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Guidance for commissioners of drug and alcohol services


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This guide has been written to provide practical advice on developing and delivering local plans and strategies to commission the most effective and efficient drug and alcohol services for adults.

Based upon clinical best practice guidance and drawing upon the range of available evidence, it describes what should be expected of a modern drug and alcohol service in terms of effectiveness, outcomes and value for money.

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Guidance for commissioners of drug and alcohol services

  1. 1. Guidance for commissioners of drug and alcohol services 1Practicalmental healthcommissioningGuidance for commissioners ofdrug andalcohol servicesJoint Commissioning Panelfor Mental
  2. 2. Joint Commissioning Panelfor Mental HealthCo-chaired
  3. 3. 2 Practical Mental Health CommissioningContentsTen key messagesfor commissionersIntroduction04What aredrug and alcoholservices?Why are drug andalcohol servicesimportant tocommissioners?06 08What do we knowabout currentdrug and alcoholservices?12What would agood drug andalcohol servicelook like?14Supportingthe deliveryof the mentalhealth strategy19References21
  4. 4. Guidance for commissioners of drug and alcohol services 3Ten key messages for commissioners1 Investment in drug andalcohol services gets results.Treatment, as part of aco-ordinated public healthapproach is proven to be costeffective for health servicesand society as a whole.Disinvestment brings with it arisk of reversing the progressmade over recent years.2 A strong evidence baseexists for the range ofinterventions that areeffective in substance misuse.Commissioning should bebased upon this evidenceusing NICE quality standards.3 To be effective, the treatmentsystem should be equippedto respond to the full rangeof complexity of needrepresented by those whomisuse substances.4 A skilled workforce, workingunder appropriate supervisionand providing care withinnational competenceframeworks, is key todelivering good outcomes.5 Collaboration and partnershipgets results. The NHS andvoluntary sector have acontribution to make in thedelivery of drug and alcoholservices.6 Commissioning of drug andalcohol services should bebased upon accurate and upto date information aboutlocal needs.7 Commissioners should ensurethat local services have clearleadership, both clinical andmanagerial, and that servicescomply with professionaland service standards.8 Commissioning ofdrug and alcohol servicesshould be outcome based andmake use of available dataand information.9 Services should placerecovery at the centre of theirapproach and commissionersshould recognise recovery ascentral to their commissioningand strategic decision making.10 Treatment is not simplyabout patients – it shouldaddress the needs of familiesand carers, and workwith patients’ wider socialnetworks.
  5. 5. The Joint CommissioningPanel for Mental Health(JCP-MH) ( a collaboration co-chaired bythe Royal College of GeneralPractitioners and the RoyalCollege of Psychiatrists.It brings together leadingorganisations and individualswith an interest in commissioningfor mental health and learningdisabilities. These include:• People with mental health problems• Carers• Department of Health• Association of Directorsof Adult Social Services• NHS Confederation• Mind• Rethink Mental Illness• National Survivor User Network• National Involvement Partnership• Royal College of Nursing• British Psychological Society• Representatives of the EnglishStrategic Health Authorities(prior to April 2013)• Mental Health Providers Forum• New Savoy Partnership• Representation fromSpecialised Commissioning• Healthcare FinancialManagement Association.IntroductionThe JCP-MH is part of the implementationarm of the government mental healthstrategy No Health without Mental Health1.The JCP-MH has two primary aims:• to bring together people with mentalhealth problems, carers, clinicians,commissioners, managers and othersto work towards values-basedcommissioning• to integrate scientific evidence,the experience of people with mentalhealth problems and carers, andinnovative service evaluations, in orderto produce the best possible adviceon commissioning the design and deliveryof high quality mental health, learningdisabilities, and public mental healthand wellbeing services.The JCP-MH:• has published Practical Mental HealthCommissioning2, a briefing on the keyvalues and principles for effective mentalhealth commissioning• has so far published seven other practicalguides on the commissioning of primarymental health care services3, dementiaservices4, liaison mental health servicesto acute hospitals5, transition services6,perinatal mental health services7, publicmental health services8, and rehabilitationservices9• provides practical guidance and adeveloping framework for mental health• will support commissioners to deliver thebest possible outcomes for communityhealth and wellbeing.Who is this guide for?This guide has been writtento provide practical adviceon developing and deliveringlocal plans and strategies tocommission the most effectiveand efficient drug and alcoholservices for adults.Based upon clinical best practice guidanceand drawing upon the range of availableevidence, it describes what should beexpected of a modern drug and alcoholservice in terms of effectiveness, outcomesand value for money.The guide will be of particular use to:• public health leaders who will holdresponsibility for commissioning theseservices• Clinical Commissioning Groups (CCGs)• wider local authority commissioners• and voluntary and independent sectororganisations.This guide does not cover drug andalcohol services for children or offenders,whose needs may be more specific.More information can be found in thepublication Practice Standards for YoungPeople with Substance Misuse Problems10.4 Practical Mental Health Commissioning
  6. 6. Guidance for commissioners of drug and alcohol services 5HOW WILL THIS GUIDE HELP YOU?This guide has been writtenby a group of drug and alcoholprofessionals, people who usedrug and alcohol services, andcarers. The content is primarilyevidence-based, but ideasdeemed to be best practice byexpert consensus have also beenincluded.By the end of this guide, readers should bebetter equipped to:• understand what an effective range ofdrug and alcohol services should look like• know the sorts of interventions thatshould be available• understand how those interventionscan contribute to achieving recoveryand make improvements in public mentalhealth and wellbeing.In doing this, the guide describes:• the benefits of drug and alcohol services• the desirable team configurations fordrug and alcohol services• the policy context for drug and alcoholservices• what good quality drug and alcoholservices look like• the benefits of providing good qualitydrug and alcohol services• how drug and alcohol services canmake a contribution to a range of otherimperatives including those in the nationalmental health strategy.The guide draws upon, and signpoststowards, previously published guidance andpolicy. Among the key documents drawnupon are:• NICE quality standards for alcoholdependence and harmful alcohol use(QS11)11• Alcohol dependence and harmfulalcohol use CG115 (NICE)12• NICE quality standards for drug usedisorders (QS23)13• Drug misuse – psychosocial interventionsCG51 (NICE)14• Drug misuse – opioid detoxificationCG52 (NICE)15• Improving outcomes & supportingtransparency – a public health outcomesframework for England, 2013-16(Department of Health)16• The Government’s Alcohol Strategy(HM Government 2012)17• JSNA Support Pack for Commissioners(National Treatment Agency)18• No Health without Mental Health (DH)1• Medications in recovery. Re-orientatingdrug dependence treatment (NationalTreatment Agency 2012)19• Commissioning for Recovery(National Treatment Agency)20• Drug Strategy 2010 – Reducing Demand,Restricting Supply, Building Recovery(HM Government)21• Healthy lives, healthy people:our strategy for public health in England(HM Government)22• the roles and competencies of doctorsworking in substance misuse23• Alcohol use disorders: physicalcomplications CG100 (NICE)24• Alcohol disorders – preventing thedevelopment of hazardous and harmfuldrinking PH24 (NICE)25.This guide does not cover non-structuredinterventions for non-dependent drinkers.
