Evidence to the Health and Social Care Committee Inquiry into Alcohol and Substance Misuse
The Welsh Government welcomes the inquiry into alcohol and substance misuse and presents the following evidence in relation to the specific terms of reference.
Introduction
More than £50m annually is invested to deliver the commitments within the Welsh Government’s 10-year substance misuse strategy, Working Together to Reduce Harm 2008-18. In recognistion of the devestating impact of substance misuse on individuals, their families and their communites, the strategy sets out a clear national agenda for tackling and reducing the harms associated with substance misuse. The strategy is supported by a substance misuse delivery plan for 2013-15 which sets out the specific actions being taken forward in this period.
Continued Welsh Government investment in this area is having a demonstrable impact on the services we provide to those whose lives are affected by substance misuse. For example, in 2013-14, 87% of all clients accessed substance misuse treatment within 20 days of their referral which is an increase from 73% in 2009-10.
The Welsh Government reports annualy on its progress in delivering the action across all four strands of the strategy and produces an in depth annual profile of substance misuse related data each year.
1. The impacts of alcohol and substance misuse on people in Wales, including young people and university students; older people; homeless people; and people in police custody or prisons.
The Welsh Government’s strategy covers both alcohol and drug use and is built around the principles of ‘harm reduction’ and ‘recovery’. The overall aim is to ensure that people in Wales are aware of the dangers and the impact of substance misuse to help make informed choices and to know where they can seek help, treatment and support. Our approach is rooted in a preventative agenda where awareness raising and the provision of information and advice is a key element in preventing and reducing harm. In addition to the investment we make in local treatment services, the Welsh Government supports a number of initiatives that target both the whole population and also those that are more targeted at specific groups.
Population Approaches
Dan 24/7
Dan 24/7 is the Welsh Government’s 24-hour, seven-day-a-week bilingual substance misuse helpline. The awareness and reach of the service over the last year has developed into a multi channel contact centre, utilising telephone, text, website and social media as a way for people accessing information, advice and support. The website is regularly updated to include any new drugs listed under the UK Misuse of Drugs Act and contains harm reduction information.
DAN 24/7 continues to support ‘Know the score’, an ongoing campaign with radio adverts with a focus on drug and alcohol education messages. Given recent hepatitis C outbreaks, Dan 24/7 is currently supporting the hepatitis C campaign ‘Don’t take a chance’ which highlights the risks surrounding hepatitis C.
DAN 24/7 also runs campaigns throughout the year focusing on both alcohol and drug misuse to educate the public surrounding risks and to reduce the harms associated with these.
Alcohol Brief Interventions
The Alcohol Brief Interventions programme is used to help reduce alcohol misuse through a structured conversation designed to motivate individuals who drink to excess think differently about their alcohol consumption and to provide them with information which allows them to consume alcoholic beverages in a safer way. To date, more than 7,500 people have been trained to deliver these brief interventions from a wide range of professionals including primary care, secondary care, health and social care, criminal justice and the armed forces.
Change 4 Life
Change4Life is the Welsh Government’s social marketing campaign which focusses on, and addresses, obesity, healthy eating, physical activity and alcohol. The alcohol “Don’t’ let drink sneak up on you” element of the campaign targets people who may be unaware they are risking their health by drinking more than they should and also aims to change people’s perceptions about their drinking, getting them to realise that even though their drinking may not be anti-social, or affecting their day to day lives, it is affecting their health.
To date over 72,000 people are signed up to the campaign and many more have accessed advice from the website, Facebook and Twitter.
Dry January
In 2015, the Alcohol Concern Cymru ‘Dry January’ campaign attracted more than 900 formal sign-ups in Wales, and intelligence at ground level shows that the actual level of participation was much higher than this.
The Welsh Government is clear that in this challenging and fast moving agenda there is a need to continually review the policy response to ensure that we can respond to new or emerging trends. This includes the rise of new psychoactive substances; an ageing substance misuse population and the drive towards recovery orientated services.
We must also focus on what more we can do to tackle the rising health and societal costs of alcohol related harm. This has led us to respond to the significant evidence that minimum unit pricing for alcohol is an effective public health measure aimed at reducing the health harms associated with excessive alcohol consumption. Work is therefore in hand to publish a draft Bill on minimum unit pricing of alcohol for public consultation in this Assembly term.
Alongside this the Welsh Government will continue to press the case for the devolution of alcohol licensing from the UK Government which will allow us to take the further action necessary to tackle alcohol related harm in Wales.
