4.3.11 Purchasers should consider the needs of young people at risk of drug misuse and those who are misusing drugs within a comprehensive local assessment of need. Meeting the needs of young drug misusers is likely to include:

- youth services which are aware of and responsive to possible drug problems;

- drugs services specifically dedicated to young people;

- arrangements for access, where appropriate to "mainstream" drug services.

ACUTE, SHORT TERM CARE

- recognise that specialist inpatient (and residential) detoxification programmes can have significant impact on certain types of drug misusers who may not benefit from outpatient detoxification.

- ensure that those needing detoxification are admitted within a specified time from identification of need. Given the levels of drug related and psychological problems likely to be present in clients in need of residential care, prompt access is likely to be important.

- gather cost information on in and outpatient detoxification programmes and monitor outcomes to inform them of the relative cost effectiveness of the different approaches.

- health authorities should identify from local needs assessments, the likely demand for inpatient services, and contract for that level in advance so that such services can undertake proper planning to meet the expected level of need.

- Purchasers should discuss with A&E providers the practicalities of collecting data on drug misuse attendance at A and E Departments.

- A&E Departments should display posters and have leaflets available on drug misuse, health promotion and harm minimisation, and where to get help from local drug treatment services.

- Purchasers should explore with A&E providers the scope for developing needle exchanges in A&E Departments.

Purchasers should establish outcome criteria for detoxification, based on evidence of safety and minimal discomfort, and the percentages of patients who complete the treatment and who go on to further treatment.

SUPPORT AND REHABILITATION

- recognise that specialist inpatient (and residential) detoxification programmes can have significant impact on certain types of drug misusers who may not benefit from outpatient detoxification

- ensure that those needing detoxification are admitted within a specified time from identification of need. Given the levels of drug related and psychological problems likely to be present in clients in need of residential care, prompt access is likely to be important.

- gather cost information on in and outpatient detoxification programmes and monitor outcomes to inform them of the relative cost effectiveness of the different approaches.

Health authorities should:

- identify, from local needs assessments, the likely demand for inpatient services, and contract for that level in advance so that such services can undertake proper planning to meet the expected level of need.

Minnesota model
Christian
Therapeutic communities
Other models

- Purchasers should ensure access to residential care for those likely to benefit.

- Given the levels of drug related and psychological problems likely to be present in clients in need of residential care, prompt access is likely to be important. Purchasers should ensure admission within a specified time from identification of need.

- Purchasers need to be able to meet the varied needs of their clients. Given the range of distinct philosophical approaches to rehabilitation adopted by centres in England, they should have access to centres of the three main types: therapeutic communities, 12 step and Christian based houses.

- Until more comprehensive and longer term outcome data become available from the National Treatment Outcome Research Study, purchasers will need to look at the rates of retention in the services they purchase. The Task Force considered that, as a preliminary measure, more than 50% should remain in treatment at the end of 4weeks - a target already achieved by some centres. Purchasers should take steps to follow up people who drop out to establish why and thus inform future purchasing strategies.

- Reduction programmes should review the status of clients and their treatment contract on a regular basis, egonce a month, according to the length of the programme.

- Purchasers should consider how to ensure clients who have become drug free can have access to appropriate support through further outpatient attendances, community projects or self-help groups such as Narcotics Anonymous.

- ensure that the programme content, structure and setting of methadone maintenance programmes reflects the needs of clients;

- expect programmes to review the status of the client on a regular basis (eg every 3months) to see if they have reached a stage where they are readier to contemplate reduction leading to abstinence.

- monitor the impact of treatment on other problem domains (eg crime etc).

- Study the longer term results from the National Treatment Outcomes Research Study to see if structured programmes produce better outcomes, and to identify optimum dispensing arrangements.

Contracts between purchasers and providers against which overall performance is assessed should incorporate specific quality standards which ensure individual clients:

- have the right to an assessment of individual need (where appropriate) within a specified number of working days;

- have the right of access to specialist services within a specified maximum waiting time;

- have the right to respect for privacy, dignity and confidentiality, and an explanation of any (exceptional) circumstances in which information will be divulged to others;

- have the right of access to a complaints procedure;

- have the right to full information about treatment options and informed involvement in making decisions on treatment;

- have the right, when referred to consultant, to be referred for a second opinion, in consultation with their GP;

- can expect the right to an individual care and treatment plan;

DATs should initially monitor local performance standards, but this should be with a view to development of national targets.

Opening hours

6.4.3

Purchasers should identify when users need services to be open, taking account of the needs of particular groups such as young people, and reflect this in contracts.

Opening times should be widely publicised.

