Needs Assessment - Final

2006/07 Birmingham Adult Drug Treatment Needs AssessmentBirmingham Drug Action Team

road to recovery

ACKNOWLEDGEMENTSThe following needs assessment would not have been possible without the input of a number of professionals and local stakeholders. The Birmingham Drug Action Team and the authors would like to thank all those who contributed their time and expertise in helping to develop this needs assessment. We would also particularly like to acknowledge the contribution of the expert group members in providing data and key informant information and the service user group who provided a unique perspective of the drug treatment system.

AuthorsJessica LoaringDavid Best

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BIRMINGHAM DRUG ACTION TEAM

Adult Drug Treatment Needs Assessment 2006 / 07

Birmingham Adult Drug Treatment Needs Assessment

CONTENTS

1. Executive Summary 5

1.1. Background 5

1.2. Aims and methodology 5

1.3. Key findings 6

1.4. Recommendations 8

2. Background 10

3. Aims and objectives, the national context 10

4. Aims of the Birmingham Needs Assessment 11

5. Methodology 13

5.1. The local context 13

5.2. Testing the resulting data 14 6. Findings 16

6.1. Epidemiological needs assessment and treatment bullseye 16

6.1.1. What can we learn about the characteristics of those not

engaged satisfactorily from the bullseye method? 18

6.1.2. Section Overview 20

6.2. Treatment system maps 21

6.2.1. Initial Treatment system map 21

6.2.1.1. City-Wide Audit 22

6.2.2. Dynamic system map 23


6.3. Drug Interventions Programme (DIP) systems map 27

6.3.1. Arrest referral worker (ARW) analysis 28

6.3.2. PPO Audit 29

6.3.3. City-Wide Audit 30

6.3.4. DIP data Analysis 31


6.4. Local data sources 34

6.4.1. Needle exchange data 34

6.4.2. Hiddun Project 35

6.4.3. Bro-Sis community led research 36


6.5. Key informant interviews 39

6.5.1. The needs of groups or communities 39

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6.5.2. Systems or process related themes 40

6.6. Expert Group Involvement 41

7. Projection Map – 2007/08 Numbers in Treatment Targets 44

7.1. Model 1: Increased turnover model 44

7.2. Model 2: Increased capacity model 46

8. Overview, Conclusions and Key Recommendations 48

8.1. Key Findings 48

8.2. Recommendations 49

9. Appendix 52

9.1. Linking the Treatment Plan to the Needs Assessment Process 52

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1. EXECUTIVE SUMMARY

1.1 Background

A core component of the National Treatment Agency’s Treatment Effectiveness Strategy

is the need to gain a shared understanding of the local need for drug treatment,

based on annual needs assessment reports. This process is a strategic activity to inform

the treatment planning process for 2007/08, as the plan outlines the methods local

partnerships will employ to deliver the Government’s Drug Strategy, including the

development of action plans to address local needs. These needs are determined through

a systematic needs assessment process, improving year on year the quality of data

obtained and methods for assessing what works and doesn’t work in treatment, planning

and managing the performance of providers, and the match of the overall treatment

system to the assessed levels of unmet need.

1.2. Aims and Methodology

This adult drug needs assessment explores and maps the needs of the problem drug using

(PDU) population in the Birmingham DAT and Community Safety Partnership area. The

first element of the needs assessment involves collection, collation, and interpretation

of data to generate a local profile map of PDUs (‘bullseye method’), which provides a

breakdown of the local PDU population by status of engagement with treatment and

identifies the proportion of problem drug users in Birmingham in contact with treatment

services, both on any one day and over the course of the previous year. The subsequent

exercise maps the treatment system in Birmingham to provide an overview of existing

provision and to map the flow of PDU clients into, out of and between these services. By

investigating the ethnicity, gender, drug use, age, and retention levels of PDU’s, the map

is used to identify if there is a local need for services that is currently not adequately met

– or where there is under utilisation of services, or blockages in the treatment system. Two

versions of the map are created – one that identifies the number of people in each part

of the system on a given day (31.3.06) and the second that attempts to chart the flow of

individuals through the treatment system – to identify where the risks are for drop-out

and to identify where there appear to be gaps in provision.

The rationale is based on combining what is known about numbers in treatment with local

knowledge to create a locally credible snapshot of activity and gaps, as the foundation

for a grounded analysis of treatment needs. Additional local sources of information

and expert input provided system mapping around criminal justice clients and locally

commissioned research. The second and complementary element of the ‘twin track’

approach to the needs assessment allowed the process to be driven and informed by a

key group of stakeholders. The stakeholders, in addition to key informant interviews,

provided ongoing feedback and input into the needs assessment process, and this method

generated both additional data and key interpretations of new findings. Finally, to

examine the 2007/08 targets for numbers in treatment, two hypothetical models have also

been proposed to address the potential system requirements to allow for an increase to

7,000 individuals in treatment during the course of 2007/08, representing the target set by

the NTA. The ‘increased turnover model’ and the ‘increased capacity’ model are examined

in the context of extending the range of delivery of structured treatment interventions.

1.3 Key Findings

Overall data, prevalence and patterns

● 11,865 is the prevalence estimate for opiate and crack cocaine users in Birmingham

based on the Glasgow estimate, based on a broader and more inclusive definition

than previous estimates

● Of this number, 5,764 PDUs (49%) are in treatment, have been in treatment, or are

known to treatment, between 2004 and 2006 (based on NDTMS) data returned to the

NTA)

● 6,101 (51%) are unknown to treatment at present, i.e. they can be classed as the

‘hidden’ or target treatment population.

