Guidance

Drugs commissioning support: principles and indicators

Updated 4 October 2018

1. Introduction

1.1 Prevalence of drug harms

An estimated 300,000 people in England are dependent on heroin and crack. Increasing numbers of people are reportedly having problems with other drugs such as cannabis, new psychoactive substances and image and performance-enhancing drugs. Concern is also growing about misuse of, and dependence on, prescribed and over-the-counter medicines. A person’s drug use or dependence can significantly affect their families, friends, communities and society. Addressing the harm caused by drug misuse is a priority for PHE.

PHE and Liverpool John Moores University have published national and local estimates of parental opiate use for 2014 to 2015 (the latest data available). Parental drug or alcohol dependence can have a significant impact on families, particularly children, and can limit the parent’s ability to care for their children. Parents are role models for their children and parental dependence increases the likelihood of children misusing drugs and alcohol themselves. Supporting parents to overcome dependence can therefore have a significant impact on parenting behaviour and can break the cycle of intergenerational substance misuse and associated problems.

1.2 Effective responses to drug harms

Investing in effective prevention, treatment and recovery interventions is essential to tackle the harm that drugs can cause, help users overcome their dependency, reduce involvement in crime, sustain their recovery, and enable them to make a positive contribution to their family and community.

Planning is essential to addressing the harms, costs and burden on public services from drug misuse. Successful plans will be based on the assessment of local needs and community assets, and will reflect evidence of what is known to work in addressing the root causes and wider determinants of drug dependence.

Effective local systems are those that provide welcoming, easy to access, flexible services that cater for the needs of a broad range of people and their different drug problems. They raise recovery-orientated ambitions and facilitate the progress of service users toward their recovery goals, while continuing to protect them from the risks of drug misuse. They will encourage service users to complete their treatment as appropriate and when safe to do so.

1.3 Current PHE work to understand drug problems better

PHE is undertaking a public health evidence review of available data and published evidence on the problems associated with some prescribed medicines, including dependence, short term discontinuation syndrome and longer term withdrawal symptoms.

PHE is working with the Home Office and others on an in-depth investigation of crack cocaine prevalence, seizure, treatment and crime figures, in response to the recent rises in prevalence and treatment numbers for crack. We have identified hotspot areas and are working with stakeholders to understand the nature and scale of the problem and come up with recommendations for future action.

1.4 Principles and indicators for commissioning

This guidance outlines important principles that local areas can consider when developing their plans for drugs prevention, treatment and recovery. The principles have indicators to help commissioners put them into practice.

2. Preventing drug misuse and dependence by early identification and interventions

Identifying drug misuse and intervening early can build resilience, reduce risks, help avoid further health and social harms and dependence.

2.1 What you will see if you are meeting the principle

Factors underpinning health inequalities and associated with dependence are addressed in a broad range of policies and strategies.

A range of evidence-based prevention programmes is supported.

Drug misuse is identified early, and people who use drugs are offered prompt access to early interventions, treatment and recovery support appropriate to their needs.

2.2 Indicators to support the principle

These indicators will help you to establish whether you are following the evidence and best practice that supports the principle.

Agencies work together to identify the needs of vulnerable young people and troubled families, build resilience through whole family interventions, and minimise harm with effective safeguarding protocols.

Commissioners work in partnership with the police to support the disruption of drug markets.

There is support for workplace programmes of early identification and intervention.

Local services are committed to making every contact count with people who use drugs and they make sure that:

• all health, criminal justice and social care professionals are aware of groups that might be at increased risk of harm from drugs
• validated identification or screening tools are used by competent staff
• brief advice or interventions (or referral to specialist treatment) are provided at early contacts with all health, criminal justice and social care services
• there are clear pathways to specialist assessment for people who are dependent and require structured treatment

Health and public health commissioners work together to prevent dependence on prescription and over-the-counter medicines, including inadvertent dependence from the prescribed use of a medicine.

Commissioners work with local organisations to improve pathways to interventions for people who may not access specialist drug services, for example working with sexual health, mental health, domestic violence support including refuges, and lesbian, gay, bisexual and transgender (LGBT) charities.

Prevention activities for drug misuse target generic risk factors and include building resilience and social capital, as well as information and campaigns.

3. Quick access to effective and evidence-based drug treatment

Successful treatment and recovery is optimised by providing welcoming, easy to access, and flexible services that cater for the needs of a broad range of people and problems. They reduce risk of harms, raise recovery-orientated ambitions and facilitate service users’ progress towards recovery goals.

