Drug Abuse

Annex E

Services for Drug misusers in England A Paper by DHSS

Introduction

1 This paper attempts to assess the level of services currently available for drug misusers. It is based on the latest factual information available in the Department, namely:

a. information gathered from Regions' out-turn reports for 1986-87;
b. other centrally available statistics;
b. data from the interim report by Birkbeck College of their evaluation of services developed as a result of the Central Funding Initiative.

Centrally Available Statistics

2 Health Service statistics available from the specialist facilities return for 1986 show that there are currently 11 drug dependence units in England, and six drug and alcohol units containing 127 and 125 beds respectively. There are no statistics for undesignated beds in the general health service units which are available.

3 There are 36 residential rehabilitation facilities in England at present. This figure includes those run by both the voluntary and private sectors.

Information from Regions' out-turn reports

4 Regional Health Authorities submit annual out-turn reports to the Department on the development of hospital and community health services over the previous year. Scrutiny of Regions' out-turn reports for 1986-87 has just been completed. In order that the responses from Regions should be as uniform as possible, we asked that the out-turn reports include answers for drug misuse services within each Region and District. In addition to questions about new developments started during 1986-87 and whether they were the result of joint planning with other service providers, Regions were asked specifically:

—    Is there a multi-disciplinary Drug Advisory Committee in every District?
—    Within the Region, is there:
—    a specialist treatment facility;
—    access to specialist advice for professionals;
—    long-term residential accommodation?
—    Within each District, are there:
—    access to advice and counselling;
—    psychiatric services and in-patient beds;
—    laboratory facilities?

Details of Regional out-turns

5 With only one exception, every district now has a Drug Advisory Committee, and the majority have wide representation including the health service, primary care, social services, the voluntary sector, education, housing, probation, and the police.

6 All Regions state that they provide access to specialist treatment facilities and specialist advice for professionals, although in one or two Regions centres are inconveniently placed and limited in scope.

7 The provision of residential rehabilitation remains patchy, with some Regions relatively well provided (Wessex) and two (West Midlands and North East Thames) without any long-term residential rehabilitation at all. Provision is almost entirely within the voluntary sector and growth has therefore been unplanned. Until the developments of the last few years (resulting largely from the Central Funding Initiative), residential rehabilitation facilities were concentrated in the south-east, but geographical distribution has now evened out, although until two units planned for the West Midlands open, there will remain no provision between Oxford and Sheffield. Facilities for women with children remain limited: only half a dozen units exist or are planned within the next few years.

8 There has been rapid development in advice and counselling services in the last few years, and these are now available to some extent in all Districts, often provided by the voluntary sector. It is noticeable that it is in this area that most progress has been made, possibly because these services are less costly and complicated to set up than, for instance, residential facilities.

9 About two-thirds of Districts have access to psychiatric services and in-patient beds for drug misusers within the District. However, in some cases these facilities are not as accessible or as extensive as they might be, and it is difficult to assess the quality of the service offered. In a significant number of Districts which report having treatment facilities within the District, there is no consultant with a special interest in drug misuse, and ready access to in-patient beds is also uncertain. It may be that some Districts represent their general psychiatric services as being the formal back-up.

10 The provision of district-based laboratory facilities appears available in all Regions. However, one Region has cited the high cost of district-based laboratory facilities which also meet the safety requirements for the protection of HIV infection as a reason why such services rely on the Regional laboratory service.

General observations

11 Approximately 200 separate developments have been indentified from these out-turn reports, the majority funded from the £5m special allocation for drug misuse services made to health authorities in 1986-87. This means that approximately one new service development was funded for each District in England in 1986-87, the first year in which the extra £5m was made available to health authorities. Of course, the size and scope of these projects varies enormously, from the appointment of a community psychiatric nurse to funding for an entire Drug Problem team, or contributions to the funding costs of a voluntary organisation providing residential accommodation. However, it provides an indication of the extent of development of services facilitated largely by the additional £5m.

12 The spread of services is also still rather patchy with gaps where little appears to be developing, often as a result of individual Districts' views that they do not have a drug misuse problem.

13 The picture across the country on joint planning with Social Services remains unsatisfactory, six Regions showing little or no evidence of this in their plans.

14 In summary, there has been progress in the level of services provided by Districts but there remains some inconsistency across the country. Regions need to continue to monitor and stimulate those districts which do not provide accessible facilities for drug misusers.