● From the bullseye method of analysis we can see that:

❍ Male PDUs have a poorer retention in treatment than females

❍ BME groups, particularly black and mixed race drug users, have a higher

representation in DIP services and poorer capture rate in community services

❍ BME groups have lower treatment retention rates in structured treatment

❍ Women are under-represented in criminal justice when compared to treatment

capture rates

❍ There is an under-representation of 15 to 24 year-olds in structured treatment

when compared to those identified through criminal justice

●A large proportion of the treated group in the last two years are no longer in contact

with structured treatment services

Patterning of risks and identified populations

●Low rates of injecting were evidenced among those in treatment (City-Wide Audit

-13% in community services and 9% in criminal justice services; New presentation

data-14%), this proportion is substantially lower than the national rate (36.5%) and

much lower than a number of local areas.

●Christo Inventory scores identified that the main problems for clients in treatment

were a lack of meaningful occupation, ongoing substance use, and limited social

support.

●Shared care service clients were more likely to be in treatment for four months to two

years, in contrast to specialist services who were more likely to treat clients for five years

or more.

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●Low levels of structured therapeutic interventions were delivered across the city

●There are high rates of unstable accommodation (22% in ‘unstable’ accommodation)

particularly women, black, and mixed race drug users

Treatment process, engagement and retention issues

● 2,635 new structured Tier 3 treatment journeys started in 2005/06, as measured by

NDTMS treatment journey information

● Of these 1,162 were unplanned discharges, equating to 44.4% of total new

presentations (including those still in treatment) and 71.3% of total discharged client

episodes. Of the 2,635 new treatment episodes, 76.9% were retained for 12 weeks or

more

● The largest referral source was from criminal justice services with 1,027 referrals,

followed by self referral with 803 referrals. The smallest referral source was from

within the treatment system with 224 referrals coming from treatment services. There

is a lack of referrals from Tier 1 services other than criminal justice, and little evidence

of planned treatment exits via Tier 4

● Crack use was especially high among black clients (36% primary crack users), with

high number of referrals from criminal justice sources for black clients

● ARWs are in contact with high risk vulnerable drug users who are hard to retain in

treatment

● Female sex workers and particularly PPOs or offenders who are classified as high-risk

in ARW matrices are poorly engaged and retained in treatment

● Of 299 clients identified as PPOs, there was evidence that 159 had had some form

of contact with DSB. However, rates of engagement and retention in treatment in this

population were variable

● There is inadequate provision for asylum seekers

● There is low utilisation of inpatient and day care services, reflecting limited success

in completing and exiting treatment careers in a planned way. Less than 250 clients

had a planned exit from treatment

● Needle exchange data is currently fragmented; this is particularly true for

community needle exchange services. There is an area of monitoring that could be

utilised if more information were to be collected on clients accessing needle exchange

services, and in particular if treatment status was a standard recording practice.

The key question to be addressed is whether needle exchange users are a hidden

population or are users of structured treatment with ongoing treatment needs

around injecting drug use

1.4 Recommendations

1. To improve pathways into treatment for key criminal justice populations identified

in custody, and to increase the translation rates from initial contact into structured

treatment episodes for those seen through Arrest Referral.

2. To examine options for delivering care planned care interventions in a wider range

of contexts – in particular through Tier 2 provision and through engagement with

Arrest Referral Workers.

3. To develop appropriate aftercare provision for clients aiming to leave structured

treatment and who require a period of continuing drug related and non-drug related

support, as part of a new ‘end of treatment journeys’ Tier 4 treatment pathway.

4. To reconfigure the assessment procedure and entry points into inpatient

detoxification and develop rehabilitation provision to increase the numbers flowing

through Tier 4 services. Within this reconfigured system, we need to develop a

method of data recording that will enable the monitoring of outcomes from these

services and the continuing client treatment journey out of structured drug treatment.

5. To explore potential safety-nets and increased outreach provision to engage drug

users in treatment and re-engage clients who have recently dropped out of treatment.

Services must focus on re-engaging clients who have dropped out of treatment and

target those who fail to engage adequately with treatment.

6. To increase the retention of clients vulnerable to dropping out of treatment with

particular focus on BME (principally black and mixed race clients), non-criminal justice

18 to 24 year-olds, vulnerably housed clients and female sex workers.

7. Build Tier 1 and Tier 2 links and awareness to increase referrals and translation into

treatment episodes. Clear training programmes for Tier 1 providers and training for

Tier 2 workers to enable them both to deliver structured interventions and to improve

their links to Tier 3 services.

8. Improve early identification of young people misusing substances outside criminal

justice and structure links between YP and adult services more effectively.

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9. To develop and improve the treatment journeys for particular under-represented

groups in an attempt to improve engagement, retention, and completion for:

● Women

● Asylum Seekers

● BME Groups

● Sex workers

● Homeless drug users

● Crack-cocaine and other stimulant users

Possible ways to tackle this could be:

● To provide extended opening times or a renegotiation of service opening

hours

● The provision of childcare support for parents attending appointments or

therapeutic sessions

● The development of language specific leaflets and information including

clear pathway information and interpreter services, possibly including Urdu,

Hindi, Bengali, Punjabi, Kurdish, Arabic, and Somali

● Providing further services specifically for the needs of sex workers

● Provide awareness raising among workers to target the needs of women

who are the victims of domestic abuse/violence

10. To develop a mechanism within needle exchange data collection for recording the

treatment status of clients using these services, and for linking data collection and

collation across community pharmacies, Drugline and BSMHT. This will improve the

quality of data available for the 2007/08 needs assessment process particularly for

profiling the ‘hidden’ population of problem drug users and for determining the need

to target needle exchange users for more structured interventions. Conversely

it would enable the development of targeted interventions and service development

towards clients in structured drug treatment who also access needle exchange services

in the continuation of injecting drug use, i.e. the group among whom injecting use

has not been curbed as a consequence of treatment engagement. However, the initial

task is the development of a coherent information strategy for needle exchange

utilisation and linkage to structured care- planned care.