3.1 What you will see if you are meeting the principle

Treatment services that are evidence-based and deliver a range of effective interventions sufficient to meet the needs of the local dependent population, ensuring:

• people who are dependent on drugs have quick access to a system that also ensures continuity of care between prison, residential and community environments
• packages of psychosocial, pharmacological and recovery interventions can be accessed by the target populations and deliver good outcomes for dependent drug users
• safeguarding practice is continuously monitored and regularly reviewed and reported on to make sure alcohol and drug users, their families and wider social groups are kept safe
• unmet need is being met
• people in drug treatment have a range of other health and social needs met
• the number of people successfully completing treatment is increasing and they sustain their recovery

3.2 Indicators to support the principle

These indicators will help you to establish whether you are following the evidence and best practice that supports the principle.

Integrated treatment and recovery

The drug treatment system is integrated and configured to address the locally identified needs of the population it serves, encompassing community, hospital and criminal justice settings.

Services are designed to be safe, attractive and accessible to all potential service users at a range of locations, and times that suit different potential service users.

Services take a whole family approach when assessing and responding to the recovery needs of people who use drugs, and they have good joint working arrangements with children and family services.

Services support people with co-occurring mental health conditions to get the help they need. Service access criteria do not exclude people based on levels of drug dependence, or on diagnoses (or lack of diagnoses) of mental illness.

Plans are in place to ensure effective continuity of care arrangements with criminal justice services and residential rehabilitation provision.

Information-exchange arrangements ensure effective inter-agency working and support continuity of care:

• between community and custody-based services
• between mental health and substance misuse services
• between hospitals and community drug treatment services
• for specific groups such as those identified under local integrated offender management and multi-agency risk assessment conference (MARAC) and multi-agency public protection arrangements (MAPPA)

Initiate recovery-focused activities early and give service users access to a range of recovery support interventions and services such as peer support, mutual aid, family and parenting support, employment, training and housing.

Commissioners and providers use the recovery diagnostic toolkit available on the National Drug Treatment Monitoring System (NDTMS) website (login required) to understand local system blocks to recovery and to help service users move through treatment and overcome dependence.

Sustaining recovery

The partnership has a written strategic plan to increase service users’ access to education, training and employment.

Ongoing support is available to help people sustain their recovery. It includes relapse prevention and support from mainstream and specialist services (including for physical and mental health conditions), or peer support and mutual aid.

The local authority uses the National Drug Treatment Monitoring System (NDTMS), Treatment Outcomes Profile (TOP) and other measures to regularly monitor and review levels of successful treatment completion and sustained recovery.

Safety and quality

There are quality governance mechanisms in place for assuring the quality and safety of drug treatment services, and they are embedded in public health systems.

The local system has a full range of services incorporating interventions in line with NICE guidance and the updated drug treatment clinical guidelines to support different treatment goals and offering psychosocial, prescribing and recovery support interventions for harm reduction, abstinence, maintenance, and relapse prevention.

Commissioners test whether the principles and features of recovery-orientated drug treatment are being achieved.

The treatment system can respond rapidly and effectively to changing patterns of alcohol and drug misuse and drug problems, such as new psychoactive substances, medicines and image and performance-enhancing drugs.

There are clearly defined and well functioning care pathways between alcohol and drug services, mental health provision, criminal justice agencies as well as social care and safeguarding services (both children’s and adult).

There are mechanisms, and appropriately trained staff, for involving families, partners and carers in users’ treatment, where appropriate.

Treatment providers have workforce plans that describe how specialist staff are trained and supported to make sure they are competent and supervised to deliver specialist interventions.

A full range of addiction specialist and non-specialist medical competencies is available among the workforce, and allows the system to provide clinical leadership and support.

Meeting specific patient needs

Commissioners and providers develop services in the context of local and national priorities, and their duties to eliminate unlawful discrimination, advance equality of opportunity and reduce health inequalities.

Services are designed to meet the needs of women, for example:

• women are offered the option of a female keyworker and women-only groupwork where practicable
• services provide women-only sessions
• there are links with women’s services that can provide treatment and recovery support

Specialist referral pathways are in place for pregnant women.

The links between domestic abuse and drug misuse – and related safeguarding issues where there are children in the house – are considered in care planning and reviews. There is joint working with, and effective pathways to, services for victims and perpetrators of domestic abuse.

Appropriate data is used to identify armed service veterans who have substance misuse problems and they know about local alcohol and drug services and are able to access them.

Reporting treatment data

All treatment providers report data to the NDTMS and this data is analysed locally to inform improvements.

