Introduction

Definitions and overall approach
 

• ‘Substance misuse’ is defined here as ‘intoxication by – or regular excessive consumption of and/or dependence on – psychoactive substances, leading to social, psychological, physical or legal problems.  It includes problematic use of both legal and illegal drugs’¹.
• For the first time in Nottinghamshire this topic combines both alcohol and drugs and young people and adults, adopting a life course approach. 
• Drugs and alcohol are combined because the use of different substances share similar root causes and can have similar overall effects on the lives of individuals, families and on communities.  Also, poly-substance use is very common².

 
This JSNA topic provides an overview of local need and current services regarding substance misuse and identifies unmet needs and gaps.  It focusses on substance misuse in the community.  It excludes substance misuse amongst prisoners, dual diagnosis patients, patients with long term health conditions as a result of substance misuse and family members and carers of substance misusers. 
 
Health and social context:
 
Substance misuse is associated with a wide range of health and social issues and has enormous health and social care financial costs (Public Health England, 2014a).  Dependency in particular is commonly associated with poor outcomes in relation to physical health, mental health, education, training, employment and housing and with anti-social and criminal activity that adversely affects individuals, families and communities. 
 
Alcohol alone contributes to more than 60 diseases and health conditions and represents 10% of the burden of disease and death in the UK, placing it in the top three lifestyle risk factors after smoking and obesity (Alcohol Concern, 2015a).
 
The conditions most strongly related to health inequalities, such as cancer and cardiovascular disease, are associated with alcohol and drug use (Marmot, 2010).  Resilience is an important personal factor and deprivation is an important social factor in the likelihood of substance misuse issues occurring.  Effectively addressing a community’s substance misuse issues means addressing the wider determinants of health and considering substance misuse in the context of the causes of broader health and risk-taking behaviour.
 
National context:
 
National evidence suggests that substance misuse in the UK has reduced significantly in the UK over the last decade.  However, substance misuse remains a significant national challenge as:

• It is estimated that 2 million people are addicted to substances. 
• There are approximately 1 million alcohol-related hospital admissions in England per year and this has been increasing consistently (Public Health England, 2014b) with significant increases regarding alcohol-related cardiovascular disease conditions.
• Between 2012 and 2014, there was a reported 42% increase in drug related deaths (from 1613 to 2120)³ and a 6.9% increase in alcohol-related deaths (from 21,485 to 22,967)⁴.  
• Binge-drinking remains a concern as well as the emergence of new substances (e.g. New Psychoactive Substances).

For a summary of the evidence, see Appendix A
 
Addressing substance misuse remains a key national priority.  The National Drug Strategy 2010 (https://www.gov.uk/government/publications/drug-strategy-2010) represented a shift towards promoting sustained recovery from drug misuse and acknowledging the importance of a whole life approach with a focus on education and prevention. The National Alcohol Strategy 2012 (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224075/alcohol-strategy.pdf) focussed on reducing the number of people drinking excessively and making ‘less risky’ drinking the norm.
 
Since 1st April 2013 the Government has delivered major health structural reform.  Health & Wellbeing Boards are in place and overall accountability is being developed through local institutions and elected individuals rather than centrally-driven performance targets. Local Authority-based Public Health is now responsible for commissioning drug and alcohol prevention, treatment and recovery support. This shift provides a platform for a more integrated approach to improving public health outcomes and addressing the root causes and wider determinants of substance misuse and the harm and impact they have.
 
It is expected that effective local systems will be those that demonstrate strong partnership working and a ‘whole systems’ approach to raising their prevention and recovery-orientated ambitions.
 
Local context:
 
Addressing substance misuse is a priority within the Nottinghamshire Health and Wellbeing Strategy and the Nottinghamshire Substance Misuse Framework for Action brings together a strategic partnership approach to tackling the harms caused by all substances. The overall vision of this strategy is to:
 
‘Prevent and reduce substance misuse and related problems through partnership working and using the best available evidence of what works so that we can improve the quality of life for people who live, work and visit Nottinghamshire’.
 
Ensuring the delivery of the key priorities in the Framework is the responsibility of the Substance Misuse Strategy Group which is a sub group of both the Safer Nottinghamshire Board and The Health and Well-being Board.  The Framework will be reviewed during 2017.
 
Nottinghamshire’s community substance misuse services were tendered in 2013/14.  Nottinghamshire Healthcare NHS Foundation Trust deliver young peoples’ services and Change Grow Live (CGL – locally branded as ‘New Directions: Nottinghamshire) deliver adult services. 
 
The young peoples’ service is focused on reducing harm, preventing substance use from escalating, and preventing young people from becoming substance–dependent adults, working as part of a wider network of universal (e.g. schools, colleges and youth clubs) and targeted (e.g. youth offending teams and non-mainstream education) services.  The adult services represent a shift from maintenance-orientated treatment to recovery and reintegration-oriented behaviour change services.  This involves transition from the clinic to the community as the locus of intervention and a commitment to partnership working to improve access to wider support for substance misusers such as sport and leisure, housing, welfare and debt advice, employment and education and opportunities to engage in mutual aid groups and other peer support activities.

Nationally, substance misuse appears to be declining but there are still significant areas of concern.  An integrated substance misuse (drugs and alcohol) approach across the life course should be taken if the root causes and wider determinants of substance misuse are to be tackled.

Locally, substance misuse is a priority within the Nottinghamshire Health and Wellbeing Strategy. 

