) when trying to access support and services?

· Single point of access

· Lack of GP shared care within community

· Lack of Tier 4 aftercare support

· Advertisement of services on offer

· Geographical

· Financial

· Emotional

· Lack of awareness of services

· Stigma

· Lack of occupational support

· Expectations

· Past experiences

· Concerns over confidentiality

· Family members and peer pressure

· Religious expectations

· Social and cultural norms

What barriers exist for services when trying to access support for client(s)?

· Lack of GP shared care services in community

· Lack of Tier 4 aftercare services in Wales

What do you consider to be barriers for staff and frontline services in working with your client group(s), or substance misuse generally?

· Integrated care pathways

· Service users own GP support from their registered surgery

· Geographical

· Financial

· Emotional

· Lack of awareness of services

· Stigma

· Lack of occupational support

· Expectations

· Past experiences

· Concerns over confidentiality

· Family members and peer pressure

· Religious expectations

· Social and cultural norms

· Excessive paperwork

· Lack of knowledge from other professionals

· Lack of regional commissioning from other services

· Homelessness and lack of housing support

· Poor communication between mental health and other social care partners.

· Lack of perpetrator schemes to reduce re-offending of domestic abuse.

· C-Card scheme is only available for under 25yrs. This increases the chance of risk taking sexual behaviour by sex workers and other substance users who may not feel comfortable accessing mainstream services.

Where do you think efforts should be targeted to address the issue of alcohol and substance misuse in Wales?

Finding adequate premises to run clinics or multi agency bases for substance misuse services in rural areas.

· Mental health support for substance misusers, lack of joint working with CMHT’s.

· Support the training and development of professionals including primary care services.

· Support the provision of flexible and local services that are able to respond to trends and local needs.

· Support the development of service user involvement to ensure peer led provision is also available.

· Support the continued funding or Tier 4 placements to provide individuals with complex care needs appropriate responses.

· Ensure that family and friends are included in services and their needs are met.

· Support the development and improvement of communication and joint working between statutory and voluntary services.

· Support the development of a regional education plan that is enforced in schools and other education facilities based on best practice and involving the local young person’s provider.

· Ensure continued supply of best practice needle exchange and harm reduction advice is available throughout Wales.

· Support the development of multiagency bases to improve joint working and single access to services.

· Support the provision of 5 year contracts to enable continuity and appropriate development of services rather than to encourage competition and apathy.

In which local authority area do you work? If you work outside of Wales, please select "Outside Wales"

Gwent

If you would like to be kept updated about the progress of the Committee’s inquiry into alcohol and substance misuse in Wales, please leave your name and e-mail address below.

Jim Henton

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Additional comments:

· 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;

what are the impacts of alcohol and substance misuse on people in Wales,

including young people:

Alcohol can impact on development physically and emotionally. Young people can have their education interrupted by non-attendance or through affect on concentration and a safe space at home to complete their allocated work. Cognitive development can be negatively affected by substance use from conception. Foetal Alcohol Syndrome is an area of continued research, and Kaleidoscope fully supports the Public Health Wales No alcohol No risk campaign and provides accredited PHW brief intervention training with pregnancy and alcohol information. This should be supported to increase delivery across Wales. Alcohol and substance misuse can lead to an increase in unprotected sex and other risk taking behaviour. Substance misuse can also exasperate or initiate mental health problems including substance induced psychosis. Young people can be affected by their parents substance use which can result in them acting as carers for their parents or younger siblings. They can also be indirectly or directly affected by domestic abuse between their parents which is linked to substance use. Substance use can result in neglect of children whether intentional or through lack of stability and financial independence.

University students; increase in risk taking behaviour and the continued impairment of cognitive development. Isolation can lead to feelings of loneliness and alcohol use for confidence and self esteem. Peer pressure is a factor that increases alcohol use, and lack of consequences from family members when too much alcohol has been drunk.

Older people; Health implications are increased in older age. This can be as a direct physical response to alcohol in the body, or that they are unable to recover from other illnesses. Falls and trips can have long lasting consequences and are increased in likelihood by the consumption of alcohol. Alcohol interacts negatively with many medications that are prescribed in older age, and many professionals do not feel comfortable giving advice or asking the correct questions about alcohol use to older people. Older people have less social support if they are isolated and living alone, they are often embarrassed and unable / unwilling to ask for help and support. Older people can also be carers for their younger family, and this can cause stress and financial difficulties which they do not have the resources to address.

Homeless people; Alcohol and substance use can leave people in vulnerable living conditions open to financial and physical abuse, by those who they are reliant for some temporary accommodation and from member of the public when living on the street. There is a lack of social support, and increased isolation and this can increase the risk of overdose and self neglect. There is lack of access to structured treatment appointments and travel opportunities to get to appointments. There is a lack clear communication between services and a culture of seeing these service users as non compliant. Homelessness has increased stigma attached to it, and can be a barrier to engaging and accessing in services.

People in police custody or prisons; Alcohol and substance misuse can lead to an increase in physical and verbal aggression against authority figures and therefore increase the likelihood of criminal justice involvement. Dependence can also lead to acquisitive crime and increase the offending behaviour. When withdrawing from substance use within police custody or prison this can lead to physical and mental health implications. Often medication is not provided through lack of previous prescribing history or lack of access to medical supervision.

· the effectiveness of current Welsh Government policies on tackling alcohol and substance misuse and any further action that may be required;

Current policy for limited prescriptions on DIP does not always work, and does not encourage sustained recovery. Perception of staff who work in a drop in environment that includes DIP service users is that this is perceived by service users to be an enforced reduction and before they are ready and therefore they do not engage their motivation to provide negative tests and reduce off methadone.

Current NWIS guidance do not require data on family support and therefore monitoring and outcomes of services are only at a local level and not Wales wide. This does not allow for review, or development at policy level and changes on a national level.

As highlighted above dual diagnosis and substance misuse need to be more joined up. The new guidance that is being developed will hopefully support this.

Housing policy allows for limited provision for vulnerable adults and often leads to our service users being classed as 'intentionally homeless" as they are unable to manage their finance, health or social obligations to live independently.

Outcome monitoring is via TOPs form. The data that is submitted for number of days alcohol use and not amount of alcohol. Therefore does not reflect substantial reduction of alcohol use that may be achieved when a service user is still drinking every day.

Kaleidoscope supports minimum unit pricing to reduce consumption of alcohol