To review the quality and performance of the substance misuse service commissioned by Herefordshire Council and delivered by Addaction.

The Addaction service manager gave a presentation which provided a service update following the update provided to committee on 21 September 2017, the main points being that:

·         There had been significant improvements and this was set to continue, both in terms of organisational performance and outcomes for service users

·         Improvements in outcomes for services users was supported by focusing on recovery and making use of support networks including volunteers, peer mentors and local communities

·         The council had reviewed the contract, effective from April 2018, which would mean some challenges to staff capacity, focused working such as time-limited and structured care, clearer pathways and use of group work. Although the outreach programme would be reduced, there would be increased information and signposting for referrals and more service advertising.

·         Addaction had listened to recommendations from the last meeting regarding publicity and this was being developed. 

The chairman welcomed the improvements and asked how people were accepting new approaches to treatment.  The service manager explained that service users understood and preferred having more contact and more on offer, particularly group work, to support recovery. There were some long-standing users who had resisted engagement but this was being addressed with the support of a key worker.

A member asked for more clarity on the groupings of types of substance misuse, and it was clarified that Public Health England had introduced a fourth primary group where there was combined use of alcohol and non-opiates. 

The member welcomed the group work approach, commenting that there should be more group work. He asked what was in place to enable support groups such as AA and Al-anon to continue, and whether the Stonebow Unit was being used for people with mental healthcare needs as well as substance misuse treatment needs.  The service manager confirmed that dual diagnosis clinics were being explored with 2gether NHS Foundation Trust and there was support to help upskill staff to refer into the service. As part of this work, it was recognised that mental healthcare needs could be addressed alongside substance recovery support and so the use of pathways was being reviewed so that people did not need to complete one care pathway or achieve recovery before accessing other care.  Addaction had clinical psychologist input but referred people to other support for one to one counselling.

The vice-chairman thanked Addaction for the opportunity for members to visit to the Leominster base, and asked what progress had been made in Leominster regarding group provision on offer and how the co-production panels were helping to increase engagement and community involvement with Addaction.  It was recognised that there was more that could be achieved around increasing Addaction’s presence in Leominster and the appointment of a new team leader would support development in this area. It had been found that the Leominster service was better suited to smaller groups of 4 or 5 people but the plan was to have a core user group each for cannabis, stimulants and low-level alcohol followed by an opiate user group.

A member asked how the Care Quality Commission inspection went.

The service manager explained that the CQC identified some areas to address but it was generally a positive inspection. The inspector was due to return this summer but had not identified any immediate concerns and it was hoped that further improvements would be noticed.  The service had acted on the CQC’s findings regarding quality of risk assessments and recovery plans and there had been comprehensive training for all staff in those aspects.

The member referred to one remaining outstanding issue regarding record keeping and it was explained that to overcome the care plans and risk assessments being in both paper and electronic format, staff were encouraged to upload paper copies to the case management system so they could be stored electronically. This had presented practical problems around needing to re-use the forms for treatment reviews and so there was a push throughout Addaction nationally to consider introducing tablets to record reviews online, although this was some way off. 

A member asked what had brought about the improvements after three years, and whether this was due to the service settling-in or because operating in Herefordshire was different. The service manager recognised that it did take time to establish a service and that short contracts could prevent services becoming fully embedded in an area. This could have a detrimental effect if service users were unable to see benefits of a new service and as a result did not engage. However, it had helped to have consistent management of the service to have staff engaged and people were starting to believe in the model of support.  He acknowledged that Herefordshire was different in terms of its cohort of long-standing service users and people on higher levels of medication. There was also a cohort of older service users whose needs were different.

In answer to a question from the chairman about whether there was contact with the police regarding drug suppliers, it was confirmed that there were meetings with the police around tackling re-offending.

A member noted that the NHS was promoting the use of e-cigarettes as an alternative to smoking tobacco. Referring to a point made at a previous meeting, he asked whether there was any new information regarding the use of e-cigarettes as a vehicle for taking opiates and whether there was any cause for concern. It was confirmed that there had been no reports of this, and because it was unusual practice, there was confidence that staff would flag this activity. 

The chairman asked for clarification regarding the main drugs used in the county. It was confirmed that aside from alcohol, heroin and crack were the most prevalent. There was little known use of new psychoactive substances such as Spice or Xanax in the county.  

The vice-chairman commented on the reduction in the outreach programme given county’s rurality, limited transportation and scattered communities, and asked about information and awareness raising of the service in focal points within the more isolated areas. It was recognised that some areas had not yet been reached and more use would be made of leaflets and building digital capacity, and advice from members about how best to target communities was welcomed.  The commissioning officer added that there were links with Smart UK which offered online meetings and which could help to widen the recovery network. Addaction also had a strong social media presence.

Healthwatch asked about the work with 2gether on developing the dual diagnosis pathways, noting feedback received that progress was not being made.

The service manager confirmed that changes were evident and services were working together to address individual cases and encouraging partnership working. 

The representative from the Clinical Commissioning Group gave assurance that people with dual diagnosis would be accepted as inpatients by the Stonebow Unit, that the community outreach team would also work with dual diagnosis and that training for staff would be welcome.

The chairman welcomed this assurance.

The director of public health referred back to the point regarding use of e-cigarettes and commented that these were promoted by Public Health England as a way of helping people to stop smoking. She asked for it to be flagged up if there was evidence that e-cigarettes were found to be used for taking opiates.

The director also asked whether more could be done to encourage people in recovery to access social enterprise and volunteering. The service manager explained that there was limited influx of volunteers to the service and the service was considering how best to co-ordinate community engagement, perhaps through the peer mentor network.  Responding to a further point made by the director of public health regarding making every contact count, he believed that other agencies were receptive to accessing training and Addaction’s in-house training was offered to other agencies to support keeping training local and accessible.

RESOLVED

That:

a)    the performance improvements be commended;

b)    continued performance improvements be encouraged; and

c)    development of group work be supported.