Drug treatment provider information systems comply with the NDTMS minimum data set and there is appropriate investment in IT systems to meet the clinical and data reporting needs of providers where required.

Commissioners use NDTMS and TOP data to measure the achievement of drug strategy outcomes and progress against public health outcomes framework measures. They use this information to improve local services and pathways.

4. Interventions to address the health harms of drug use

Health harms from drug misuse can be prevented or minimised using evidence-based treatments, screening, vaccinations and coordinating multi-agency care plans.

4.1 What you will see if you are meeting the principle

All people who use drugs have prompt access to interventions to address the health harms of drug use, including interventions to prevent drug-related deaths and blood-borne viruses.

4.2 Indicators to support the principle

These indicators will help you to establish whether you are following the evidence and best practice that supports the principle.

All people who inject drugs (including new psychoactive substances and image and performance-enhancing drugs) have ready access to a suitable range and sufficient quantity of injecting equipment, to advice and information on blood-borne viruses and bacterial infections, and to alternatives to the most harmful ways of taking drugs.

Hepatitis B vaccinations for people who use drugs are promoted in line with national guidance.

Confidential tests for HIV and hepatitis B and C, and screening for tuberculosis, are promoted in line with national guidance.

Commissioners have agreed pathways and support that ensure ready access for people who use or have used drugs to treatment for hepatitis and tuberculosis and other respiratory diseases.

Commissioning and services are coordinated or integrated to improve service users’ access to mental health support (including crisis and severe and common mental illness), wound care, sexual health and dental health. Service users are offered general healthcare assessments that cover these issues and referred to specialist services where appropriate.

Where people are identified as having a co-occurring mental or physical health condition, treatment providers attempt to address both conditions and refer on when needed, rather than only addressing one area of need.

There is a good understanding of, and effective responses to, the health impacts of emerging drug-use trends, such as chemsex among some men who have sex with men.

There are interventions to raise awareness of the harms of drug use for at-risk groups, such as pregnant women, older people, people with mental health issues and those with existing long-term conditions.

Drug services address the high rates of tobacco smoking among their service users and staff. They have integrated, whole-service strategies. They offer (or work with stop smoking services to offer) stop smoking support (nicotine replacement therapy (NRT) and psychosocial), and harm reduction for people unable or unwilling to stop smoking.

All relevant services (especially primary care and emergency departments) are able to identify and refer to specialist care for the acute health harms caused by some new psychoactive substances (NPS).

Local agencies have a good understanding of NPS use in their area, and use this knowledge to develop local responses to these substances.

Treatment services have links with emergency departments and primary care services to pick up people with acute NPS problems who may need to receive treatment or harm reduction interventions.

Effective overdose-awareness training and information and naloxone are provided for service users, drug users not in treatment, family and carers and hostel staff.

There is easy access to an appropriate range of opioid substitution medications and to supervised consumption. Supervised consumption is available for all those starting opioid substitution treatment and for anyone needing to continue or return to supervision to ensure medication-compliance and reduce overdose risk.

Excessive or increasing alcohol use among drug users in treatment is addressed.

There are appropriate local reviews of drug-related deaths and action in response to their findings.

5. Working with partners to commission effective alcohol and drug services

This section is relevant to drug and alcohol commissioning and is repeated in the adult alcohol commissioning support pack. In addition to the indicators set out below, commissioners and their partners will also need to comply with all relevant legislation, regulations and other statutory requirements as appropriate.

5.1 What you will see locally if you are meeting the principle

Effective integrated policies and commissioning of services that achieve positive outcomes for individuals, families and communities by:

• co-ordinated policies to promote less risky drinking and drug use, and to prevent harm
• effective partnership working between local authority-led public health, the NHS (clinical commissioning groups and NHS England health and justice commissioners), mental health services, Jobcentre Plus, Work and Health Programme providers, adult social care, housing and homelessness agencies, children’s services, criminal justice agencies and emergency services
• a commissioning system operating transparently according to assessed need
• improving connections between treatment providers and mutual aid organisations
• full involvement of service users and local communities, including through Healthwatch

More people in treatment are supported into work by an effective partnership between the treatment and employment support sectors. There is an integrated support offer involving greater support around training, education, voluntary work and general improvement of skills and work experience.

People with alcohol and drug problems have the best possible access to warm, safe and affordable homes, suitable for their needs in the community that local conditions will allow.

5.2 Indicators to support the principle

These indicators will help you to establish whether you are following the evidence and best practices that support this principle.