  7. 7. 6 Practical Mental Health CommissioningWhat are drug and alcohol services?Effective treatment providesa central means for peopledependent on drugs or alcoholto recover from their addictionand to live independent lives.It can deliver a wider range ofpublic health and social benefits,and can also bring abouteconomic savings at the localand national level (see page 9).Local authority-based publichealth is now responsible forcommissioning drug and alcoholprevention, treatment andlinked recovery support. Thisshift will provide a platform fora more integrated approachto improving public healthoutcomes. This approachaddresses the root causes andwider determinants of drugdependence and alcohol misuse,and the harm and impact theyhave on people who use drugsor alcohol, carers, families andcommunities (such as mentalhealth, employment, education,crime and housing). It alsodelivers the greatest gains forindividuals and the community.There is no nationally agreedmodel for the commissioningand delivery of drug and alcoholservices. The result of this hasbeen a continuation of localplans for services that attemptto address not only local need,but also national imperatives.Although a locally basedapproach is important it canhave the negative consequenceof different and variedapproaches across the country.However, the existence of NICEquality standards, the NationalDrug Treatment MonitoringSystem, local needs assessments,Joint Strategic Needs Assessmenttools and the publication ofguidance such as this, meansthat commissioners now havea wide range of tools to enablethem to commission effectively.THE SERVICES
  8. 8. Drug and alcohol services aremainly provided by NHS Trustsor voluntary sector services,although the private sector alsoplays a smaller role in provision.In the majority of cases, patients comingto drug and alcohol services self-refer ratherthan being referred by a GP. Drug andalcohol services employ a range of expertiseincluding front line doctors, psychologists,senior nurses, and drug workers. This skillmix makes them well equipped to conductcomplex work with a client group oftenperceived as challenging.In the past, drug and alcohol servicestended to be provided by separate drugand alcohol teams, but recently they aremore commonly delivered from teamsthat deal with both. These aim to providea more integrated approach, particularlyfor those people who have a problematicuse of both substances. For some peoplethis approach has not been successfulin relation to enabling access to services(e.g. due to the stigma associated withparticular types of substance misuse).Most secondary care services tend toconcentrate their interventions on peoplewith addictions to drugs such as heroin,crack cocaine and alcohol. However,other substances, for example emergingclub drugs and prescribed drugs, may beamong those for which people are treated.Given the complexity of these problemsand the range of needs, services arerequired to collaborate with other parts ofthe health, social care and criminal justicesystems. This is essential to the delivery ofeffective high quality treatment.This is especially the case when providingservices to those people with co-morbidillness, (e.g. substance misuse and mentalillness, or substance misuse and physicalhealth needs). This is often because peoplewith co-morbid illness are often excludedfrom general mental health services.One of the functions of drug and alcoholservices is to work with this group.In parts of the country where Drug &Alcohol Action Teams (DAATs) are inoperation, these have introduced LocalArea Single Assessment and ReferralSystems (LASARS) as part of a nationalpilot of drug recovery Payment by Results.The core function of LASARS is to assessand set a tariff, refer and in some casesreview achievement of outcome. Theymay also reduce the number of assessmentsthat an individual has to undertake in orderto access those services26.WHO WORKS IN THESE SERVICES?A wide range of people froma number of disciplines andspecialisms work in drug andalcohol services including:• medical staff including specialistdoctors (addiction psychiatrists anda small number of highly specialistGeneral Practitioners)• nurses (both mental health andgeneral nursing)• drug and alcohol support workers• non-medical prescribers (especiallytrained nurses or pharmacists)• peer mentors• pharmacists• psychologists and other specialisttherapists• people who are experts by experience• social workers/care managers.Those working in drug and alcohol servicesare expected to work to a set of nationaloccupational standards and, potentially,also the skills framework promoted byThe Substance Misuse Skills Consortium.Alongside these are the competenciesrequired by specific professionalbodies, including the Royal College ofPsychiatrists, Royal College of Nursing,Royal College of General Practitioners, andthose representing other allied health andsocial care professionals.The Substance Misuse Skills Consortiumis an independent, sector-led initiative toharness the ideas, energy and talent withinthe substance misuse treatment field, tomaximise the ability of the workforce,and help more drug and alcohol misusersto recover27. Commissioners will findhelpful guidance in the Drugs and AlcoholNational Occupational Standards (DANOS)framework described later in this guide(page 14), but should be aware that itdoes not cover all professional groups.Guidance for commissioners of drug and alcohol services 7
