Guidance

Young people commissioning support: principles and indicators

Updated 4 October 2018

1. Introduction

1.1 Overview of national prevalence and data trends

Adolescence is a crucial time for physical, emotional and social development. It’s also a time of intense learning, both in terms of formal education and informally from family and peers. Alcohol and drug use which affects, impairs, interrupts or hinders young people in their physical, emotional, social or academic development is harmful.

The most recent advice for young people’s alcohol consumption was from the Chief Medical Officer in 2009. The advice is that an alcohol-free childhood is the healthiest and best option and that if children do drink alcohol it should not be until at least the age of 15 years.

The latest estimates from NHS Digital’s Smoking, Drinking and Drug Use Among Young People in England survey shows that 44% of 11 to 15-year-old pupils have ever had an alcoholic drink, 19% have ever smoked cigarettes and 24% have ever taken drugs.

Data from young people’s specialist substance misuse services indicates that the young people who go to these services with a need for drug and alcohol treatment have a range of vulnerabilities and that the majority present with poly-drug use.

The most recent treatment data tells us that cannabis and alcohol are the most common substances that young people are seeking help with. However young people also come to treatment services using a range of substances including ecstasy (MDMA), new psychoactive substances and cocaine. A very small minority will present using heroin.

Young people’s health behaviour is driven by the world they grow up in, and so exposure to smoking role models and cheap illicit tobacco increases the likelihood of them taking up smoking. Conversely, sustained efforts to reduce smoking prevalence among adults and to restrict access to cigarettes are among the most effective measures to prevent young people from starting to smoke.

The latest crime survey for England and Wales shows that younger people are more likely to take drugs than older people. The level of any drug use in the last year was highest among 16 to 19 year olds and 20 to 24 year olds. Young adults 16 to 24 were more likely to be frequent drug users than the wider age group.

Local authority level data on drug, alcohol and tobacco use from the What About Youth study was published in December 2015.

Over recent years, e-cigarettes have become the most popular stop smoking aid among adults in England. As e-cigarette use among adults has increased, so too has experimentation among young people. Data from ASH shows that 12% of 11 to 18 year olds in Great Britain having tried them. However, regular e-cigarette use among young people is rare, with 2% using them at least weekly, and is largely confined to regular smokers. Among young people who have never smoked, regular use is negligible and less than 1%. NHS Digital’s data shows that smoking rates among young people have continued to decline and there is no evidence so far that e-cigarettes are acting as a route into smoking for young people.

1.2 Wider children and young people’s data

The Association for Young People’s Health, with support from Public Health England (PHE), has published a compendium of important data on young people’s health.

The Child and Maternal Health Intelligence Network (ChiMat) website provides information and intelligence about the health of young people at local authority level. ChiMat has produced the benchmarking tool, which presents a selection of indicators that are most relevant to the health and wellbeing of children and young people, in an easily accessible way to support local decision making.

1.3 Risk factors, vulnerabilities and protective factors

Although risk factors have gone down over the last decade among both girls and boys, there still appears to be a small group of young people that remain vulnerable to risk-taking who may be putting themselves at risk through engaging in multiple risk behaviours - see ‘Health behaviour in school age children (HBSC): data analysis’.

Evidence suggests that a number of risk factors and vulnerabilities increase the likelihood of young people using drugs, alcohol or tobacco.

The more risk factors young people have, the more likely they are to misuse substances. The Association for Young People’s Health has shown that risk factors include experiencing abuse and neglect (including emotional abuse), truanting from school, offending, early sexual activity, antisocial behaviour and being exposed to parental substance misuse.

Young people are more likely to smoke if they have a parent, carer or sibling who smokes. ASH data shows that lower socio-economic status, higher levels of truanting and substance misuse are all associated with higher rates of youth smoking.

The strongest single predictor of the severity of young people’s substance misuse problems is the age at which they start using substances.

Evidence summarised by the United Nations Office on Drugs and Crime (UNODC) shows that physical and mental wellbeing, and good social relationships and support are all protective factors. Important predictors of wellbeing are positive family relationships, a sense of belonging at school and in local communities. Other factors include good relationships with adults outside the home, and positive activities and hobbies.

Girls with the lowest life satisfaction have been found to be more likely to have consumed alcohol in the last month and ever been drunk (consumed alcohol to excess). They are also 10 times as likely to report having smoked tobacco in the last month as those with the highest life satisfaction. The Health behaviour in school age children (HBSC) data analysis shows that they are also more likely to report having ever used cannabis, having had sex, and being involved in physical fighting.