Targeted Approaches
We recognise that certain groups such as children and young people are at particular risk. We have demonstrated a commitment to target our efforts in this area through ring fencing £2.75m of the Substance Misuse Action Fund (SMAF) specifically for services to support children and young people. Examples of targeted approaches for children and young people, along with other groups identified through the committee’s inquiry are as follows:-
Children and Young People - Steroids and Image Enhancing Drugs (SIEDs)
Over the last few decades, the use of steroids and image enhancing drugs has become more widespread and young people are particularly at risk. Alongside the increase in use there has also been an associated rise in the number of reported infections and complications associated with use.
In partnership with Public Health Wales, the Welsh Government has established a Harm Reduction Database which records activity and demographic data on people who inject drugs and access statutory and voluntary needle and syringe programmes across Wales. In 2013-14, the database recorded 1,422 service users aged under 25, of which 75% reported primarily using steroids and image enhancing drugs.
The Welsh Government and Public Health Wales have also developed an educational toolkit for young people between 11 and 16 in relation to steroids and image enhancing drugs. The toolkit is designed as a series of workshops intended to increase young people’s knowledge and understanding of these drugs and the associated risks. Each workshop contains a number of interactive activities designed to allow learners to explore the subject matter, strengthening their understanding and ability to make informed choices in the future.
Children and Young People - Counselling
We have taken steps to support children and young people who are experiencing emotional difficulties through the development of counselling services. £300k of the Substance Misuse Action Fund is ring fenced for counselling services, a proportion of which is used specifically for children and young people. This includes supporting children and young people where there is substance misuse in the family, or supporting children and young people who themselves are substance misusers. Within schools, counselling complements the different approaches already in place to support the health, emotional and social needs of pupils. By supporting children and young people with emotional and behavioural difficulties, we can encourage them to avoid risk-seeking behaviours.
Children and Young People – All Wales Schools Liaison Core Programme (AWSLCP)
The Welsh Government continues to jointly fund the AWSLCP with the four Welsh Police and Crime Commissioners. During the 2013-14 academic year, the scheme was operational in 99.7% of primary and secondary schools across Wales, an increase of 1.2% on 2012-13 figures. Lesson content is regularly reviewed to ensure up to date information about drugs and alcohol is provided.
The programme is currently under review and the Welsh Government has ensured that the school-based recommendations from the committee’s report on new psychoactive substances, published on March 18, 2015, have been included in the terms of reference.
University Students
The Welsh Government acknowledges the importance of engaging with further and higher education institutions surrounding the subject of responsible drinking, new psychoactive substances and other drugs. We will consider including specific actions to address this in our next substance misuse delivery plan for 2016-18.
Older People
We know that substance misuse issues in people over 50 is predominantly related to alcohol use; however both illicit and prescribed drugs will also be an issue. In general, older men are considered to be at greatest risk of substance misuse, including alcohol and illicit drugs but older women may be more at risk of problematic use of sedative/hypnotic and anxiolytic medication. Further, some factors that apply more generally to older adults mean that substance misuse in this group may be more complex and present management problems that differ from those in younger people.
In response to these challenges and in order to improve access to treatment and support a specific Substance Misuse Treatment Framework – ‘Improving access to substance misuse treatment for older people’ was published by the Welsh Government on November 13, 2014.
We have also asked the independent expert Advisory Panel on Substance Misuse to consider the policy interventions necessary to tackle substance misuse in an ageing population and expect to receive its report on this issue in summer 2015.
Older People - Add to Your Life
‘Add to Your Life’, is the health and well-being check for people aged 50 or over in Wales. The on-line self-assessment includes a section on alcohol, which provides users with feedback on their alcohol consumption and tips/support on how to reduce it where necessary. Since ‘Add to Your Life’ was rolled out nationally 16,633 people have accessed the site with 7,926 completed health and well-being assessments undertaken.
Veterans
The Welsh Government is committed to providing priority NHS treatment for veterans’ health conditions related to their military service and access to specialist in-patient services. In February 2014 we also developed specific guidance to improve access to substance misuse treatment for veterans which outlined a range of actions to support veterans with substance misuse problems. We are now working closely with Substance Misuse Area Planning Boards (APBs) to implement the guidance.
Treatment for Offenders in Custody
In relation to offenders within the custodial setting, focus has concentrated on improving substance misuse service delivery at critical points both at reception, into and discharge from custody. Access to accurate advice and clinical intervention remains a dominant theme for the offender at whatever point of contact pre or post custody. The Welsh Government has worked with NOMS and representatives from health boards and the local APB to enhance specialist nurse cover within HMP Cardiff and this is being considered within other parts of the public sector prison estate.