  9. 9. Why are drug and alcohol servicesimportant to commissioners?Among the reasons whydrug and alcohol services areimportant to commissioners are:1 drug and alcohol use canhave a significant andnegative impact on individualsand wider society2 drug and alcohol use can alsohave a public health impact3 considerable economic costsare associated with drug andalcohol use4 there is a relatively commonuse of drugs and alcoholamong the UK population5 these harms, impacts andcosts can be reduced througheffective treatment, withimportant economic savings.1 SOCIAL IMPACTThe Government’s drug strategy identifiesthat drug and alcohol problems not onlynegatively impact on the lives of peopleusing these substances, but are also the“key causes of societal harm, includingcrime, family breakdown and poverty”21.For example:• crime – there were 278,000 recordeddrug offences in the UK in 2009/1028and9% of the population were engaged inillicit drug use in 2010/1129. As a society,although drugs cost the UK £15 billioneach year29, investment in drug serviceshas been estimated at approximately£1.3 billion per year28. However, drugtreatment has been shown to be effectivein preventing drug-related offending,with an estimated five million offencesbeing prevented in 2010-11 alone30.Each year, alcohol is associated with500,000 recorded crimes in England,125,000 instances of domestic violenceand 1,000,000 assaults31.• family difficulties – families with parentalsubstance misuse frequently appear insocial services statistics: around one infive families referred to children’s socialservices in the UK have a history ofalcohol or drugs problems, rising to onein two families on the Child ProtectionRegister and affecting three out of fourfamilies involved in care proceedings32.• poverty – English local authority areaswith higher levels of deprivation willhave higher numbers of problem drugusers, and higher admission rates for drugtreatment services33. The Marmot Reviewpublished in 2010 highlighted a range ofhealth inequalities and set out actions toaddress them, including an approach tosubstance misuse to alleviate the impactof alcohol in particular on people living inmore deprived settings33.2 PUBLIC HEALTH IMPACTThe public health consequences of drugand alcohol use are also significant.The primary harms include transmission ofblood borne viruses, including Hepatitis B,C and HIV. Estimates suggest that around216,000 individuals are chronically infectedwith hepatitis C in the UK34.There are also various forms of harm thatmay be caused by addiction to drugs oralcohol including acute harms:• death by overdose• intoxication• accidental injury• suicide• precipitation or exacerbation of mentalillnesses such as psychosis.Chronic harms can also occur, including:• cirrhosis and other liver damage• consequences of injecting – for example,abscesses, vein damage, endocarditis• sexually transmitted diseases• dependence including withdrawalsymptoms• hypertension• stroke• coronary heart disease• pancreatitis• depression• anxiety disorders.8 Practical Mental Health Commissioning
  10. 10. Guidance for commissioners of drug and alcohol services 9BOX 1: Reasons fordrug and alcohol usePeople use drugs and alcohol for avariety of reasons. For many peoplethis use of substances does not turninto what is termed misuse. It isequally important to bear in mindthat no-one starts using substanceswith the intention to develop misuseproblems. Some of the reasons whypeople begin to use drugs and/oralcohol might include: because theinitial reactions and experiences arepleasurable; response to social or familycircumstances, such as bereavement/loss, unemployment, relationshipdifficulties, loss of accommodation;response to peer pressure; to removestress or other psychological difficulties;criminal or other antisocial 2: Types of drug use36Recreational useMany people are able to usepsychoactive substances in a recreationalmanner that causes no problems to theindividual or those around them.This pattern of use is usuallycharacterised by moderate levels ofconsumption and periods when theperson stops using the substancewithout difficulty.Harmful useA pattern of psychoactive substanceuse that is causing damage to health.The damage may be physical orpsychological.Dependent useDependence has both psychologicaland physiological elements.Psychological dependence involves aneed for repeated doses of the drug tofeel good, or avoid feeling bad.Physiological dependence is associatedwith tolerance, where increased dosesof the drug are required to produce theeffects originally produced by lowerdoses, and development of withdrawalsyndrome when the drug is withdrawn.Withdrawal syndrome is characterisedby physiological and psychologicalsymptoms that are specific to a particulardrug. The term ‘dependence’ is oftenused interchangeably with ‘addiction’.3 ECONOMIC COSTSAlcoholThere were 1.2 million alcohol-relatedhospital admissions during 2010/1117.Alcohol consumption has nearly trebledsince 1950 with more than seven millionpeople drinking at harmful or hazardouslevels and who together account for about80% of all spending on alcoholic drink35.It costs the NHS in England up to£2.7 billion a year to treat the chronicand acute effects of drinking24. TheGovernment’s alcohol strategy indicatesthat alcohol-related harm is now estimatedto cost society £21 billion annually17.Drug useDrug use costs the UK £15.4 billioneach year, including welfare benefitexpenditure costs of approximately£1.6 billion per year21.4 PREVALENCEDrugsPrevalence of substance misusevaries fordifferent types of substances. Recent yearshave shown different patterns of use, witha trend towards an increase in the misuseof over the counter medicines and newsubstances, including those known as clubdrugs such as mephedrone, ketamine andlegal highs.