Embedding in local systems

There is an explicit link between the evidence of need and service planning within alcohol and drugs needs assessments, drug and alcohol commissioning strategies, clinical commissioning group strategy, and the joint health and wellbeing strategy.

Mechanisms are in place for reporting on alcohol and drugs to the health and wellbeing board, to the police and crime commissioner and to local safeguarding systems for vulnerable adults and children.

Public health commissioners have partnership arrangements with key agencies including clinical commissioning groups, clinical networks, NHS England area teams, children’s and adult social care and criminal justice agencies.

Integrating local authority and health planning to reduce alcohol and drugs harm has been supported by introducing place-based sustainability and transformation partnerships and integrated care systems.

Arrangements are in place for joint commissioning where there is a shared responsibility for commissioning and planning, such as with the NHS for secure settings

A fully integrated system of health improvement, treatment and recovery for people with alcohol and drug problems has been developed by a formal strategic partnership involving relevant stakeholders and agencies.

The general public, service users and staff in other services understand the alcohol and drug services available locally, the pathways between services and points of entry for drug and alcohol treatment.

Quality governance mechanisms assure the quality and safety of alcohol and drug treatment services and are embedded in public health systems.

Needs assessment

The needs assessment includes a comprehensive section on the full spectrum of alcohol and drug-related harm and it acknowledges the impact of alcohol and drug work across the public health and NHS outcomes frameworks.

There is a shared understanding of the level of demand and need, based on a range of local and national data across a range of public services.

The following are identified locally:

• gaps in delivery of primary, secondary and tertiary prevention for alcohol and drugs
• the extent of unmet need for drug treatment among the estimated population of adult dependent drinkers in need of structured treatment
• unmet need among specific populations such as people with co-occurring mental health conditions or substance misusing parents
• the impact of services on health and wellbeing, public health and offending

Health and public health commissioners use hard and soft intelligence to understand need in relation to misuse of or dependence on prescription and over-the-counter medicines, including dependence arising inadvertently from the prescribed use of a medicine.

Local networks are used to find and share information with partners about new psychoactive substances and new patterns of drug use.

Data is collected on alcohol and drug interventions provided in hospitals, primary health care and other settings, to inform needs assessment.

Levels of alcohol and drug-related admissions to hospital are analysed, to target interventions.

Specialist alcohol and drugs treatment data is monitored and analysed, to compare current treatment provision with need.

The needs assessment takes account of the needs of the local population including:

• children affected by parental drug or alcohol misuse
• people (predominantly women and girls) vulnerable to alcohol and drug misuse as a result of domestic abuse, sexual assault, child sexual exploitation, or prostitution
• prisoners and continuity of care requirements for alcohol and drug-misusing offenders moving between custody and the community
• people with protected characteristics under the Equality Act 2010
• the carers and family members of people who have alcohol and drug problems
• people with co-occuring mental health and alcohol and drug use conditions

A mutual aid self-assessment tool has been completed as part of the needs assessment.

Finance

Investment is sufficient to provide a range of prevention, harm reduction and treatment services commensurate with the level of identified need.

Decision-makers have been enabled to understand the potential return on investment from alcohol and drug interventions and the possible cost of under-investment. Tools like the Value for Money Commissioning Support Tool can help commissioners demonstrate the benefits derived from local investment.

Decision-makers understand the effectiveness and cost-effectiveness of their commissioned services and can identify ways of improving these where necessary. The Value for Money Commissioning Support Tool is designed to help local areas understand and improve the cost-effectiveness of local treatment systems.

Commissioners can identify the total level of local investment by all partners.

There is close communication with finance colleagues to ensure that planned and actual expenditure on drug and alcohol prevention and treatment interventions is accurately reported to the ministry of Housing, Communities & Local Government as part of required local authority financial returns. For help in disaggregating local substance misuse expenditure and estimating unit costs, commissioners can refer to the Value for Money Commissioning Support Tool.

Effective commissioning

Commissioning is based on evidence based guidelines, such as the drug treatment clinical guidelines and NICE guidance, for effective interventions in tackling alcohol and drug-related harm.

There is an alcohol and drugs planning document that describes how best to meet local need, which clearly identifies:

• the level of demand
• existing strengths and assets and ways in which services can be commissioned to build on them
• finance and available resource

Investment in alcohol and drug prevention, treatment and recovery is based on an understanding of expenditure, performance and cost-effectiveness.

Contracts for commissioned services specify the outcomes to be achieved and these outcomes are regularly monitored and reviewed.

Care pathways and services are geographically and culturally appropriate to the people they are designed for.