Links with the PCC-led Drug Interventions Programme across all aspects of Wales is well established and allows specialist levels of treatment continuity where the need is identified.
Homeless people
Good links have been established between the Supporting People Programme Regional Collaboration Committees and substance misuse APBs. Three pilot projects exploring the barriers to meeting needs of homeless people with co-occurring mental health and substance misuse problems have been completed, which culminated in a feedback and good practice event in Cardiff in March 2014. The final report was published by the Welsh Local Government Association in October 2014.
A progress report, issued in March 2015, on the Implementation of the Health Standards for Homeless and Vulnerable Groups, showed continuing progress in access to services.
The homelessness provisions of the Housing (Wales) Act 2014 came into force on April 27, 2015. This legislation includes new duties on local authorities to help prevent and relieve homelessness, irrespective of their priority need status. This will ensure that everyone with substance misuse problems is assisted to address their housing and related needs.
2.
The
effectiveness of current Welsh Government policies on tackling
alcohol and substance misuse and any further action that may be
required
The Welsh Government uses a range of measures to assess the effectiveness of current Welsh Government polices in tackling substance misuse. Alongside independent evaluations conducted on specific projects and interventions we focus on a number of key indicators.
Alcohol Related Deaths 2013
Latest statistics, published by the ONS on 11 February 2015, showed that in 2013, there were 467 alcohol-related deaths in Wales. This was a decrease of 7.3% from the previous year (504). This reduction was almost entirely due to the fall in the number of alcohol related deaths amongst women, with the number of deaths decreasing from 193 in 2012 to 161 in 2103 (16.6%). Among men, there were 306 alcohol related deaths in 2013, a reduction of five (1.6%) compared with 2012.
Drug Related Deaths 2013
Latest statistics, published by ONS on 3rd September 2014 showed that in 2013 there were 135 drug misuse deaths (involving illegal drugs) and 208 drug poisoning deaths (involving both legal and illegal drugs) in Wales. The drug misuse deaths were unchanged from 2012 figures, whilst the drug poisoning deaths in Wales a decreased by six (2.8%) when compared to 2012. Both drug misuse and drug poisoning deaths have continued to fall since 2010 when both reached a peak of 162 and 224 respectively.
Key Performance Indicators (KPIs)
The Welsh National Substance Misuse Database is the official source of validated data for treatment service providers and enables the Welsh Government and Area Planning Boards to monitor and report performance against the national Key Performance Indicators in respect of waiting times and engagement rates.
On a national level, the KPIs indicate that there has been an improvement from 75.2% in 2008/09 to 87.2% in 2013/2014 in the number of people who achieve a waiting time of within 20 days between referral and treatment.
Latest data also shows a reduction in the percentage of people who did not attend or respond to follow up contact reducing from 22.9% to 10% over the same time period.
We are also committed to measuring progress in terms of client outcomes (for example ‘quality of life is improved between start and most recent review/exit’). These measures are known as Treatment Outcome Profiles (TOPs)and were introduced for the first time in 2012-13. Therefore an analysis of trends is difficult and there is currently a mixed picture across Area Planning Board reporting against these measures in the past twelve months.
Evaluation on the implementation of the strategy
During 2012, the University of South Wales conducted an independent process evaluation of the substance misuse strategy, the results of which were published in June 2013. The evaluation concluded that the Welsh Government’s strategy was essentially sound, and had widespread support. The emphasis on alcohol as well as illicit drugs was also widely praised. The evaluation made a number of recommendations which the Welsh Government has since implemented.
2016 - 2018 Substance Misuse Delivery Plan
We are currently consulting on the development of our final delivery plan to ensure that the actions that we and our delivery partners will take in 2016-18 are evidence based, outcome focused and deliverable. In developing the next plan we have sought to ensure that we do so in the content of the Well being of Future Generations (Wales) Act 2015. Six stakeholder workshops have been held across Wales during April to explore what actions are needed in the next delivery plan to deliver the substance outcomes identified. 109 people attended from approximately 50 organisations, including Housing, Probation, DWP, service users, commissioners and education representatives.
Further consultation will continue throughout the summer with the draft delivery plan scheduled to go out for formal consultation in the autumn of 2015.