  11. 11. 10 Practical Mental Health Commissioningbox 3: Prevalence ofdrug and alcohol use• Estimates from the 2010/11 BritishCrime Survey show that 36% of adultsaged 16-59 have used illicit drugs intheir lifetime, which equates to almost12 million people. Among this group,almost 9% or 2.9 million adults hadused illicit drugs in the last year29.• The National Treatment Agencyreported that in 2009-10 in Englandthere were 306,000 users of opiatesand/or crack cocaine corresponding toalmost 1% of the adult population (thisnumber represents the total number ofusers, rather than those in treatmentalone). In 2011 reported use ofmephedrone in the last 12 months was1.4% and ecstasy 1.4% among 16-59year olds31.• Investment in drug treatment servicesis widely recognised to have been afactor in the reduction of illicit drug use.• Around 200,000 people get help fordrug dependence in England everyyear, with around 135,000 beingtreated on any given day37.• Nearly one third of users in the lastseven years successfully completed theirtreatment and did not return, whichcompares favourably to internationalrecovery rates38.• Drug misuse in this country remainsa significant factor in poor healthoutcomes, criminality and worklessnessand continues to have far reachingeffects upon individuals, families andsociety as a whole.Alcohol• Alcohol consumption in the UK hasalmost trebled since 1950 with morethan 7 million people drinking at harmfulor hazardous levels. Together theyaccount for about 80% of all spendingon alcoholic drink35. Since 2002/03 therehas been a 40% increase in admissionsto hospital where the primary diagnosiswas attributable to the consumption ofalcohol39.• In the same period there were almost168,000 prescription items for drugs forthe treatment of alcohol dependencyprescribed in primary care settings orNHS hospitals and dispensed in thecommunity which is a 63% increasecompared to 200339.• Quantities of alcohol consumptionacross the population have been rising.Recent research shows that 24% ofadults engage in hazardous drinkingwhile nearly 4% engage in harmfuldrinking. Almost 6% of adults areknown to be dependent on alcohol40.Higher consumption of alcohol isassociated with depression and the riskof suicide is eight times higher amongthose with current alcohol misuse ordependence. Alcohol misuse by youngpeople is associated with a six-foldincreased risk of depression41.• The Royal College of Psychiatristsreport, Our Invisible Addicts showedthat the misuse of drugs in older people(65 and over) is a problem that is likelyto grow and that misuse in the over-40shas increased significantly in recentyears42. By 2031 there is predictedto be a 50% increase of complexsubstance misuse in the over 65s (e.g.excessive alcohol consumption as wellas inappropriate use of prescribed andover the counter medications).Co-morbidity• The 2002 Co-morbidity ofSubstance Misuse and Mental IllnessCollaborative study (COSMIC)concluded that:– 75% of users of drug services and85% of users of alcohol services wereexperiencing mental health problems– 30% of the drug treatmentpopulation and over 50% of those intreatment for alcohol problems had‘multiple morbidity’– 38% of drug users with a psychiatricdisorder were receiving no treatmentfor their mental health problem– 44% of mental health service userseither reported drug use or wereassessed to have used alcohol athazardous or harmful levels in thepast year43.• The term ‘co-morbidity’ covers abroad spectrum of mental healthand substance misuse problemsthat an individual might experienceconcurrently. The nature of therelationship between these twoconditions is complex. Possiblemechanisms include:– a primary psychiatric illnessprecipitating or leading tosubstance misuse– substance misuse precipitating,worsening or altering the courseof a psychiatric illness– intoxication and/or substancedependence leading topsychological symptoms– substance misuse and/orwithdrawal leading to psychiatricsymptoms or illnesses44.• The complexity of issues can makediagnosis, care and treatment moredifficult, with service users being athigher risk of relapse, readmission tohospital and suicide44.• Dual diagnosis: a challenge for thereformed NHS and for Public HealthEngland has reinforced the need forcommissioners to develop effectiveservices for dual diagnosis and thatthose services are central to theachievement of key policy objectives,including drug recovery43.High risk groups• There are a number of groups ofpeople who may be at higher riskof misuse of drugs and alcohol.As an example, recent researchhas shown that drug use amongLesbian Gay Bisexual and Trans-gender groups is higher than amongtheir heterosexual counterparts,irrespective of gender or the differentage distribution in the populations45.
  12. 12. Guidance for commissioners of drug and alcohol services 115 Effective treatment canreduce harm and increaseeconomic savingsCommissioners know that drug and alcoholmisuse affects an individual’s health andimpacts their local communities. Theimpacts outlined in this guide should all beof interest and importance to commissionersas they seek to meet the health needs oflocal populations, and deliver improvedpublic health and wellbeing.Where provided by trained and experiencedstaff, the evidence base for drug andalcohol treatment is strong, demonstratingthe positive impact that such services canhave. From a purely economic point ofview, investment in effective treatmentand recovery services makes sense forcommissioners as they seek to ensure goodvalue for the public purse. The NationalInstitute for Health and Clinical Excellence(NICE) produced clinical guidance for theseservices in 2007, accompanied by a CostingReport for their implementation. TheCosting Report indicates that:• the total savings through implementingthe guideline attributable to healthcarehave been estimated as being almost£4 million46• an additional £37 million of savingsto society have been estimated outside ofthe NHS in the criminal justice system46• at an individual level research has shownthat for every £1 spent on treatment,an estimated £2.50 is saved47.Good quality drug and alcohol services areimportant to commissioners for more thanpurely financial reasons. They can helppeople to achieve their recovery potentialand as such benefit individuals directly.Intervening early can reduce the chancesof ongoing misuse and the consequentharms it may cause, thus reducing demandon the use of NHS and other public servicesin the future.This can be particularly important giventhe statistics in relation to co-morbidity.Within the substance misuse treatmentsector, the prevalence of dual diagnosis hasbeen estimated at around 75% for thosein drug services48, and 85% for those inalcohol services49. In mental health servicesettings, prevalence studies50have indicatedthat around one-third of people with seriousmental health problems (such as psychosisand bipolar disorder) have some level ofsubstance use problems.Commissioning quality drug and alcoholservices will help to address the healthand well being needs of the localpopulation, reduce the burden on servicesand help achieve improved value for money.Drug services have developed significantlyover recent years, in part due to increasedinvestment and clear delivery imperatives.The investment in drug services has led toimproved access to services coupled to areduction in waiting times for treatmentand support:• of the approximately 204,000 clientsaged 18 and over in treatment contactduring 2010-11, just over 191,000 werein treatment for 12 weeks or more, orcompleted treatment free of dependencybefore 12 weeks (93%)• nearly all clients waited less than threeweeks to commence treatment (96%)51– successful completion of treatment in2011-12 was up by almost three timesthe level seven years prior (approximately11,000)38.These figures tell a story of success interms of improving access and outcomesin drug services. However they do nothighlight the variation in service provisionand quality across the system. In part thishas been a consequence of the varyingpriority commissioners have placed uponinvestment in high quality drug and alcoholservices. We also know that some serviceshave found it hard to offer a comprehensiverange of interventions and to link effectivelywith other services, particularly in cases ofco-morbidity and complex needs.In terms of alcohol services, there werejust over 111,000 clients in contact withstructured treatment aged 18 and over whocited alcohol as their primary problematicsubstance in 2010-11. More than four-fifths(82%) of all clients waited less than threeweeks to commence treatment. The numberof new treatment journeys commencingin the year increased to almost 74,000 in2010-11. The number and proportion ofsuccessful completions also increased fromapproximately 31,000 (48%) in 2009-10 tonearly 36,000 (54%) in 2010-1152.These figures show improvement, butthe relative lack of investment in alcoholservices and minimal prioritisation ofalcohol treatment explains in part whythese services have been described as beingpatchy and in some places underdeveloped.Commissioners need to take account of thenecessity to enable providers to (a) offerthe NICE guideline approved psychologicaland pharmacological treatments and(b) plan service developments that alignwith public health needs and imperatives,as well as emerging quality standardsdeveloped by NICE.