11. To utilise DIR data to create a method for linking initial criminal justice contacts with

client treatment status to enable clearer profiling of the criminal justice population

against their engagement with the wider treatment system. To also have clear data for

profiling the outcomes and onward treatment journeys for criminal justice clients.

2. BACKGROUND

According to the 2006/07 treatment plan, the estimated number of problem drug users in

the city was 6000. This was based on the Hickman-Frischer estimates conducted in 2001,

although the local estimate was significantly higher at 7,500. However, as reported below

the Home Office commissioned estimates, conducted by Glasgow University, provide an

estimated problem drug-using population of 11,865, necessitating a significant rethink

of treatment capture rates and the nature and size of hidden populations. The analysis

below is designed to use the overall estimated prevalence as part of a systematic and data-

driven approach to identifying out of treatment populations and linking their needs to the

treatment planning process.

The 2006/07 plan goes on to list nine partnership treatment priorities relating to

increasing treatment capacity, developing neighbourhood based approaches, developing

the workforce, developing a housing strategy for drug users, improving user and

carer engagement, delivering a crack strategy, continuing to prioritise criminal justice

interventions, improving learning and skills and performance managing the system. To

achieve these objectives, the plan proposed that there would be a total of 6,900 treatment

‘slots’ in 2006/07 across residential, prescribing, counselling, day programmes and other

structured interventions, increasing to 7,750 by 2007/08. It is the aim of the analysis below

to link these objectives – and the specific targets set around issues such as crack treatment,

harm reduction and housing against a systematic mapping of locally available data to

improve the planning for 2007/08 and to ensure that adequate data systems are generated

to enable its testing.

3. AIMS AND OBJECTIVES, THE NATIONAL CONTEXT

The Governments 10-year Drug Strategy (1998) specified a number of time-limited targets

in order to achieve goals to challenge the negative effects of substance misuse. Specifically

for drug treatment, targets were set to increase the participation of problem drug users in

drug treatment programmes:

● By 55% by 2004 and 100% by 2008 (baseline 1998)

● To increase year on year the proportion of users successfully sustaining or

completing treatment programmes

The quality of drug treatment in England was widely criticised in an Audit Commission

report “Changing Habits” (Audit Commission, 2002) in which services were characterised

as unwieldy and failing to identify or respond to individual needs, that treatment was not

readily available or accessible and that there were poor links between different providers

of treatment. The follow-up report, “Drug Misuse, 2004” (Audit Commission, 2004)

acknowledged that there had been significant improvements in a number of these issues

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with more flexible treatment provision identified. However, the report concluded that

there were still problems in inter-agency working and in retaining clients in treatment.

This lead to the introduction of the conceptual ‘treatment journey’, in which drug users’

needs are seen to vary over time and suggests that drug services must work together, and

alongside providers of linked services including employment, housing and mental health,

to offer a flexible package of care-planned treatment that supports users through phases

of treatment needs that may include housing and criminal justice support, as well as

health care and therapeutic interventions directly targeting drug use, such as prescribing

services and detoxification and rehabilitation services. This set the tone for the National

Treatment Agency (NTA) to introduce the Treatment Effectiveness Strategy (2005) to focus

on improving the effectiveness of drug misuse treatment. The main aims were to:

● Provide speedy access to treatment (i.e. access to first episode of treatment within

three weeks)

● Retain clients in treatment long enough for them to benefit (i.e. for 12 weeks or

more)

● Enable clients to access the range of drug treatment and social care (e.g. housing

support) they need to improve their lives

A core component of the strategy is the need to gain a shared understanding of the local

need for drug treatment, based on annual needs assessment reports in line with an agreed

methodology (NTA, 2006), and required local partnerships to produce an annual needs

assessment based on data collated centrally, provided to each partnership area by the NTA.

The current analysis goes beyond the requirements of this original model and provides

added value to the planning process.

4. AIMS OF THE BIRMINGHAM NEEDS ASSESSMENT

This adult drug needs assessment aims to explore and map the needs of the problem

drug using (PDU) population in the Birmingham DAT and Community Safety Partnership

area. This process is a strategic activity that constitutes an integral part of the partnership

treatment planning process for 2007/08. The Treatment Plan outlines the methods

local partnerships will employ to deliver the Government’s Drug Strategy, including the

development of action plans to address local needs. These needs are determined through

a systematic needs assessment that will be an on-going process, improving year on year

the quality of data obtained and methods for assessing what works and doesn’t work in

treatment, planning and managing the performance of providers. The National Treatment

Agency guidance, developed as part of the Treatment Effectiveness Initiative (NTA, 2005)

has indicated that a needs assessment should identify:

● What works among those in treatment and what the unmet needs are

● Where the system is failing to engage and retain people

● Hidden populations and their risk profiles

● Enablers and blocks to treatment pathways

● Relationship between treatment engagement and harm profiles

In other words, it is an attempt to create an annual map of ‘what works’ in local treatment

systems and to develop a method for identifying unmet local needs with a view to

building these in to the treatment planning process. The rationale is based on the idea of

combining what is known about numbers in and out of treatment with local knowledge

to create a locally credible snapshot of activity and gaps, as the foundation for a grounded

analysis of treatment needs.