These shortcomings are being followed up with Regions either directly or through the review processes.
The Central Funding Initiative

15 The Government set up the Central Funding Initiative in 1983 to pump-prime the development of local services. All the funds available under the Initiative have now been fully committed. £17.5 million has been allocated to 188 local projects. The Department has commissioned a research project from Birkbeck College examining the impact of the CFI on service provision. The project has recently published an interim report, and some interesting and positive data has emerged. Although the data relates only to projects funded under the Initiative, these constitute a substantial proportion of recent service development, and the report provides a useful picture of recently developed provision.

16 There has been significant development of the voluntary sector under the Initiative — voluntary projects constituted 42 per cent of those funded.

17 Almost half the funding went to community-based services and half the projects funded (in money terms) constituted new services, as opposed to extensions of existing ones.

18 One of the indicators of the demand for and appropriateness of the projects funded under the CFI is the extent to which statutory authorities are prepared to pick up the funding for these projects once central funding ends after the maximum of three years. At the time of the research team's interim report, information on 29 of the first 35 projects whose funding had ended was obtained. It is encouraging that all but two projects had either secured future funding or were still negotiating with potential funders. Of the two which were not continuing, one had been an information-gathering exercise and was therefore not appropriate for ongoing funding, and the other, while not continuing in its present form, was under consideration by the DHA as a permanent service from this year.

19 The report indicates that 54 per cent of clients from projects studied in detail were women. This is an interesting finding, and reinforces the need for services to be aware of women drug users' particular needs.

20 Of the factors that caused projects to change their objectives since they were first set up, issues surrounding HIV infection were most prominent.

Services for Drug Misusers in Scotland
A Paper by the Scottish Office (Abridged Version)

1 Service Provision — General

1.1 The provision of primary medical care and hospital services for the treatment of drug misusers under the NHS is the responsibility of Health Boards who are expected to determine the level of hospital and community-based specialist services to be provided in their areas in the light of their assessment of local needs, taking account of national guidance. Drug misusers may receive treatment from general practitioners, hospital or community-based services or doctors in private practice. Non-emergency hospital services for drug misusers have hitherto been provided in Scotland in mental hospitals or psychiatric units of general hospitals. Only two hospital-based services specifically for drug misusers are in operation in Scotland.

1.2 The rehabilitation of drug misusers and their re-integration into society, which is an essential part of treatment, may be undertaken by local authority social work departments, by the Health Service or by voluntary bodies. Local authorities do not have specific powers or duties in relation to drug misuse but may provide services, including residential accommodation, in terms of their general powers under the Social Work (Scotland) Act 1968. In practice, outwith Strathclyde Region, existing rehabilitation services for drug misusers are provided mainly by voluntary organisations often with support from local authority or NHS personnel. In Strathclyde, the social work department has placed special emphasis on the planned provision of services for drug misusers and has developed a range of community-based services.

1.3 Prior to 1983-84 services for drug misusers in Scotland (other than hospital-based services) were almost non-existent; but a range of community-based services has developed rapidly in the last three to four years from this low base. The Register of Helping Agencies published by the Scottish Health Education Group (third edition, August 1987) contains a full list of the services available in Scotland.

2 Grants to assist Local Initiatives

2.1 To assist and encourage the development of services for drug misusers the Scottish Home and Health Department established with effect from 1984-85 a scheme of three-year grants to support local initiatives by Health Boards, local authorities and voluntary bodies. Additional support was provided by the Social Work Services Group by way of three-year pump-priming grants under section 10 of the Social Work (Scotland) Act 1968. Some 26 projects have received support under these programmes. The selection of projects for funding was made on the basis of three main criteria: resources should be directed to areas of widespread drug misuse; the desirability of funding a range of projects with a view to future evaluation; and the need to increase the provision of community-based projects.

2.2 Monitoring of the centrally-funded projects was undertaken on a model known as `implementation monitoring' which was designed to assess in a systematic way how well each project was achieving the objectives which it had set itself. The evaluation covered all aspects of the projects work including objectives, organisation, management, methods used and staff training. It also assessed the status of each project within its local community and the identity which it had established; but it did not attempt to measure the performance of the project in terms of client outcome in view of the many variables involved and the relatively short period for which the projects had been in operation.