  13. 13. What do we know about current drug and alcohol services?The last decade saw considerableinvestment in the planningand provision of drug servicesin England and more peoplehave had access to services.For example in drug services,there has been a doubling inthe number of people receivingtreatment, while waiting timeshave reduced significantly.The picture is less encouraging in relationto alcohol services. Recent reports suggestthat PCTs on average spent only 0.1% oftheir budgets on alcohol services53. TheHealth Select Committee reported in 2010that many commissioners did not havea strategy for alcohol services and it wasacknowledged that the picture in relationto provision was patchy35. In the past18 months the policy direction has shifted,not only in respect of drug and alcoholservices but across health and social caremore broadly.Below we set out the key areas of policythat impact on the commissioning of drugand alcohol services.Government strategies: drugs,alcohol, and mental health• the Drug Strategy: ‘Reducing demand,restricting supply, building recovery:supporting people to live a drug-free life.’Published in December 2010, this has anemphasis on supporting recovery fromdrug and alcohol dependence. The firstannual review of the drug strategy wasreleased in May 2012.• the Alcohol Strategy: published inMarch 2012, this sets out theGovernment’s proposals to addressalcohol use. It focuses on plans to dealwith ‘binge drinking’. It also aims toreduce alcohol related violence anddisorder and reduce the number ofpeople drinking to damaging• the mental health outcomes strategyfor people of all ages: ‘No Healthwithout Mental Health’ makes acommitment to ‘parity of esteem betweenmental and physical health services’,and has a clear objective to improve thephysical health of those with a mentaldisorder54. The strategy is now supportedby an Implementation reformsA range of changes to the way in whichservices are commissioned and deliveredare contained in the Health and SocialCare Act. They include:• Clinical Commissioning Groups: holdthe local budget for health care and areresponsible for deciding what servicesshould be delivered and by whom. Theywill be accountable to NHS England.• NHS England: will support and regulatethe CCGs, and it will have a limitedcommissioning function in respect ofspecific national services.• ‘Any Qualified Provider’: the marketenvironment in the NHS and socialcare has expanded to admit a widerrange of independent and voluntarysector providers.• Health and Wellbeing Boards (HWBs):The aim of HWBs is to consider howprioritising health improvementand prevention will best deliver benefitsfor the health and wellbeing of thelocal population.• Public Health England (PHE): PHEwill take on the responsibility for themonitoring of drug treatment through itsKnowledge and Information Directorate55.Directors of Public Health will be locatedwithin local authorities, which will haveresponsibility for health improvementwithin their areas.• outcomes: Improving outcomes &supporting transparency – A publichealth outcomes framework for England,2013-16 was published in early 2012.It sets out two outcome measures toimprove and protect the nation’s healthand wellbeing, and improve the health ofthe poorest fastest:– outcome one: increased life expectancy,i.e. taking account of the health qualityas well as the length of life– outcome two: reduced differencesin life expectancy and healthy lifeexpectancy between communities(through greater improvements in moredisadvantaged communities).The outcomes have four domains and aset of indicators. Table 1 (overleaf) setsout the outcomes that are of relevance todrugs and alcohol services.12 Practical Mental Health Commissioning
  14. 14. Guidance for commissioners of drug and alcohol services 13The drug strategy: ‘Reducingdemand, restricting supply, buildingrecovery: supporting people to livea drug-free life’Commissioning which leads to gooddrug and alcohol services as describedin this guide will support the deliveryof the national drug strategy. Bycommissioning for outcomes andrecovery, commissioners can enableservices to:• enable people to be free fromdependence on drugs or alcohol• prevent/reduce drug related deathsand blood borne viruses• improve mental and physical healthand wellbeing• contribute to a reduction in crime andre-offending• improve the ability of patientsto access and sustain suitableaccommodation• improve the ability of patients togain and maintain appropriateemployment and/or training as partof their recovery• provide accurate information ondrugs and alcohol through substancemisuse education.These are among some of the centralelements that the drug strategy seeksto deliver.The Government’s alcohol strategyEffective alcohol services will supportthe delivery of the objectives describedin the Government’s alcohol strategy.Commissioners should commissionservices that will:• contribute to a reduction in thenumber of alcohol-related deaths• a reduction in the number of adultsdrinking above the NHS guidelines.These are among some of the centralelements that the alcohol strategy seeksto deliver that specialist alcohol servicescan contribute to.NICE guidelinesDrug and alcohol services shouldbe commissioned to provide arange of interventions, includingthose recommended by NICE. Ofparticular importance is the need forcommissioners to ensure serviceswill deliver NICE guideline TA114 inrespect of the management of opioiddependence56and NICE GuidelineCG51 in respect of psychosocialinterventions for drug misuse14.Drug and alcohol services shouldalso be able to demonstrate adherenceto the NICE quality standards (boxes6 and 7).table 1Domains Improving the widerdeterminants of healthHealth improvement Health protection Healthcare public healthand preventing prematuremortalityIndicators People with mental illnessor disability in settledaccommodationHospital admissions causedas a result of self-harmPeople presenting with HIVat a late stage of infectionMortality from causesconsidered preventableRe-offending Successful completion ofdrug treatmentPublic sector organisationswith board-approvedsustainable developmentmanagement plansMortality from liver diseaseEmployment for thosewith a long-term healthcondition including thosewith a learning difficulty/disability or mental illnessPeople entering prisonwith substance misuseissues who are previouslynot known to communitytreatmentMortality fromcommunicable diseasesDomestic abuse Alcohol related admissionsto hospitalSuicideViolent crime (includingsexual violence)Self reported wellbeing Excess under 75 mortalityin adults with seriousmental illnessStatutory homelessness