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5. METHODOLOGY

The methodology used in this needs assessment followed the NTA guidance utilising a

broad health needs assessment approach. Within this approach three elements were used

to create a framework for the comprehensive needs assessment, namely:

● Epidemiology and Research: the collection, analysis and interpretation of both

qualitative and quantitative data

● Corporate: determining and balancing the views of a range of local and regional

stakeholders

● Comparative: assessing existing provision against service standards, national targets

and other comparable areas

The first task of the needs assessment process was to collect and bring together data from

a number of locally and nationally available sources, primarily structured treatment data

from NDTMS and DIP data on treatment uptake in criminal justice populations. Data from

locally commissioned research was also collected to provide qualitative data and to provide

information on existing provision of treatment services, as was standard monitoring data

available through the main treatment providers. Following collation of these data, basic

patterns were analysed and interpreted to provide PDU population and treatment profiles.

As part of the corporate aspect of the needs assessment an expert group was convened

to drive the process and interpret the data as a function of the experiences of the local

treatment providers and service users. This group met three times and all group members

were asked for feedback on the process to date after each of the expert group meetings.

Service user groups were also utilised in order to gain and put in context the views of users

and ex-users within the treatment system. Finally the local profile will be translated into

measurable needs that can be quantified and addressed through the treatment planning

process to fulfil the comparative aspect of the outline above.

5.1: The Local Context

The city of Birmingham has a population of 977,087 individuals (2001 Census Profile),

of whom 473,266 are male and 503,821 are female. This equates to 48% and 52%

respectively. The breakdown of ethnicity for residents of Birmingham can be seen overleaf

in Table 1.

Table 1: Ethnicity groups displaying local numbers per category, %, and national

comparison.

The age split of the Birmingham population is approximately in line with national

averages. However, Birmingham appears to have a higher proportion of 15-24-year-olds

and a smaller population of over 45-year-olds compared to the national average.

Table 2: Age groups with total local numbers per group, %, and national comparison

Within the nationally produced Index of Multiple Deprivation (2004), Birmingham has

243 (37.9%) super output areas (SOAs) which are within England’s top 10% of most

deprived areas. When looking at Primary Care Trust areas (PCT), the most deprived area

is the Heart of Birmingham PCT where just under three-quarters of the SOAs within the

Trust’s boundaries are among the most deprived in England. Its neighbouring trust, East

Birmingham, is the next most deprived with 45.7% of its SOAs among the most deprived

category.

5.2: Testing the resulting data

To ensure the local applicability and validity of the quantitative data, a testing structure

was put in place to ensure that ownership of the process and a viable assessment approach

were employed. This took the form of three expert group meetings, held at monthly

intervals over the course of the needs assessment process with specific objectives:

White 687386 70.4% 90.9%

Asian/Asian British 190761 19.5% 4.6%

- Indian 55774 5.7% 2.1%

- Pakistani 104052 10.6% 1.4%

- Bangladeshi 20847 2.1% 0.6%

Black/Black British 59784 6.1% 2.3%

- Black Caribbean 47798 4.9% 1.1%

- Black African 6191 0.6% 1.0%

Mixed ethnicity 27928 2.9% 1.3%

Chinese & other ethnic group 11198 1.1% 0.9%

Aged 15 to 24 132543 37% 31%

Aged 25 to 44 276803 28% 29.4%

Aged 45 to 74 270745 28% 32.1%

Aged 75 or over 68155 7% 7.5%

Ethnicity Number % England Average %

Age Group Number % England Average %

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Expert group 1: To assess the initial NTA data and to critically evaluate it in the context

of the local PDU prevalence estimate (Glasgow estimate). The initial group meeting was

aimed to assess these data against local experiences, as a method for determining what

other local databases could be used and for testing the main analytic methods.

Expert group 2: Again the group was conducted using the same basic method. The first

half of the session was designed to test the data and interim findings, and the attempts to

link different data sources, while the second half of the session was designed to plan for

the overall key unmet needs, based on the professional experiences of the expert group.

Expert group 3: The final expert group session was designed to be held immediately prior

to the distribution of the initial report and is used as a testing mechanism for the final

data collation and interpretation, for the initial translation into unmet need and to assist

with the generation of recommendations for inclusion in the treatment planning process.

6. FINDINGS

6.1. Epidemiological needs assessment and treatment bullseye

The primary starting point for the analysis is the data provided by National Drug

Treatment Monitoring System (NDTMS) on numbers in ‘structured’ treatment - as defined

in Models of Care (NTA, 2002) - on a given day and over the course of the last year,

supplemented by the Glasgow estimate of prevalence of problem drug use for the city.

Estimates of the prevalence of problematic drug use are a key piece of evidence for

informing the monitoring of the drug strategy; especially given that the strategy aims

both to reduce drug use in the population and increase the number and proportion of

problem drug users in treatment. The Home Office commissioned Glasgow University

(Hay et al 2006) to assess the prevalence of problem drug use by applying two statistical

methods: the capture-recapture method and the multiple indicator method to estimate

the prevalence of problem drug use in England in 2004/05. These estimates were

generated for each Drug Action Team (DAT) area, and will be repeated in each of the next

two years.

The Glasgow prevalence estimate of opiate and crack cocaine users in the Birmingham

DAT area was 11,865. There is a confidence interval of 95% associated with this estimate,

therefore the prevalence estimate could lie anywhere between 11016 and 12913 PDUs

within Birmingham, although for the purpose of the needs assessment we will use the

central figure until sufficient contradictory evidence is generated to discard this. This

estimate then provides the denominator for all assessments of ‘treatment capture’ – in

other words, each assessment of treatment numbers is a proportion of this estimated total

target population. Although the NTA set targets for numbers in treatment, this is not

calculated formally as a percentage of the Glasgow estimate figure but is based more on

anticipated growth in the treatment system.