Evidence from UNESCO indicates that substance use among children and young people has been linked to a number of negative education-related consequences including poor educational performance.

1.4 The benefits of specialist substance misuse interventions

Specialist interventions for young people’s substance misuse are effective and provide value for money. A Department for Education cost-benefit analysis found that every £1 invested saved £1.93 within 2 years and up to £8.38 long term.

Specialist services quickly engage young people, the majority of whom leave in a planned way and do not return to treatment services.

1.5 Principles and indicators for commissioning

This guidance outlines important principles and supporting indicators that local areas can consider when commissioning universal and targeted drug, alcohol and tobacco prevention interventions, and specialist interventions for young people already experiencing harms from these substances. The principles have indicators to help commissioners put them into practice.

2. Commissioning evidence-based universal and targeted interventions

2.1 Information to support the principle

At a universal level, UNODC evidence suggests that prevention approaches for young people which focus on reducing risk and increasing resilience are more effective than those that focus on topic specific programmes and interventions.

Focusing on factors such as raising educational achievement, training and employment, promoting positive health and wellbeing, positive relationships and meaningful activities are all valuable objectives to pursue as part of a local drug misuse prevention strategy.

Approaches that the evidence base suggests are least effective include:

• scare tactics and images
• knowledge-only approaches
• ex-users and the police as drug educators where their input is not part of a wider prevention programme
• peer mentoring schemes that are not evidence-based

At a school level, the National Institute for Health and Care Excellence (NICE) recommend that ‘whole school approaches’ to alcohol are most effective, where the formal personal, social, health and economic education (PSHE) and relationships and sex education (RSE) curriculum is complemented by other actions, including promoting a positive ethos and environment, and engagement with parents and carers.

NICE evidence shows that school-based interventions are effective in reducing smoking uptake and NICE have published guidance that set out clear guidelines for commissioners. However, the impact of these interventions are considered more effective when also delivered as a package of cross-cutting tobacco control measures aimed at adults in the community. School-based prevention interventions, including those delivered as part of the curriculum, have cost-benefits for society. For example, research from the London School of Economics has shown that interventions to tackle emotional learning save money in the first year by reducing costs for social services, the NHS and criminal justice system, and have recouped £50 for every £1 spent.

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 this principle.

Universal prevention

Young people have universal access to accurate, relevant and timely information about the health harms of alcohol, drugs and tobacco.

Schools are implementing intelligence-led, targeted sessions at all stages within the school environment, adopting a ‘whole school approach’ to prevention.

Schools are equipping children and young people with the knowledge, skills and attributes that they need to keep themselves healthy and safe, and prepared for life and work, through the effective delivery of personal, social and health eduction (PSHE).

Prevention programmes use the European drug prevention quality standards (EDPQS).

Commissioners have built good links with local schools in order to develop the drugs and alcohol education agenda.

Schools have a drugs, alcohol and tobacco policy, that includes the need for external providers delivering drugs and alcohol education programmes to be appropriately qualified.

Schools include evidenced based and quality marked drugs, alcohol and tobacco education as part of the PSHE curriculum, such as Mentor’s Alcohol and Drug Education and Prevention Information Service (ADEPIS) resources and those quality assured by the PSHE Association.

Schools are discouraged to use approaches that are proven to be least effective, such as scare tactics, ex-users and knowledge-only approaches.

Parents and carers are offered information and advice to enable them to support their children to stay safe from harm.

Tobacco prevention work in schools evidence-based and linked to NICE PH23 and alcohol school-based interventions to NICE PH7.

National resources that provide information (FRANK) and build resilience (Rise Above) are considered as part of the local approach to prevention.

The appropriate authorities are working in partnership to prevent under-age sales and proxy sales. Action is being taken against premises that regularly sell alcohol to people who are under-age or making illegal purchases for others.

The local authority undertakes test purchases to ensure compliance with the law on under-age sales for alcohol, tobacco and e-cigarettes.

Targeted prevention

Young people at increased risk of harm are being targeted, with the aim of strengthening their resilience.

Alcohol, drugs and tobacco prevention approaches are aligned with other services serving the same ‘at risk’ groups (such as sexual and reproductive health services and services supporting young parents, including maternity services, family nurse partnerships, health visiting and children’s centres).