2.3 With one or two exceptions the projects were found to be well-managed with clear lines of responsibility and good support systems for workers. Overall, the community-based projects were judged to have made a significant contribution to combating drug misuse through the direct provision of services to drug misusers and their families and through informing the local communities about the problems of drug misuse.

3 Future Planning of Services

3.1 The need to develop services quickly in response to a rapidly-increasing 0drug problem and the use of short-term central government funding (as originally announced) to meet this need meant that little effort was devoted to forward planning which now needs to be addressed. In addition to service provision, training needs should be identified and met.

3.2 In February 1987 SHHD issued a Circular which set out detailed arrangements under which Health Boards would assume responsibility from 1 April 1987 for the administration of the local projects previously funded by SHHD. In order to provide continuity and a more secure financial base for managers and staff, particularly in voluntary projects, the arrangements provided that projects would be funded for at least a further three years from 1987-88 up to a maximum of seven years, subject to evaluation. Copies of the evaluation reports produced on each project by the Scottish Office (see section 2 above) were sent to the Health Boards concerned. Health Boards are now required to monitor the performance of these projects in consultation with the local authority social work department as appropriate.

3.3 Local drug projects, particularly those run by voluntary bodies, have tended to feel detached and isolated from the usual processes of local service planning and provision by Health Boards and local authorities. The new arrangements for the administration of projects by Health Boards are intended as an integral part of the range of services for which they are responsible. In this connection there are encouraging signs in several areas that local drug liaison committees are becoming increasingly involved in the detailed planning and provision of services.

4 HIV Infection and the need to expand Drug Misuse Services

4.1 The Circular issued in February 1987 also invited Health Boards to co-ordinate local proposals and apply to the Department for an allocation of funds for the expansion of services for drug misusers. Counselling about HIV infection and the risk of AIDS is now an integral part of the work of drug misuse services throughout Scotland but particularly in Edinburgh, Dundee and Glasgow. Discussion with drugs workers suggests that the counselling time required for each client (including the families and friends of misusers) as a result of the AIDS problem has increased by as much as 50 per cent. An extra £300,000 per annum is being made available from 1987-88 under this support programme, bringing the total set aside in the Health programme specifically for the support of drug misuse services to over £1m per annum. The Circular made clear that one of the factors taken into account in deciding to increase the resources available under this 0programme was the need for these services to provide information, advice and counselling about HIV infection for drug misusers and their families and friends; and proposals for new initiatives would be expected to take account of this need.

4.2 In considering individual proposals and determining the allocations to Boards, the Department reviewed the pattern of existing services and took into account available information about the incidence of drug misuse, in particular by injecting, and the areas where the main concentrations are of people at risk of contracting or transmitting HIV infection through injecting drug misuse. We concluded that in view of the scale of the drugs and HIV infection problem in Edinburgh, Glasgow and Dundee and the very heavy pressure on the existing drug misuse services in these areas, the allocation of funds should be confined to proposals in these areas. We discussed the proposals from these areas with the Health Boards and local authorities concerned and agreed with their view that priority should be given to strengthening or expanding the range of existing services rather than establishing new projects.

4.3 The Department's scrutiny of the proposals submitted by Boards indicates that some gaps in the services provided — in geographical terms and the type of services available — will remain. In particular there were several proposals from Glasgow and one or two other parts of Strathclyde Region and from Lothian, Central and Grampian Regions which we considered worthy of support but which did not merit a higher priority than those accepted for funding. We hope that Health Boards and local authorities will explore other ways in which these proposals might be funded.

4.4 Training

In addition to the additional funds being allocated to the three Health Boards we are increasing substantially our support for the Drugs Training Project at Stirling University to enable it to recruit two additional training organisers. This is one of the most important and most successful of the local initiatives to which we gave grant support in 1984. The project's original remit was to provide training for drugs workers and volunteers in the new local projects and for staff in social work departments. As the number of local projects has grown and in-service training programmes for teachers, community education workers and other professional groups have been developed, the role of the Stirling project has developed to the point where it is effectively a national drugs training centre providing training and training advice for a wide range of bodies. HIV infection and AIDS have also added a major new dimension to drug-related training. The expansion of local services will also add to the project's workload so we see the expansion of the drugs training project as an essential part of the development of these services.

4.5 SHHD is also providing support for three years for an additional lecturer post at the Alcohol Studies Centre at Paisley College of Technology to concentrate on the provision of in-service training for NHS staff on drug misuse, to maintain close liaison with the Drugs Training Project at Stirling University and the Scottish Health Education Group, and to seek to work in co-operation with these bodies as appropriate.