Using the mechanism of the treatment bullseye developed by the NTA, it is possible to

calculate the ‘unknown to treatment’ population for the outer ring of the bulls eye by

reconciling the estimated prevalence with the NDTMS data as shown below:

Glasgow estimate 11865

Minus - in treatment ‘now’ - 3474

Minus - in treatment last year - 1444

Minus - known to treatment but not treated in last year - 846

Total estimate for population ‘unknown to treatment’ = 6101

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846

1444

3474

1716

The NDTMS data for Birmingham were collated and examined to address the initial

question of ‘treatment capture’. In other words, what proportion of problem drug users

as derived from the prevalence estimates and the numbers in treatment figure were in

structured drug treatment both on the last day of 2005/06 and at any point in the year

2005/06. Thus, the basic capture rate for 2005/06 is 4918/11865 (41.4%) and for 31.3.06 is

3474/11865 (29.3%). In other words, if we accept the accuracy of both Glasgow estimates

and NDTMS returns, just under half of the problem drug users in Birmingham had contact

with structured drug treatment services in 2005/06 and slightly less than one-third were in

treatment on the last day of the financial year. This is slightly below the national estimates

of 55.4% for the last year, and 36.8% for 31.3.06 (NTA, in press).

The tool used to examine saturation, define and quantify the population in need is the

Treatment Bullseye (NTA, 2006). The treatment bullseye characterises the problematic drug

using population in Birmingham and group them by their engagement with structured

(Tier 3 and 4) drug treatment services during the period 1st April 2005 through to 31st

March 2006. The centre of the bullseye represents clients currently being treated. As

the rings progress outwards they are differentiated through their levels of contact with

treatment services. Clients within each ring of the bullseye are then profiled in respect

of their age, gender, ethnicity and injecting status in order that any differences between

clients who are successfully engaged and those who are not can be better understood.

Figure 1 below illustrates how these data are used to populate the basic treatment

bullseye for the overall assessment of treatment capture for Birmingham.

Figure 1: Number of Opiate and/or Crack Cocaine PDUs reported to NDTMS, segmented by

treatment status.

Not known to treatment but in contact with DIP

Known to treatment but not treated in last year

In treatment in last year

In treatment now (31/03/06)

Sex - % Male clients Ethnicity - % BME

Figure 2: Bullseye analysis by gender and ethnicity

Figure 2 shows that while males are less well represented in DIP than in the rest of

the treatment system, males also have a slightly higher dropout rate from structured

treatment than females, i.e. they are represented at lower levels in the central ring

of the bullseye. With regard to ethnicity, there is a higher incidence of BME groups in

DIP than in structured drug treatment suggesting that this is a group that is not being

adequately captured through the treatment system. Additionally, BME groups have

slightly lower treatment retention rates. Although the differences are small, this implies a

double risk around BME groups – they are both more poorly engaged in structured drug

treatment and those that are engaged in treatment are not retained as well within the

treatment system. A more detailed analysis of ethnicity and retention is provided below.

The remaining characteristics defined and analysed through the treatment bullseye are

presented in tabular form in Table 3 overleaf.

In treatment now

In treatment in last year

Known to treatment but not

treated in last year

Not known to treatment but in contact DIP

25%

28%

26%

34% DIP

74%

77%

75%

85% DIP

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6.1.1: What can we learn about the characteristics of those not engaged satisfactorily

from the bullseye method?

While the map in Figure 1 provides an overall assessment of the population both in

treatment and not in contact with structured treatments, it tells us nothing about the

characteristics of the groups less likely to be in treatment, in other words, the groups

whose needs are not being adequately addressed by the current configuration of the

treatment system. However, by using data available from NDTMS and DIP on these

different populations, it is possible to examine the characteristics of those engaged and

retained in treatment by demographic characteristics and by substance use profile. Figure

2 below shows the basic analysis for gender and ethnicity:



(within all drug types recorded)

26% 23% 48% 13% 21% 97% 29% 53% 16%

23% 25% 49% 11% 17% 90% 37% 44% 18%

25% 23% 47% 15% 16% 90% 33% 53% 19%

15% 35% 46% Currently Unknown 85% 40% 54% 26%

Gender1 Age Group1 Injecting Status1 Main Drug2 Main Drug3

Treatment (Tx) Status

In Tx (On 31.03.06)

In Tx during past year

Known to Tx but not treated in last year

Known to DIP but notTx series

Female 15-24yrs 25-34yrs Current Former Opiates Crack Opiates Crack

-Cocaine

(within opiates and/orcrack cocaine users)

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1 data reporting on primary opiate and/or crack-cocaine users only. 2 Data reporting on primary drug of use within the opiate and or crack-cocaine users group. 3 Data reporting on primary opiate or crack-cocaine use within all drugs recorded.

Table 3: Drug use profile and demographic characteristics by drug treatment engagement

and retention

While there is no clear pattern of retention using three comparison sources of data – in

treatment on the last day of the year, in treatment at some point in the last year and in

treatment more than one year ago – for gender, women are better represented in drug

treatment than among criminal justice groups identified with drug problems. A much

clearer picture emerges with age, with drug users under the age of 24 much more likely to

be identified through criminal justice than through structured drug treatment and, as with

BME groups, those that are engaged are more poorly retained in treatment.

Comparisons using the NDTMS data for new presentations can be carried out to look at

the variation between local, regional and national characteristics to understand how our

client group compares to the national profile from the NDTMS returns.

A description of data reveals

● The number of male clients in structured treatment is 3% higher in

Birmingham than the national percentage (76.8% Birmingham, 73.7% nationally).