Service users, their families and carers and people in recovery are involved at the heart of planning and commissioning. This is evident throughout needs assessment and key priority-setting processes both for community and prison-based services.

Commissioning functions are fit for purpose. There is sufficient alcohol and drug misuse commissioning capacity and expertise, including information management.

A workforce strategy and improvement plan ensures that commissioning staff are competent to commission safe and effective services.

Service specifications clearly indicate the level of professional competence required to deliver safe and effective services.

The transfer of care is managed safely and effectively, when the contracted provider changes, with appropriate communication of patient information to enable seamless management of risks.

The commissioning strategy includes the formal evaluation of the range of alcohol and drug interventions.

Services for people in contact with the criminal justice system

There are clear pathways into assessment, treatment and support services for people in contact with the criminal justice system who have drug or alcohol problems and where possible, integrated pathways for people with co-occurring mental health and alcohol and drug use conditions.

There is a collaborative approach with police and crime commissioners and NHS England health and justice commissioners to commission integrated services that support and engage people as they move between prison and community settings, taking the latest PHE guidance into account.

Commissioners have engaged with their local National Probation Service and community rehabilitation company to agree capacity for treatment interventions and specific requirements for offenders who are subject to statutory supervision in the community and on release from prison.

Mutual aid

There is a shared, locally developed vision of recovery where mutual aid is appropriately integrated with all alcohol and drug services including in-patient and residential treatment.

People in treatment have access to a range of peer-based recovery support options, including 12-step, SMART Recovery and other community recovery organisations.

Local services are encouraged to support service users to engage with mutual aid groups through the inclusion of specific requirements in their service specifications.

Housing and homelessness

The housing needs of people with alcohol and drug problems in the community, prison and residential treatment have been identified and are used to inform commissioning plans for housing, homelessness and housing related services.

The housing needs of people with alcohol and drug problems, and their families and carers where appropriate, are assessed at the right time, to prevent homelessness or to help them move on to a suitable home.

There is a range of housing options to meet different needs

Housing information and advice are readily available for everyone in treatment.

Front-line housing staff are trained to meet the housing and related needs of people who have alcohol and drug problems.

The needs of homeless people and rough sleepers are specifically considered as part of local substance misuse commissioning arrangements.

The health needs of homeless people who misuse alcohol and drugs have been identified and they are supported to access primary care and other healthcare, such as mental health services.

People with lived experience of homelessness are consulted as part of a health needs assessment, to identify gaps in service delivery and solutions.

Where an eligible person is homeless or at risk of homelessness, the local housing authority carries out an assessment and agrees a personalised plan to provide tailored support in line with the Homelessness Reduction Act 2017.

People who are sleeping rough and have alcohol and drug problems are able to access emergency accommodation and support and are are contacted and encouraged to access drug and alcohol treatment and mental health services, where required.

Policies and procedures for homeless people with alcohol and drug problems support people to access suitable accommodation on discharge from hospital or residential rehab, or on release from prison.

Employment, training and education

Joint planning arrangements are in place between treatment commissioners and providers and Jobcentre Plus (JCP) and Work and Health Programme (WHP) leads to meet the employment, training and education (ETE) needs of the alcohol and drug misusing population.

Relationships have been established with the JCP partnership managers and community partners, including the specialist drug and alcohol community partners in areas where they are in place.

Worklessness and employability strategies reflect the ETE needs of people who misuse alcohol and drugs.

Commissioners incorporate ETE in their performance monitoring arrangements with treatment providers and providers address ETE in supervision for keyworkers.

JCP, WHP and treatment providers have agreed a process of joint working between agencies, including arrangements for three-way meetings and co-location.

Local single points of contact have been identified in JCP, WHP and all treatment teams and these details have been circulated.

There are employment champions in treatment teams, whose role it is to liaise with JCP and WHP, and to champion ETE.

Treatment providers, JCP and WHP routinely engage with local employers to make the case and address negative preconceptions and stigma about employing people with a history of alcohol or drug dependence.

Discussions about employability are introduced early on in treatment journeys, and commissioners and treatment providers continually review the extent to which the ETE agenda is prioritised in local recovery provision.

Treatment staff encourage clients to consider appropriate disclosure of their alcohol and drug misuse within JCP and WHP to help them get individual support.

Commissioning hospital-based alcohol and drug services

Services are in place to meet the needs of hospital patients who misuse alcohol or drugs.

There is a strategic understanding of how alcohol and drug services for people in hospital are part of the wider treatment system and awareness of the role they play in addressing need.

Patients leaving hospital and requiring further treatment and recovery support are encouraged to access community alcohol and drug services.