Commissioners in the public health team are working with the NHS England local area team that is responsible for offender health commissioning to agree a joint approach for substance misuse services in the young people’s secure estate.

Commissioners are working with mental health commissioning frameworks such as NHS England, clinical commissioning groups (CCGs) in line with local transformation plans and the NHS Five Year Forward View.

Targeted brief interventions are being offered in emergency departments, GP practices and with school nurses.

Commissioners are working with police and crime commissioners to discuss plans for investing in preventing substance-misuse related youth crime and commissioning early interventions that can prevent risk and harm from escalating.

Commissioners take account of the needs of young people who suffer from domestic abuse, sexual assault and sexual exploitation, who are more likely to be vulnerable to substance misuse. Commissioners need to consider this group by gender.

Additional funding has been identified for early identification and interventions to provide targeted support for specific groups of young people (this could be from the police and crime commissioners to support the targeted substance misuse interventions provided by the youth offending teams or from wider local authority funding).

Hospital care pathways are in place for young people presenting to emergency departments with alcohol-related problems including those with an alcohol problem and either mental health problem or violence related injury.

Local clinical and safeguarding leads review and support the design and delivery of specialist substance misuse services.

There is engagement with the local troubled families team by the alcohol and drugs commissioner.

3. Making a range of specialist drug, alcohol and tobacco interventions available to young people in need

3.1 Information to support the principle

Specialist substance misuse interventions are individual packages of care-planned support, which can include medical, psychosocial or specialist harm-reduction interventions that build young people’s resilience and reduce the harm caused by substance misuse.

Specialist substance misuse services help young people to stop using drugs and alcohol, to reduce the harm they cause themselves and others, to develop their resilience and to manage the risks they face so that they sustain their progress when they leave services. This might include giving support to parents and carers to help the young people with healthy decision making.

Responses to adversity, including abuse, tend to be different by gender. Boys are more likely to externalise problems (and to act out anger and distress through antisocial behaviour) and girls to internalise their responses in the form of depression and self-harming, as Lankelly Chase’s Women and girls at risk report found out. Substance misuse services for young people may need to consider these gender issues.

Young people’s substance misuse services also need to have the knowledge to understand, identify and respond to child sexual exploitation and abuse, because of the links to the use of alcohol and drugs.

There is a complex relationship between adolescent mental health and adolescent substance use. There needs to be clear joint working arrangements between child and adolescent mental health services (CAMHS) and young people’s substance misuse services. The potential for children and young people to fall through the net has been highlighted in numerous reports, such as this one from the Children and Young People’s Mental Health Taskforce.

All frontline workers should ask young people if they smoke and advise that the most effective form of quitting is with a combination of behavioural support and stop smoking medications. If a young person expresses motivation to quit, they should be referred to the local stop smoking service. The period between expressing motivation to quit and accessing the stop smoking service should be minimal. These principles should apply even when the young person is also experiencing other health issues, such as mental health problems.

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.

Ensuring delivery of high-quality evidence-based interventions

The full range of evidence-based treatment is available to young people in need.

There is a quality governance framework in place that sets out expectations for:

• appropriate specialist interventions
• quality standards
• risk management
• staff competence
• case load management
• clinical supervision
• compliance with local safeguarding policies
• compliance with legal requirements, which require services to be child-centred and appropriate to the young person’s age and maturity
• development of the young person, to take account of individual vulnerabilities

Young people receive a range of interventions that vary in intensity and duration according to changing needs, including around risk and resilience factors.

Interventions are in line with relevant NICE guidance (such as NG64, CG115 and NG58).

The interventions are appropriate to the age and development of young people.

Services and commissioners regularly review the range and type of interventions available, who receives them, and which service is best placed to deliver them depending on risk and harm levels.

Young people with multiple vulnerabilities or a high risk of substance misuse-related harm get extra support. This includes young people affected by child sexual exploitation and abuse, parental substance misuse, experiencing domestic violence, early problematic misuse, class A drug users, looked-after children, those with a mental health problem, those not in education, employment or training and those involved in crime.

Services are tailored to the needs of vulnerable girls (for example, girls are offered the option of a female keyworker).

Services are safe, non-judgemental environments to meet the needs of young people who identify as lesbian, gay, bisexual or transgender.