This demonstrates a lower level of female recruitment into structured treatment in

Birmingham

● Birmingham has a higher percentage of 18 to 25-year-olds compared to the

national figure (27.9% Birmingham, 22.55% nationally). However, this figure is still

low when compared with DIP figures for the same characteristics

● The BME picture reflects Birmingham’s ethnic diversity with a higher percentage of

BME clients and lower percentage of white clients than national comparisons

(28.3% BME and 71.7% White in Birmingham, with 12.3% BME and 87.7% White

nationally). This is supported by census information for the city

● Opiate as a primary drug of use is higher in Birmingham (79.4% of clients

reporting opiates as primary drug used) compared to the national figure (66.8%)

● Primary crack use in Birmingham is similar when compared nationally (7.3% and

7.2% respectively)

● Self reported current injecting status is low in the Birmingham area (14.6%

compared to 36.5% nationally)

● Birmingham has a higher percentage of criminal justice referrals into treatment

compared with the percentage nationally, as detailed in table 4 below

Referral Source Bham n= Bham % National %

Treatment 224 8.53 11.7

Primary Care 446 17 11.3

Self 803 30.6 40.7

CJIP 1027 39.1 24.1

Other 125 4.8 12.2

Table 4: Numbers referred into structured treatment by referral source

6.1.2 Epidemiological Needs Assessment -– Section Overview

The key findings from the NDTMS and bullseye analysis are presented below in bulleted

form:


● Of this number, 5,764 PDUs are in treatment, have been in treatment, or are

known to treatment, between 2004 and 2006

● Therefore 6,101 are unknown to treatment at present, i.e. they can be classed as

the ‘hidden’ or target treatment population


❍ Male PDU’s have a poorer retention in treatment than females

❍ BME groups have a higher representation in DIP services, and poorer

capture rate in community services


❍ Women are under-represented in criminal justice when compared to

treatment capture rates

❍ Under-representation of 15-24 year-olds in structured treatment when

compared to those identified through criminal justice

This gives us a basic mapping of the treatment population and retention parameters

against which the needs of particular groups can be analysed.

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6.2: TREATMENT SYSTEM MAPS

6.2.1 Initial treatment systems map

An aspect of the comparative element of the needs assessment is the creation of

treatment system maps as a method of charting the provision of treatment available in

the city and linking this to the progression of clients through treatment journeys. This first

map aims to identify the number of clients in treatment, to understand how many people

are in the system at any one time and where they are within this system.

Two data sources have been utilised to compare relative numbers in treatment for Tier 3/4

service the first being NDTMS data and the second a City-Wide Audit of Birmingham drug

treatment services, which is described in more detail below.

Figure 3: Initial treatment system map for Birmingham

PRIMARY CARE/PSYCHIATRY

HOUSINGSERVICES

PROBATION/COURT/POLICE

PRISON

OTHER

NEEDLEEXHANGE

OUTREACH

CARAT/INREACH

INFORMATION&

ADVICESERVICES

ADDACTION

Movement through system in both directions

EXIT

DIPS TEAMS Total=344

CDT’s Total=761

DSB

DRUGLINE

Total AcrossService n=119

NorthN=38

SouthN=178

HoBN=126

EastN=102

SharedCare

N=1101

CriminalJusticeN=135

Slade RdN=203

Barker StN=143

Mary StN=176

AzaadiN=239

BRO-SIS INCLUSION SAFE

DAYCARE

INPATIENT

Aft

erca

re

Tier 1 Tier 2 Tier 3 Tier 4

2322

What the above map indicates is the high proportion of Birmingham treatment clients who

are engaged in either Tier 2 criminal justice services or in shared care treatment provision

within the city, with the number in shared care treatment exceeding those in community

drug treatment provision. Additionally, the chart has identified around 344 drug-users

are engaged in the DIP process, with a further 165 in DRR and around 150 in criminal

justice treatment with Drug Solutions Birmingham, primarily those users identified as

Prolific and Priority Offenders (PPOs). The implications this has for movement through the

system are discussed below in the context of the dynamic treatment mapping process.

6.2.1.1 City-Wide Audit

The audit process gathered information from 15 treatment agencies in Birmingham to

provide a “Snapshot” analysis of drug users currently in treatment in the city. A total

number of 2,806 clients were identified based on interviews with workers in all of the

providers of structured services, of whom 2,162 were in ‘community’ services and 644

clients were in contact with criminal justice services, demonstrating the large part criminal

justice services play in referral and treatment provision. When these two groups were

compared:

● Criminal justice clients younger, more ethnically diverse – larger proportion of black

clients in criminal justice, shorter time in treatment

● Adequate dosing but inconsistencies in dispensing and supervision practices

● Low levels of structured interventions delivered

● Low rates of IV use (13% community; 9% criminal justice). Both of these rates

are lower than the 17.7% injecting rate reported by the West Midlands Public

Health Observatory based on NDTMS data. However, irrespective of the source,

the rate of injecting among Birmingham drug users in treatment is substantially

lower than the national rate and is much lower than a number of local areas (the

heroin injecting rate is reported as 57% in Dudley and 60% in Worcestershire,

although only 15% in Solihull)

● 15% had alcohol problems last year but poorly managed

● Christo Inventory scores identified main problems for clients in treatment were a

lack of meaningful occupation, on-going substance use, and limited social support

● Shared care service clients were more likely to be in treatment for four months to

two years, in contrast to specialist services who were more likely to treat clients for

five years or more

In terms of unmet need, one of the key findings of the audit was in relation to the high

rates of unstable accommodation. 22% of those in treatment were described by their

workers as having ‘unstable’ accommodation. A higher proportion of female drug users

had unstable accommodation (32%), while for ethnicity, both mixed race (31%) and

black drug (31%) users in treatment were more likely to have unstable accommodation

than white (22%) or Asian (13%) drug users. This suggests a significant concern relating

to overall accommodation with additional identification of key groups with enhanced

housing risk.