There is a need for purchasers and providers to distinguish clearly between structured counselling approaches, with clearly defined goals, and information and advice giving.

Delivery of structured counselling needs training and skills and purchasers should encourage this by requiring services to increase their numbers of accredited counsellors.

Further research is needed to evaluate the effectiveness of different counselling approaches.

5.11.28 All specialist drug agencies should be prepared to offer treatment to primary cocaine users.

Services should provide rapid access to treatment.

Purchasers need to monitor that cocaine drug misusers are getting appropriate and adequate treatment.

- youth services which are aware of and responsive to possible drugs problems;

- drugs services specifically dedicated to young people;

- arrangements for access, where appropriate, to "mainstream" drug services.

4.4.6 The Task Force endorsed the recommendations of the Social Services Inspectorate. Social Services Departments should build on the positive start which may have been made and make sure that adequate priority is given to services for drug misusers and especially young people misusing drugs.

The process of "shared care", with appropriate support for GPs, should be available as widely as possible. Health authorities should encourage its expansion to enable GPs to take overall clinical responsibility for drug misusers and agree with a specialist a treatment plan which may involve the GP prescribing substitute opiate drugs.

GPs should be sufficiently skilled to identify a problem drug misuser who may be consulting them for other, perhaps related, problems. This may require a programme of specialised training for some GPs.

GPs should know to whom they can refer in a crisis and for ongoing support, either from specialist drug workers, such as community psychiatric nurses, regularly attending their clinics, or by access to a named key worker in a local specialist agency.

The service provided by the GP should be agreed between the Local Medical Committee and specialist services and should clearly set out the respective roles of the GP and the specialist services, and the support the GP can expect in delivering the service.

Purchasers should ensure that GPs have straightforward access to urine testing facilities.

Where they have concerns about compliance with consumption arrangements GPs should have access to facilities where supervised consumption can take place.

The agreement between the Local Medical Committee and specialist services for the provision of shared care should include arrangements for referral, assessment and management. Purchasers should monitor local arrangements and ensure adequate controls are in place.

Where the service is defined as exceeding the requirements of general medical services, following consultation and agreement with the profession, the question of additional payment for the delivery of a specialist service needs to be considered.

- ensure a comprehensive coverage of needle-exchange facilities, using pharmacy outlets as well as specialist agency services, outreach workers and potentially A&E departments;

- consider the extent to which participating pharmacies can deliver health promotion messages. These could include advice to protect others as well as drug misusers themselves, for example on storing controlled drugs to prevent harm to children and to educate misusers on the risk of, and methods to avoid, overdose;

- take steps to improve links between pharmacies and prescribers and feedback in both directions, and ensure participating pharmacies have effective links with specialist services for advice.

- ensure comprehensive local coverage by syringe exchange schemes.

- ensure that minimum service specifications for exchange schemes include provision of basic health checks for clients and that exchange scheme staff receive training to enable them to provide these.

- require all exchange schemes to collect basic client data. They should also collect information on costs including cost per exchange.

- agree targets with syringe exchange schemes on volume of clients, frequency of visit, duration of contact and percentage of referrals to treatment. Details of targets should be set locally.

- review arrangements for delivering HepatitisB vaccinations locally and monitor progress towards universal vaccination of drug service clients.

Information about existing groups such as Narcotics Anonymous and Families Anonymous, and services such as ADFAM, should be made available in all treatment settings.

Where possible, self help groups should be evaluated more rigorously.

Arrest referral schemes should be provided at each police station. DATs should consider whether there are cost benefits to provision of support from specialist drug workers.

DATs should explore ways of monitoring the effectiveness of cautioning and arrest referral schemes as a means of reducing re-offending.

DATs should encourage their police representative to consider training needs of police surgeons so they are equipped with the skills to manage the clinical needs of drug misusers within police custody.

In those areas with prisons, DATs should review the arrangements for managing drug misusers on release and ensuring that effective arrangements exist for referring drug misusers to appropriate services.

Maternity;
Dentistry;
Hepatitis B vaccination

Purchasers should explore the need for maternity drug liaison workers.

5.3.19 Purchasers should review arrangements for delivering Hepatitis B vaccinations locally and monitor progress towards universal vaccination of drug service clients.

Purchasers should require providers to examine skill levels of staff working with drug misusers and make sure that service budgets include enough to enable the right training to be undertaken.

6.7.6 People appointed as service directors should have good management skills and in post training should be made available to them, and other managers, as appropriate.

Voluntary sector management committees and NHS Trust line managers should recognise their own responsibilities to ensure these directors perform effectively.