Young people who smoke are offered advice and referral to local stop smoking services by frontline workers.

There is easy access to a stop smoking service for every young person who smokes or uses tobacco in any other form.

Young people with increased suicide risk are offered specialist psychosocial assessment by a child and adolescent mental health professional, as outlined in The Lancet, and local safeguarding protocols are followed.

Psychosocial interventions

Interventions include evidence-based psychological, psychotherapeutic or counselling-based techniques to help young people change their behaviour and lifestyles and to improve their coping skills.

These also include evidence-based interventions such as motivational interventions, cognitive behavioural interventions, relapse prevention and structured family interventions.

Appropriately trained and competent staff deliver these interventions.

Harm reduction

All needle and syringe programmes, including those provided in pharmacies, are operating in line with NICE guidance PH52 on needle and syringe programmes and working to policies that have been agreed by the local safeguarding children’s board (and its future replacement).

All young people receive age-appropriate advice and information on:

• the spread of blood-borne viruses
• sexual and reproductive health including local chlamydia screening, condom provision, early pregnancy testing and unbiased pregnancy options advice
• overdose
• health harms and reducing risky behaviour

Care pathways are in place for young people to access age-appropriate sexual health services and testing and treatment for blood-borne viruses.

Pharmacological interventions

Pharmacological interventions include prescribing for detoxification, stabilisation and symptomatic relief of substance misuse as well as medication to prevent relapse, as outlined in the UK clinical guidelines for drug treatment .

Pharmacological interventions are delivered alongside and integrated with specific psychosocial interventions.

Pharmacological interventions are delivered in an age-appropriate manner and in the context of a clear clinical governance framework which sets out how prescribing should happen.

Age-appropriate pharmacological interventions are provided in line with the clinical guidelines.

Mechanisms are in place to support the parent or carer’s involvement in the assessment, care planning and delivery of clinical interventions as appropriate.

High-intensity support for the most vulnerable young people

Vulnerable young people with complex needs receive multi-agency care packages.

These packages include substance misuse treatment and detoxification, along with support for housing (potentially via short term fostering arrangements) and education if appropriate.

Multi-agency funding is available through complex care panel arrangements. This is underpinned by funding protocols for young people requiring high-intensity multi-agency provision.

Complex care systems support the needs of 16 and 17-year olds whose substance misuse has become problematic.

Joint working protocols with CAMHS are in place, and include meeting the needs of young people with complex needs.

Professionals consider local solutions for complex cases before looking for non-local residential placements, to help young people maintain links with their families and other sources of support.

There are arrangements to provide residential interventions away from home for the few young people it is appropriate for, such as fostering arrangements, secure units or child and adolescent mental health inpatient units.

Commissioners promote a joined-up response across children’s services using care and referral pathways for children who have been sexually exploited.

Professionals are supported and competent to identify and respond appropriately to victims of child sexual exploitation.

Targeted protective work is undertaken with young people who are known to have significant or multiple vulnerabilities that would heighten their risk of sexual exploitation.

Workers are trained and supported to identify and undertake risk assessments for pregnant young women, teenage mothers and young fathers who are accessing alcohol and drug use services. A PHE support framework for teenage mothers and young fathers is available.

Access and engagement

Services utilise You’re Welcome standards, which provide a clear framework for ensuring services locally meet the needs of young people and improve access, particularly for vulnerable and at risk groups.

Young people’s specialist substance misuse services are open at accessible times, in appropriate settings and locations.

Services proactively engage with young people who miss appointments or stop attending.

The service evaluates why young people engage or fail to engage, and responds to the findings by adapting services.

Services enhance their response to young people who are returning for treatment and whose needs have increased.

Services ensure young people do not receive specialist interventions any longer than necessary.

Services make appropriate use of technology (for example, texting and social media) to engage, maintain contact and follow-up young people.

Young people’s secure estate

There are arrangements to support continuity of care for young people entering, transferring within or leaving the young people’s secure estate. They include a referral to a specialist service nearest the young person’s home and a pre-release contact with a professional to encourage engagement with the service after release.

This is underpinned by a formal agreement that sets out the roles and responsibilities of each agency and clarifies who is responsible for coordinating care.

Arrangements are in place to monitor National Drug Treatment Monitoring System (NDTMS) reporting across the secure estate to track outcome improvements in continuing care.