2322

6.2.2: Dynamic system map

The second type of treatment map that is generated is much more ambitious in that it

attempts to link the numbers in treatment on a given day to pathways through treatment.

In the NTA guidance on needs assessment, this is defined in terms of movements of users

across services to assess treatment pathways. For the current analysis, this is modelled as

both a projection based on actual numbers in treatment and in section 6 an indicated

model that might be applicable for the partnership to achieve the target of 7,000 drug

-users in treatment in 2007/08.

The treatment system map is a graphical representation of a treatment pathway for an

individual or for groups of individuals. The map aims to plot how clients move through

four stages of their treatment journeys:

● System Entry – the referral routes into treatment

● In Treatment – clients receiving structured treatment (Tier 3/4)

● Movement within the system – clients moving between agencies

● Exiting the system – clients discharging from structured treatment

The treatment system map aims to identify where the blockages are in the system and

where clients are at the greatest risk of dropping out and failing in treatment services.

This is the process of creating an initial data based process for identifying where safety

nets are likely to be needed and what aspects of the system structure are not facilitating

either client choice or client movement through the services based on their planned

treatment journeys.

From a systems perspective, the essence of the tool is to identify flows, but also to assess

the adequacy and effectiveness of entrance points to the treatment system, unintended

drop out points, planned exit routes and safety nets for those who drop out from within

or between interventions. Figure 4 overleaf is the initial attempt to characterise the

current flow of clients.

Figure 4: Adult Drug Treatment System Dynamic Map

The above dynamic map illustrates the flow of clients into and through the system as

recorded by the City-Wide Audit. The second data source for exploring the flow of

clients through the system is the NTA treatment journey data for Birmingham new

presentations to the treatment system in 2005/06. The analysis was based on the most

recent treatment journey undertaken by clients receiving inpatient treatment, prescribing

services, structured counselling and day care or other structured interventions in 2005/

06. It does not include those who receive treatment only in prison, who are primarily

alcohol misusers but also received treatment for drug misuse or received less structured

forms of intervention such as advice and information, and needle exchange services.

Thus, for clients who had multiple treatment journeys in the course of the year, only

the most recent journey is included. An overview of the data gives further information

on the characteristics of new or re-engaging clients. The following is a summary of this

information:

2524


HOUSINGSERVICES

PROBATION/COURT/POLICE

PRISON

OTHER

NEEDLEEXHANGE

OUTREACH

CARAT/INREACH

INFORMATION&

ADVICESERVICES

ADDACTION


EXIT

DIPS TEAMS DSB

DRUGLINE

DAYCARE n=70

INPATIENT

Admitted n=250Completed n=150 A

fter

care

Tier 1 Tier 2 Tier 3 Tier 4

CDT’s


New & Retained n=300

New n=1200

Transfered n=250

Dropped Out n=50

Continuous n=600

New n=400

Continuous n=100

Drop Out n=200

Complete n=50

Transferred n=100

New & Retained n=50

New n=900New & Retained n=300Continuous n=800Dropped Out n=600Complete n=100Transferred n=100

New n=1000Continuous n=100CJ disposal n=200Dropout n=500Complete n=0Transferred n=300



2524

● Birmingham clients constituted 3.2% of all new treatment journeys undertaken by

drug clients in England in 2005/06

● There were 2,635 treatment journeys started in 2005/06

● 38.1% of all new treatment journeys were referrals from the criminal justice system

● 66.3% white; 76.8% male

● The largest minority group was Pakistani, constituting 7.8% of the Birmingham cohort

● Main drug – heroin (74.8%); cannabis (7.4%); crack cocaine (7.2%)

● 12 week retention – 76.9%; of those discharged (55.1%) 28.7% had planned

discharge reasons (therefore 71.3% had an unplanned discharge)

● Black clients – older age at start of treatment episode, 36% primary crack users,

8.2% NFA; 61.5% referred from criminal justice

● Asian clients – 6.2% female; 84.8% opiate users

● Mixed race – 30.0% female (highest rate across ethnic grouping); mean age – 29.0.

● Mixed race clients were most likely to drop out straight after triage and to have an

unplanned discharge

● Highest rates of unplanned discharge in black and mixed race clients; highest rate

of 12-week retention in Asian clients

6.2.3: Mapping Analysis - Section Overview

From the initial treatment map based on data from the City-Wide Audit the following

information can be summarised in order to identify the number of clients in treatment

and their location within the services in the system:

● A total of 2,806 clients were identified in treatment at the time of audit

● The three largest providers of structured treatment are shared care services,

community specialist drug services, and criminal justice services

● Criminal justice clients are younger, larger proportion of black or mixed race

clients in criminal justice services, shorter time in treatment

● Overall, there are low rates of injecting among those in treatment (17.7%

according to the PHO analysis of injecting rates regionally for 2004/05)

● There were high rates of unstable accommodation (22% in ‘unstable’

accommodation) particularly among women, black, and mixed race drug users,

suggesting a multiple vulnerability in this group

From the dynamic system map we can attempt to identify flows, assess the adequacy and

effectiveness of entrance points to the treatment system, unintended drop out points,

planned exit routes and safety nets for those who drop out from within or between

interventions. The following is a summary of information obtained from NDTMS new

treatment journey data and the City-Wide Audit:

● 2,635 treatment journeys started in 2005/06, of whom around 45% were still in

treatment at the end of the year

● Of those who had left treatment within the first year, only 29% had a planned

discharge


followed by self-referral with 803 referrals. The smallest referral source was from

‘other’ sources with 125 referrals

● The highest rates of unplanned discharge were amongst black and mixed race clients

● Crack use was especially high among black clients (36% primary crack users), with

high number of referrals from criminal justice sources

● According to NDTMS data there were 1,162 unplanned discharges across the

treatment system in 2005/06

● Low utilisation of inpatient and day care services

● 750 clients were transferred within the treatment system

● Less than 250 clients had a planned exit from treatment

Of the 2,635 treatment journeys initiated within the year, although more than three-

quarters were retained for 12 weeks, implying some outcome gains, less than half were

still in treatment at the end of the year. Of greater concern is the fact that of those who

do leave within the year, only around one quarter had planned discharges.