5 Scottish Drugs Forum

5.1 In 1986 a new national voluntary organisation, the Scottish Drugs Forum, was established with grant support from SHHD. The forum draws its membership from the voluntary and statutory sectors and its main objective is to undertake a co-ordinating and supporting role for the work of local drugs groups and other individuals and organisations concerned with drugs problems.

SHHD October 1987

Services for Drug Misusers in Wales

A Paper by the Welsh Office

1 Advice and Counselling

Most areas in Wales have advisory and counselling services and many involve the voluntary sector. They include drop-in centres and peripatetic health professional staff offering a response to both casual enquiries and specific case-related problems. The All Wales Drugline launched in August 1986, is a 24 hour manned telephone service. Funded by the Department, it provides immediate advice and guidance to drug misusers, their families, friends and to professional carers. Callers are also advised to seek follow up support from their local services.

2 Treatment and Rehabilitation

Specialist treatment and rehabilitation services for drug misusers are limited in Wales. Apart from statutory provision, two voluntary organisations: Teen Challenge, funded by urban aid, and the Rhoserchan Project, both in Dyfed, offer residential treatment and rehabilitation. The Welsh Committee on Drug Misuse (WCDM) is currently examining the extent of services throughout Wales and is shortly to produce recommendations for action.

3 County services

3.1 Clwyd: Community workers and psychiatric nurses form a community-based counselling and advisory service from two main centres. They work with voluntary councils and statutory agencies including general practitioners and hospital staff. There is a drug treatment unit at the North Wales Hospital. The authority is planning the employment of a counsellor specifically for AIDS and drugs misuse.

3.2 Dyfed: The health authority is developing a pilot multi-disciplinary team. At present only the project leader is in post working with a counsellor from the local voluntary council on alcoholism and drugs. The intention is to provide an advisory and counselling service based at a drop-in centre supported by a consultant psychiatrist, local GPs and members of the local mental health team. Detoxification occurs at general and psychiatric hospitals. In the county there are two residential treatment and rehabilitation centres operated by voluntary agencies — Teen Challenge and the Rhoserchan Project.

3.3 Gwent: The service in Gwent revolves around the health authority's HARP Project. It is an advisory and counselling walk-in centre where information, counselling and development workers operate. Linked to it is a Development Officer in the voluntary sector working with self-help groups. In-patient and out-patient treatment is available from the general psychiatric services.

3.4 Gwynedd: The Gwynedd Drug Advisory Service provides information, advice and counselling. This is staffed by community workers who work closely with trained voluntary counsellors. Consultations are available at psychiatric out-patient clinics. Misusers are generally referred to a consultant psychiatrist who specialises in substance abuse. The Drug Treatment Unit at the North Wales Hospital, Clwyd, also admits patients from Gwynedd.

3.5 Mid Glamorgan: Currently counselling services are provided by the voluntary sector. The health authority is planning a community drug team consisting of a psychiatrist, psychologist, community psychiatric nurse and social worker. Counselling drug misusers about AIDS is also to be a part of the team's work.

3.6 Powys: There are plans for employing an officer to co-ordinate training of volunteer counsellors throughout the county. There is no existing specialist service for drug misusers.

3.7 South Glamorgan: The principal focus for health care for drug misusers is the ADFER, Alcohol and Drug Treatment Unit at a psychiatric hospital. A day care unit has also been established with a community drug team comprising a psychiatrist, psychologist, social worker and nurse. There is specific provision for counselling drug misusers about AIDS. Local voluntary groups also provide information and counselling services.

3.8 West Glamorgan: The main provision of service is in the voluntary sector which offers advice and counselling. There is in-patient and out-patient general psychiatric treatment.

4 Training

Training and the selection of counsellors are considered by many organisations as being of key importance. Drug Advisory committees (DACs) have seen training as an essential element of their strategies for combating drug misuse and this is supported through central funding in a number of counties. The WCDM has issued guidance to DACs on the selection and training of counsellors.

5 Information and Monitoring

DACs have identified considerable problems in collecting reliable information on the incidence and nature of drug misuse. WCDM is introducing two complementary data collection systems. One involves the collection of core data by each DAC on a common basis at six-monthly intervals, for collation nationally. The other is a more in-depth study of problem drug users and their use of services, to be piloted in two counties.