  15. 15. What would a good drug and alcohol service look like?A good drug and alcoholservice should be comprisedof a number of elements.This section sets out some ofthe key issues for commissionersto think about.Key components of a goodquality serviceA comprehensive drug and alcohol servicewill have the following features:Assessment of patients’ needs• the provision of comprehensiveassessment of need, including riskassessment using recognised tools• ensuring that assessment of need includesnot only the needs that arise from theirsubstance use, but identifies the recoverygoals and outcomes the service will seekto achieve with the patient• taking account of the physical needs ofthe patient including the harms associatedwith substance misuse, including bloodborne virus screening• taking account of the psychiatric andpsychological needs of the patient,including psychosis, depression, cognitiveimpairment and broader issues of healthand wellbeing• taking account of social factors includinghousing and homelessness, employmentand social and family networks.The provision of a range of interventions,which may include:• structured psychological and psycho-social interventions – commissionersshould refer to NICE guidance and qualitystandards for more information aboutspecific interventions• appropriate and timely access toprescribing including opioid substitutiontherapy including methadone,buprenorphine, giving access to injectabletreatments where this is clinically indicated• medically assisted withdrawal for alcohol,opioids and other drugs• access to appropriate in-patient beds forthose people who require a period ofadmission• peer led support – where people provideknowledge, experience, emotional, socialor practical help to each other (peersupport relies on the assets, skills andknowledge in the community, and therecognition that local people can offerhelp in ways that are sometimes moreeffective than professional help)55• a directory of all local services should beavailable to both professionals and thepublic – commissioners should ensure thatsuch a directory exists in a range of waysthat enable easy access to information• signposting to other services, such asneedle exchange, sexual health, housing,employment, mental health servicesincluding talking therapies• be a source of information and adviceto other services, including colleaguesin primary care, general hospitals, adultsocial care and children’s services• fulfil responsibilities relating tochild protection and adult and childsafeguarding• the provision of support for families andcarers, including the conducting of carerassessments to identify support needs.Workforce standardsCommissioners will need to commissiondrug and alcohol services that candemonstrate that they meet the necessarystatutory standards as set out by therelevant professional regulatory bodies.Individual professionals working in drugand alcohol services should be able todemonstrate and meet a range of corestandards and competencies.There are a number of other advisory andregulatory bodies including NICE, CQCand Royal Colleges of Psychiatrists andGeneral Practitioners, Nursing & MidwiferyCouncil, General Medical Council, BritishPharmaceutical Association, BritishPsychological Society, the Health CareProfessions Council, and British Associationof Social Workers.This guide has described the range ofprofessionals that are often employed indrug and alcohol services. To be able toprovide the right range of interventionsand services, commissioners and providerswill need to ensure there is a mix ofappropriately qualified and skilled staffworking within the service.The Drugs and Alcohol NationalOccupational Standards (DANOS) specifythe standards of performance that peoplein the drugs and alcohol field shouldbe working to. They also describe theknowledge and skills workers need inorder to perform to the required standard.DANOS can be used to ensure that serviceshave a competent workforce and thateveryone has the knowledge and skillsto deliver services to the required qualitystandards27.14 Practical Mental Health Commissioning
  16. 16. Guidance for commissioners of drug and alcohol services 15A good drug and alcohol service willusually function best as a specialist,integrated team that includes a rangeof professional health and social carestaff, under single management.Commissioners and patients shouldexpect any services to have at its corethe aim of providing a holistic andpersonalised care package for patientsthat is both tailored to their specificneeds and which is focused on recovery.The Expert Reference Group that hasdeveloped this guide, has produced theset of core principles described below toassist commissioners. These state that agood drug and alcohol service should be:• commissioned on the basis of localneed and recognise the motivationsthat underpin drug and alcohol use• staffed by an appropriatelyqualified and skilled group of staffworking within agreed standards ofcompetence with the necessary levelsof supervision and support – thereshould be sufficient staff to ensurethere is the capacity to maintain theservice• able to manage the full range ofcomplexity of need, including beingable to address the issues of co-morbidity including mental andassociated physical health needs• providing interventions that areevidence based and should implementthe relevant NICE guidance• providing a therapeutic environment forpatients that is non-judgmental wherethey can expect to receive a goodquality assessment of their needs and arange of evidence based treatments• working with patients to enhancetheir recovery potential and addressnot only their substance dependencebut also the other factors impacted bythat dependence, including housing,employment and social and familynetworks• providing continuity of care insupporting people in recovery• establishing, maintaining and buildingon good links with other services,including mental health services andhave a good knowledge of other localresources• using data and information to enableregular and accurate performancemonitoring and review of effectivenessand outcomes• providing value for money tocommissioners and the public purse.The DANOS standards are applicable to arange of professionals working in substancemisuse services including commissioners ofsubstance misuse services, drugs and alcoholworkers, psychiatrists, psychotherapists,social workers and probation officers whoregularly work with substance misusers27.The sorts of skills that should be expected tobe present within drug and alcohol servicesshould include:• assessment of substance misuse• risk assessment and management• care planning• knowledge of the law in respect of drugsand alcohol• knowledge of other relevant legislationincluding the Mental Health Act, theMental Capacity Act and Safeguarding• knowledge