Whilst good progress has been made in improving local substance misuse services there remains a substantial degree of need among the population, particularly in relation to alcohol misuse.  Where substance misuse intersects with other social and health issues there are also further public health concerns to be addressed.
 
Historically, there has been a strong focus on drug (in particular, opiate and/or crack) treatment services.  A renewed focus is needed on meeting broader substance misuse needs as well as action ‘upstream’ on education, prevention and early intervention – considering substance misuse in the context of broader risk-taking behaviour and inter-generational issues.

Unmet needs and gaps

There needs to be a stronger focus and a more consistent approach to education and prevention across Nottinghamshire, with substance misuse being considered in the context of broader risk taking behaviour.  Resilience programmes (including substance misuse) in schools and youth-centred venues are not currently quality assured.
 
More needs to be done to reduce the supply of substances in communities, such as influencing the Licensing process and lobbying MPs on decisions that will positively influence the substance misuse agenda, support healthy behaviours and reduce health inequalities – e.g. minimum unit pricing.  Lobbying is a powerful tool and is central to raising the profile of health issues and protecting and promoting health and wellbeing. Elective representatives such as MPs and councillors not only have the power to make decisions, they can be strong advocates in their own right and help influence others regarding national and local policy. Lobbying needs to be a co-ordinated effort using up-to-date evidence (See Recommendation 5).
 
The prevalence of substance misuse in Nottinghamshire is difficult to establish, although synthetic modelling indicates that there is still a great deal of unmet need out there in terms of individuals who would benefit from a substance misuse intervention. 

Little is known of substance misusers who come into contact with other services, such as hospital Emergency Departments, primary care, maternity services, mental health services, pharmacy services, fire and rescue services, criminal justice services, social security services, social care services, ambulatory services, homeless and housing services and community and voluntary sector services.  Substance misuse data is not consistently or reliably collected due to historical reasons or recent infrastructure changes.  An analysis of the sources of referrals to treatment may indicate that substance misusing individuals are not being identified and referred on as levels of self–referral are high.
 
There is no current systematic process for sharing existing data between partner agencies to provide an overview and basis for action to tackle substance misuse strategically.
 
A full picture of substance misuse treatment and support services in Nottinghamshire is now being collected for the first time, but the data presented is only for year one as a baseline.  For future years, trends need to be established to understand the full extent of those accessing services and it needs to be understood whether resources are being allocated proportionately in the areas of greatest need (see recommendation 10).

Recommendations for consideration by commissioners

These recommendations should be considered in the context of the Local Authority having a stronger focus and more consistent approach to education and prevention across Nottinghamshire, with substance misuse being considered in the context of broader risk taking behaviour. 
 
Reducing Demand:

1. Resilience programmes should be commissioned for delivery in targeted schools across the county where risk taking behaviour and problems are identified.  Schools should be supported to identify substance misuse issues and should be advised as to quality evidence-based interventions that can be delivered. 
2. Stakeholders and services should continue to engage in national campaigns and initiatives aimed at addressing substance misuse and promoting healthier lifestyles, such as Dry January, Sober in October and Stoptober.
3. A ‘Making Every Contact Count’ (MECC) approach should be systematically adopted within the delivery of all services, supported by the necessary staff training and IT infrastructure to record activity and outcomes.
4. Identification and Brief Advice (IBA) should be systematically offered by frontline workers to individuals who are drinking at increasing risk or high risk levels, supported by the necessary staff training and IT infrastructure to record activity and outcomes.

Reducing Supply:

1. Local partners should collectively take any opportunities to lobby at a national level on issues that will positively influence the substance misuse agenda.  These efforts should be co-ordinated and make use of the best available up-to-date evidence.
2. Licensing Authorities (District Councils) should consider data presented in their local alcohol profile to inform future policy and decision making.
3. Closer partnership working with Trading Standards is required. This will align and join up activity between Nottinghamshire partners across the three strategic themes of Restricting Supply, Reducing Demand and Reducing Harm.

Providing Services:

1. Via the Safer Nottinghamshire Board governance structure, a long-term solution to meeting the complex needs of the most vulnerable individuals in local communities needs to be agreed.  The main support needs of this cohort are mental health, housing and substance misuse (New Psychoactive Substances).
2. Commissioners and providers of mental health and substance misuse services should continue to implement the new Mental Health/Substance Misuse Pathway, including a process for reviewing the effectiveness of the pathway.
3. Reasons should be explored as to why Nottinghamshire and some of its districts are doing significantly worse than England and comparator areas for certain types of alcohol-related hospital admissions and partnership plans should be developed to address this.
4. Services that come into contact with the at-risk and most vulnerable populations should routinely and systematically include substance misuse in the Risk Assessments they complete and referrals should be made as appropriate.
5. Reasons should be explored for the high levels of adult self-referrals to local services and whether there are any barriers to other agencies identifying substance misuse issues or making referrals.
6. Those who have been in treatment for 4 years or more should continue to receive targeted support to move them through the system and exit successfully.For those who are unlikely to leave treatment, improvements made whilst in treatment should be monitored.
7. Nottinghamshire should explore ways in which local frontline services can be more trauma smart, in line with the latest Director of Public Health Report.  Any pilots should be formally evaluated and inform future commissioning.

Data:

1. Data gaps identified across other services such as hospital Emergency Departments, primary care, maternity services and criminal justice services (including prisons, probation and community rehabilitation companies), should be addressed as these prevent a complete picture and strategic overview.
2. Along with improved data collection, data and information sharing amongst these agencies should be improved and co-ordinated via the Nottinghamshire Substance Misuse Strategy Group to improve strategic overview and also district-level action.