6 Central Funding

6.1 Central funding has contributed significantly to the provisions of core prevention and counselling services in the majority of counties. Further development is planned to make the facilities more comprehensive and particularly to promote developments in treatment and rehabilitation.The Department has allocated £1.64 million since 1985-86 to help statutory authority and voluntary group schemes and bids for funding from 1988-89 are currently being considered. Bids for funding are considered very carefully in the context of county strategies detailing plans for service provision and development, training and co-ordination. These were recently approved by the Secretary of State subject to certain specified improvements being made.

6.2 Recently, the Welsh Office received bids from district health authorities for funds to support AIDS prevention activities and funds (£33,500 p.a.) have been made available specifically for the counselling of drug misusers. Support for further measures is being considered including the provision of clean injecting equipment in the light of the results of pilot schemes in England and Scotland. As a means of monitoring and evaluating the investment, recipients of grant monies have been required to produce thorough progress reports to the Department where they are scrutinised by both administrators and professional staff. To complement the scrutiny officials are to visit a broad selection of these schemes. While funding is on a recurrent basis for the duration of the project, it is subject to review after three years that the service continues to be needed and is effective.

7 Welsh AIDS Campaign

The Welsh AIDS Campaign (WAC) organised a conference and follow up day for drugs fieldworkers on AIDS which was well attended by members from all the principal agencies, both voluntary and statutory. Many agencies now provide information and counselling for drug misusers on AIDS. WAC is seeking to work with these agencies to provide information, educational and training resources on AIDS and drug misuse. They are currently preparing a leaflet for drug misusers on hygienic practices with the advice of WCDM on its content.

Services for Drug Misusers in Northern Ireland

A Paper by the Northern Ireland Office

1 All available statistical information suggests that the overall drugs problem in Northern Ireland is relatively small by comparison with the rest of the United Kingdom. The number of persons charged for offences relating to controlled drugs in 1986 was 317 compared with 286 in 1985. The majority of offences related to cannabis and there is no evidence of any major `hard drugs' problem, in particular an intravenous injection problem. Evidence from the RUC Drugs Squad indicates that it is very unusual to find individuals in possession of injecting material or equipment in Northern Ireland. The number of addicts notified to the Chief Medical Officer of the Department of Health and Social Services who were still receiving controlled drugs at 31 December 1986 was 11 compared with 13 in 1985. Hospital statistics for 1985, the latest year for which figures are available, show a decrease in admissions for drug-related problems, 101 compared with 135 in 1984, with almost three-quarters of such cases involving non-controlled drugs.

Services

2 Northern Ireland has one regional unit (located in Belfast) which specialises in the treatment of alcohol and drug dependence. In addition facilities for such treatment are available in the six psychiatric hospitals in the Province and in psychiatric units attached to some general hospitals. Each of the six psychiatric hospitals has an identified consultant who specialises in the treatment of addiction. The professional viewpoint in Northern Ireland to date has been that routine maintenance therapy using oral methadone as a substitute for other controlled drugs cannot be regarded as an effective or advisable regime in the management of drug addiction. Aftercare in the community following hospital discharge can be provided by means of hospital out-patient, day hospital and community support services. Current information indicates that existing services are adequate to cope with the extent of the problem so far identified.

AIDS

3 The incidence of AIDS in Northern Ireland is so far relatively small with three cases identified (all of whom contracted the disease outside the Province and all have since died) plus a further 37 individuals infected with the HIV virus. There have been no cases involving intravenous drug misuse. Screening for HIV antibodies is available from the locations referred to in paragraph 2 and so far all tests have proved negative.

4 Because of the low incidence of injecting drug misuse in the Province the Department of Health and Social Services has decided not to actively promote this element of the Government's national public education campaign in the Province. Facilities at sexually transmitted disease clinics have been enhanced to meet the anticipated increase in demand for HIV testing and counselling. The main voluntary group in Northern Ireland is AIDS Helpline (Northern Ireland) which provides a mainly telephone advice and counselling service. It receives funding from the Department for providing this service.

5 The Department has established a local AIDS Committee to ensure that action to control the spread of infection in the Province is properly co-ordinated and that the public education campaign, whilst continuing to have a largely national focus, is supplemented and adapted as necessary to have maximum impact locally. Because of the potential dangers, the AIDS Committee and the Northern Ireland Committee on Drug Misuse continue to monitor the situation closely.

< Prev		Next >