of other local services andagencies including the criminal justicesystem, housing, adult social care,children’s services.Commissioners and providers should also beable to ensure that the workforce is suitablyequipped to meet the quality standardsdescribed by NICE for the delivery of specificintervention in drug and alcohol services.OutcomesThere is increasing emphasis on the deliveryof outcomes in health services, not just interms of the wider public health outcomesdescribed earlier in this guide, but morespecifically those that apply to the serviceprovided and the outcomes experienced bythe patient. Commissioners may apply theirown outcomes at local level, in partnershipwith providers, as part of their planning andreview processes.The NICE Quality Standards for drug andalcohol services provide a comprehensiverange of outcomes that commissionersshould ensure their local services aredelivering against. The quality standards canbe found in boxes 6 and 7.Commissioners will be able to reviewperformance by using data from theNational Drug Treatment MonitoringSystem (NDTMS) and use other NHS andsocial care national outcome frameworksto ensure delivery of improved 4: Model of service delivery and core principles
  17. 17. 16 Practical Mental Health CommissioningCommissioning processThe commissioning process has beenwell described in a range of JCP-MHguides, including Practical Mental HealthCommissioning, published in March 20112.The National Treatment Agency hasalso developed specific guidance for thecommissioning of recovery focused drugand alcohol services with a set of resourcesto support the Joint Strategic NeedsAssessment process18.Both documents provide commissionerswith helpful information about thecommissioning process and arerecommended for further reference.Alongside those documents, the top-tipsin box 5 should help commissioners intheir thinking when commissioning adrug and alcohol service.What would a good drug and alcohol service look like? (continued)• the commissioning process is acontinuous cycle through three keystages: strategic planning, procuringservices and monitoring andevaluation2– commissioning shouldbe a dynamic process that is aboutidentifying and prioritising needand apportioning resources to meetthose needs and achieve positiveoutcomes in a spiral of continuousimprovement2• examine the current services,statutory, independent and voluntarysector to determine what exists nowand what might be needed in thefuture – understand the drug andalcohol treatment system locally,and address recovery challenges20• the Joint Strategic Needs Assessmentprocess should be used to establishlocal patterns of need and inpartnership with other stakeholdersagree local priorities for investment anddevelopment and decommissioningwhere necessary – taking account ofservice re-design, changing servicemodels and practice, and ensuring theprovision of an appropriately skilledand experienced workforce• ensure that service providers are ableto deliver a range of services, withan appropriate mix of staff that willeffectively address the complexityof issues that those with addictionpresent – this should include co-morbidity with mental health andphysical health problems• ensure there is an appropriaterange of services that are able tomeet demand and secure requiredclinical treatment, reintegration andrecovery outcomes20, and decidewhich provider(s) will best meet thelocal needs and procure clinicallyeffective services. In doing socommissioners should be particularlymindful of issues of quality andpatient safety, and where appropriatecommissioners should stimulate thelocal market to ensure the value formoney, the right range of provisionand improved outcomes• use the national benchmarks asa guide for quality and standardsincluding NICE guidance fordrug and alcohol services andinterventions, CQC standards andrelevant good practice guidance.Work in partnership with providersto ensure contract compliance andcontinuous improvements in qualityand outcomes20, and ensure linkageto clinical and corporate governancerequirements and monitor delivery,effectiveness, outcomes and 5: commissioning principles
  18. 18. Guidance for commissioners of drug and alcohol services 17Statement 1Health and social care staff receivealcohol awareness training thatpromotes respectful, non-judgmentalcare of people who misuse alcohol.Statement 2Health and social care staffopportunistically carry out screeningand brief interventions for hazardousand harmful drinking as an integralpart of practice.Statement 3People who may benefit from specialistassessment or treatment for alcoholmisuse are offered referral to specialistalcohol services and are able to accessspecialist alcohol treatment.Statement 4People accessing specialist alcoholservices receive assessments andinterventions delivered by appropriatelytrained and competent specialist staff.Statement 5Adults accessing specialist alcoholservices for alcohol misuse receivea comprehensive assessment thatincludes the use of validated measures.Statement 6Children and young people accessingspecialist services for alcohol usereceive a comprehensive assessmentthat includes the use of validatedmeasures.Statement 7Families and carers of people whomisuse alcohol have their own needsidentified, including those associatedwith risk of harm, and are offeredinformation and support.Statement 8People needing medically assistedalcohol withdrawal are offeredtreatment within the setting mostappropriate to their age, the severityof alcohol dependence, their socialsupport and the presence of anyphysical or psychiatric co-morbidities.Statement 9People needing medically assistedalcohol withdrawal receive medicationusing drug regimens appropriate tothe setting in which the withdrawalis managed in accordance with NICEguidance.Statement 10People with suspected, or at highrisk of developing, Wernicke’sencephalopathy are offered thiaminein accordance with NICE guidance.Statement 11Adults who misuse alcohol areoffered evidence-based psychologicalinterventions, and those with alcoholdependence that is moderate orsevere can in addition access relapseprevention medication in accordancewith NICE guidance.Statement 12Children and young people accessingspecialist services for alcohol use areoffered individual cognitive behaviouraltherapy, or if they have significantcomorbidities or limited social support,a multi component programme of careincluding family or systems therapy.Statement 13People receiving specialist treatment foralcohol misuse have regular treatmentoutcome reviews, which are used toplan subsequent 6: NICE Quality Standards for Alcohol Dependence and Harmful Use11