Advisory Panel on Substance Misuse (APoSM)
The Welsh Government will continue to seek advice on the delivery of our substance misuse from the independent Advisory Panel on Substance Misuse. We have agreed a work programme for APoSM for 2014/15which includes reports on alcohol minimum unit pricing (published: July 2014); a review of tramadol and other opiates and a review of the policy interventions needed to tackle substance misuse in an ageing population.
Public Health Wales
We also have a service level agreement with Public Health Wales to undertake work on our behalf in areas such as prevalence data, WEDINOS and the implementation of the harm reduction database. Public Health Wales also work closely with Welsh Government officials to develop actions to reduce drug and alcohol related death. This includes guidance on the review process of fatal and non fatal poisonings and current work in relation to the review of alcohol related deaths. Lessons from both review process (fatal/nonfatal and alcohol) will help inform the Welsh Government’s future policy responses in these areas.
3. The capacity and availability of local services across Wales to raise awareness and deal with the impact of the harms associated with alcohol and substance misuse.
Emerging Challenges
Given the rapidly evolving nature of the substance misuse agenda it is important that the Welsh Government is reviewing its policy response on a regular basis.
It is recognised that the increase in new psychoactive substances are placing an increased demand on services. Following the recent inquiry carried out by the Health and Social Care Committee, the Welsh Government has accepted all 14 recommendations. Action associated with these, together with the devolved implications from proposed UK Government legislation on NPS and further advice requested from the Advisory Panel on Substance Misuse will be incorporated in the next substance misuse delivery plan.
We are also working with the Home Office to ensure that the proposed legislation to tackle new psychoactive substances announced in the Queen’s Speech 2015 reflects the Welsh Government’s policy position and the delivery environment in Wales.
Furthermore, we know that an aging population; an increased focus on tackling the harms associated with alcohol misuse and the drive towards recovery orientated services as well as the principles of prudent healthcare are driving services to rethink their traditional models to one which is more flexible and meets a diverse range of needs.
Funding and Delivery Landscape
Welsh Government funding for local substance misuse services includes ring-fenced allocations for substance misuse to health boards and more than £22m is provided annually, as part of the Substance Misuse Action Fund to seven Area Planning Boards. The APBs are - in turn - responsible for the commissioning and delivery of services and other policy interventions linked to the implementation of the Welsh Government’s strategy and delivery plan.
Service Quality/National Core Standards
The quality of services is driven through compliance with the Welsh Government’s National Core Standards for substance misuse. There are 25 core standards which aim to strengthen the governance and accountability of substance misuse service planning and delivery; ensure that a citizen-focused approach is integrated into all key activities related to service planning, review and delivery; and ultimately ensure that the full range of services is delivered effectively, safely and consistently across Wales.
Arrangements are in place within Welsh Government to monitor APBs’ performance against Key Performance Indicators, APB actions within the 2013-15 delivery plan and national core standards.
Capacity and Availability of Services
In order to assess the current challenges and future trends it is important to analyse the available data to shape services.
i)Referrals
There were 24,806 referrals in 2013-14, excluding 39 referrals where there was no gender information provided, and a further 5,233 referrals who had a DNA prior to assessment.
54% of these referrals were described as having alcohol as the main problematic substance and 39% had drugs as the main problematic substance; in 6% of cases the main problematic substance at referral was not recorded, although this reduced to 2% of cases at the time of assessment.
Males accounted for 62% of Alcohol referrals and 72% of drug referrals.
ii) Treatments
The total number of clients starting treatment in 2013-14 was 14,143, down by 9% on 2012-13. In 2013-14 the number of drug clients starting treatment was 6,685 compared with 7,168 alcohol clients.
iii) Waiting Times
Of the 14,136 clients who started treatment (and had valid waiting times), the percentage that started within 20 working days increased from 73% in 2009-10 to 87% in 2013-14, continuing the trend of improvement over the five-year period.
84% (5,990) of clients with alcohol as the main problematic substance were treated within 20 working days, whilst 92% (6,132) of clients with drugs as the main problematic substance were treated within 20 working days.
Together for a Healthy Working Wales Strategic Programme: Out of Work Peer Mentoring Service Programme (Substance Misuse / Mental Health)
In order to address a currently unmet need for employment focused services and building on the successful Substance Misuse Peer Mentoring Project 2009-2014, the Welsh Government’s Department for Health and Social Services is developing a bid for the European Social Fund. The proposed project will support long-term unemployed and economically inactive people recovering from substance misuse and/or mental health issues. The focus of this service will be on attaining employment; via peer mentoring and specialist employment support.