4. Commissioning integrated prevention and specialist interventions with wider children’s services

4.1 Information to support the principle

If this principle is being met, local areas will have effective integrated policies and commissioning of services that achieves positive outcomes for individuals, families and communities by having:

• co-ordinated policies to promote less risky drinking and drug use, and to prevent harm
• effective partnership working between public health, the NHS, child and adolescent mental health services, children’s services, youth justice agencies and emergency services
• a commissioning system operating transparently according to assessed need

It is important to have an integrated support involving training, education, and general improvement of skills and work experience.

As well as 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.

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 this principle.

Integrated commissioning

There is a focus on the life course, including early interventions and particularly generic pre-school programmes that focus on improving literacy and numeracy and that have a long-term effect of strengthening resilience in young people.

A protocol with children’s services has been agreed by the local safeguarding children’s board (LSCB) and to the new multi-agency safeguarding arrangements which will come into effect from September 2019. The protocol covers identifying and responding to safeguarding concerns related to young people’s substance misuse.

Protocols have been developed between alcohol and drug systems, and children and family services in line with PHE guidance on developing local substance misuse safeguarding protocols.

Policies and protocols are in place that cover information sharing with parents and carers and with other agencies, including children’s services.

Substance misuse is addressed across the wider children’s agenda: at the LSCB and future multi-agency safeguarding arrangements , youth offending team (YOT) management boards, at serious case reviews (and the new arrangements for child practice safeguarding reviews, which will replace serious case reviews from 2019), within child and adolescent mental health services and across children’s services more widely.

Treatment services follow the statutory guidance relating to section 11 of the Children Act 2004 and this is regularly audited using a standardised audit tool.

Effective referral pathways and joint working arrangements are in place with children and family services where there are safeguarding issues and with local Troubled Families provision where alcohol or drug misuse is a factor.

Treatment services identify and address needs for parenting and family support at the ‘early help’ level as part of the care planning process.

The health and wellbeing board oversees collation and analysis of data on parental alcohol misuse from a range of local services.

Transition to other services

A transition policy, based on NICE guidance, is in place that sets out roles and responsibilities between different services that sets out expected outcomes and standards for effective transfers.

There are reviews involving the the young person, their current service and the service they are moving to (adult or other young people’s service) to make sure there is an effective handover and continuity of care,

Young people who have reached the upper age limit of the service, but don’t need to move to adult services, are informed how to access adult services later if they need to.

Services should be based on developmental need, using NICE guidance rather than age.

Universal and targeted services support young people who have been discharged from substance misuse specialist services, to address their wider health and social needs.

Children’s social care services assess young people before they turn 18 if there is significant benefit in doing so and if it is likely those young people will need adult care and support after turning 18.

5. A skilled workforce to provide effective interventions

5.1 Information to support the principle

The therapeutic relationship young people have with their keyworkers is vital. Positive outcomes depend on a positive and trusting relationship between them.

Research suggests that young people’s feelings about the quality of their relationships with adults and peer mentors contribute significantly to their wellbeing and positive outcomes. Staff who deliver specialist interventions such as motivational interviewing, cognitive behavioural therapy (CBT) and multi-systemic therapy need to be appropriately qualified and competent.

5.2 Indicators to support the principle

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

Young people’s substance misuse services are commissioned to ensure that staff have the skills and knowledge necessary for working with children and young people and they are qualified and competent to deliver the interventions they provide.

Staff are appropriately trained in identifying child sexual exploitation and abuse, and in ensuring that young people have access to appropriate services.

Staff are appropriately trained to support young people with poor sexual health and unplanned pregnancy.

Staff are skilled in building therapeutic alliances with young people.

Commissioning mechanisms are in place to ensure services are delivered by a competent workforce.

Competencies are in line with Skills for Health national occupational standards and relevant professional standards.

Mechanisms are in place to encourage a culture of learning via peer reviews, team meetings, appraisals and supervision.

Workers in children and family services are competent to screen young people for substance misuse and refer as appropriate to specialist substance misuse care.

There are reciprocal arrangements, such as joint working protocols, mentoring arrangements, attachments and secondments, to help children and family workers and specialist substance misuse staff to support each other in screening and referring young people, and in responding to their wider health and social care needs.

Staff who deliver specialist interventions are able to access regular clinical supervision with appropriately qualified clinicians.

Frontline workers in schools and youth settings are trained to discuss drugs, alcohol and smoking with young people.