  19. 19. 18 Practical Mental Health CommissioningThe quality standarddescribes markers of high-quality, cost-effectivecare that, when deliveredcollectively, shouldcontribute to improving theeffectiveness, safety andexperience of care for peoplewith drug use disorders.Statement 1People who inject drugs have accessto needle and syringe programmesin accordance with NICE guidance.Statement 2People in drug treatment are offereda comprehensive assessment.Statement 3Families and carers of people withdrug use disorders are offered anassessment of their needs.Statement 4People accessing drug treatmentservices are offered testing and referralfor treatment for hepatitis B, hepatitis Cand HIV and vaccination for hepatitis B.Statement 5People in drug treatment are giveninformation and advice about thefollowing treatment options: harm-reduction, maintenance, detoxificationand abstinence.Statement 6People in drug treatment are offeredappropriate psychosocial interventionsby their keyworker.Statement 7People in drug treatment are offeredsupport to access services that promoterecovery and reintegration includinghousing, education, employment,personal finance, healthcare andmutual aid.Statement 8People in drug treatment are offeredappropriate formal psychosocialinterventions and/or psychologicaltreatments.Statement 9People who have achieved abstinenceare offered continued treatment orsupport for at least six months.Statement 10People in drug treatment are giveninformation and advice on the NICEeligibility criteria for residentialrehabilitative 7: NICE quality standard for drug use disorders13What would a good drug and alcohol service look like? (continued)
  20. 20. Supporting the delivery of the mental health strategyThe JCP-MH believes that commissioningwhich leads to good drug and alcoholservices as described in this guide willsupport the delivery of No Health withoutMental Health.Shared objective 1:More people will havegood mental health.Commissioning effective drug and alcoholservices will enable the identification ofassociated mental health problems andensure access to appropriate assessment,diagnosis treatment and support.Shared objective 2:more people with mentalhealth problems will recover.Many people with drug and alcoholproblems have co-morbidity, thereforeeffective services will be able to jointlywork with people, alongside mental healthservices utilising a recovery orientedapproach that enables them to achievegreater independence and enhance theirprospects of sustained recovery.Shared objective 3:more people with mentalhealth problems will havegood physical health.Ensuring the provision of effective drugand alcohol services will enable thosepeople who have co-morbid mental healthproblems to have their physical healthneeds properly assessed and treated.The identification of these needs andaction to address them will result inimproved physical health.Shared objective 4:more people will have a positiveexperience of care and support.Addressing drug and alcohol dependencyalongside mental health problems (wherethey are present) can improve the chancesof the patient experiencing a more holisticservice that should have a positive impacton their health and wellbeing. A joined-up approach is more likely to improve aperson’s experience of services. The useof peer support and mutual aid can be ahelpful means through which to engagethose who use services in a contribution,not only to recovery, but to building apositive experience of care and treatmentfor others57.Shared objective 5:fewer people will sufferavoidable harm.Assessing the risk of harm and providinga service that will have as one of its aimsan objective to reduce it should help toreduce the incidence of harm, reducethe need for future intervention such ashospital admission and ongoing treatment,and provide patients with strategies forremaining free from both harm anddependence on drugs and/or alcohol.Shared objective 6:fewer people will experiencestigma and discrimination.By commissioning services that recognisethe connections and linkages betweendrug and alcohol misuse and mental healthproblems, commissioners will be activelyaddressing the stigma and discriminationthat many people experience as aconsequence of their addiction and/ormental health needs.Guidance for commissioners of drug and alcohol services 19
  21. 21. 20 Practical Mental Health CommissioningDrug and AlcoholExpert Reference Group Members• Owen Bowden-Jones(ERG Chair)Consultant Psychiatrist and LeadClinician for Club Drug ClinicCentral and North West London NHSFoundation Trust• Andre GeelChartered & ConsultantClinical PsychologistCentral and North West LondonNHS Foundation Trust• Chris FitchResearch and Policy FellowRoyal College of Psychiatrists• Diane GoslarService user consultant• Emily FinchClinical DirectorSouth London and Maudsley NHSFoundation Trust• Ellie GordonClinical and Transformational Leadfor NHS Continuing HealthcareNorth Yorkshire and HumberCommissioning Support UnitDevelopment processThis guide has been written by a groupof drug and alcohol service experts,in consultation with patients and carers.Each member of the Joint CommissioningPanel for Mental Health received draftsof the guide for review and revision, andadvice was sought from external partnerorganisations and individual experts. Finalrevisions to the guide were made by theChair of the Expert Reference Group incollaboration with the JCP’s Editorial Board(comprised of the two co-chairs of theJCP-MH, one user representative, onecarer representative, and technical andproject management support staff).AcknowledgementsThis guide was led and written bySteve Appleton, Owen Bowden Jones,and Chris Fitch.Steve AppletonSteve Appleton is the Managing Directorof Contact Consulting, a specialistconsultancy and research practice workingat the intersection of health, housing andsocial care. He has held operational andstrategic posts in local authorities andthe NHS, with a specialist interest in thehealth, housing and social care needsof people with mental health problems,substance misuse needs, learning disability,older people and offender health• Jonathan CampionDirector for Public Mental Healthand Consultant PsychiatristSouth London and MaudsleyNHS Foundation Trust• Kostas AgathMedical DirectorAddaction• Lesley AndrewsHead of ServiceKent Drug and Alcohol Action Team• Martin BarnesChief ExecutiveDrug Scope• Mick DaviesRegional ManagerHuntercombe Group• Nuzhat AnjumHead of Public Health CommissioningNHS Redbridge• Pete Burkinshaw (Observer)Skills and Development ManagerNational Treatment Agency• William ButlerChair (at time of guide development)Substance Misuse Skills Consortium
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  25. 25. A large print version of this document is available fromwww.jcpmh.infoPublished May 2013Produced by Raffertys