Almost two-thirds of all black referrals were from the criminal justice system and around

one third of the black group were primary crack or cocaine users, indicating a possible

area of unmet need here, while there is a low representation of females among the Asian

group. A similar unmet need identified relates to the lower retention rates and higher

rates of unplanned discharges among black and mixed race users who enter treatment.

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2726

6.3: DRUG INTERVENTIONS PROGRAMME SYSTEMS MAP

In addition to a static map, the analysis below combines data derived from the NTA

analysis with three local sources of information – DIP monitoring data developed in

conjunction with the DIP Data Management Team, information from the City-Wide Audit,

and information from an analysis of risk assessments conducted by Arrest Referral Workers

with drug users at the point of arrest.

What is immediately striking is the extent to which the DIP treatment system is a major

component of the overall Birmingham treatment system. Indeed, among the black

community entering treatment, 65% of the new treatment journeys in Tier 3 in 2005/06

were reported as DIP referrals, according to the analysis of NDTMS treatment journeys in

this year. In order to gain an understanding of the journey for DIP clients, Figure 5 below

illustrates a basic pathway map for the DIP system.

Figure 5: Basic DIP system pathways map

The primary routes into drug treatment for offenders are via courts, police custody and

from the prisons; although there is some system flexibility with clients also referred from

community drug services into the criminal justice teams. Thus, the DIP teams, DRR and DSB

criminal justice will have as primary referral sources Tier 1 referrals. For clients accessing

DIP throughcare and aftercare teams (53.4% of criminal justice cases identified in the

POLICEARREST

REFERRALWORKERS(TOUGH

CHOICES)

BIRMINGHAMPRISONS

CARAT TEAMS

COURTS‘RENSTRICTION

ON BAIL’,PROBATION

PRE-SENTENCINGREPORTS

DRRDRUG REHABILITIATION

REQUIREMENT

DSBCRIMINAL JUSTICE

TEAM

DSBSHARED CARE

NORTH

SOUTH

HoB EASTDIP

12 wks

TIER 4INPATIENT/

RESIDENTIAL

SLADE RD AZAADI

MARY STTERRACE

CDTs

exit

exit

exit

PPO’s

PPO’s


DIPOutreach

Referral Routes CJ Treatment Services Non-CJ Tier 3 Services Tier 4 Services

Aft

erca

re

Tre

atm

en

t E

xit

City-Wide Audit), the system requires additional fluidity as the primary model is for clients

to be engaged and retained for 12 weeks and then referred on to either Community

Drug Teams or shared care. However, the 12-week target varies as a result of placement

opportunities and client preferences, and the issue of planned exits from this treatment

pathway will be discussed below.

6.3.1: Arrest Referral Worker Analysis

Arrest Referral Workers (ARWs) use a risk matrix to assess what the ‘risk of harm to others’

is in terms of violence, offending, and drug spend. This allows the workers to divide

offenders into high, medium and low risk categories. An analysis of 1,082 risk matrices

collected in 2006 and completed by ARWs offers us an opportunity to examine the

population of drug users accessed through criminal justice non-treatment and to assess the

‘capture rate’ of this population who are already in contact with adult treatment services.

Below is a summary of this information:

● 30.9% of the sample were reporting a weekly drug spend of more than £500

● 12.3% of the drug using offenders assessed by ARWs were rated as high risk

● There was a clear positive association between the drug spend and the offending

risk in this group

● At the time of the analysis 184 (17.3%) of the drug-using offenders were in

treatment– suggesting a large custody population not currently engaged with

drug treatment services, justifying this as a core area for potential diversion from

the criminal justice system to drug treatment

● Those in treatment had a markedly lower risk profile score overall (mean = 33.3)

than those not in treatment (mean = 57.6, t=12.47, p<0.001), and a significantly

lower offending risk score (18.7 compared to 37.9; t=11.56, p<0.001).

● Those not in treatment were nearly twice as likely to be classed as ‘high risk’

(13.3% compared to 7.1%; _2 = 70.28, p<0.001)

● Of those in treatment 12.3% were identified as ‘high risk’ in the police analysis

– women more likely to be high risk than men yet less likely to be in treatment

● 10.4% of those arrested were identified by workers as already being PPOs. 27.3%

of those identified as PPO’s were in treatment

● PPOs in treatment reported significantly lower levels of offending than PPOs not in

contact with treatment services

● 6.7% reported weekly drug spend of more than £1000

● Those in treatment reported lower levels of offending and drug spend but

numbers in treatment were low

The analysis would suggest a relatively low capture rate for drug-using offenders in

treatment – with only 17% of all the users arrested already being in treatment. However,

there is clear evidence of treatment gain with lower levels of offending reported by all

offenders in treatment and also by the sub-group of PPOs who were in contact with

treatment services. The data also suggest high levels of drug spend in this population, and

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29

offending closely linked to substance use, indicating the importance of targeting this

population for treatment. This may apply particularly to female offenders who reported

higher mean risk scores and were less likely to be in contact with treatment services at the

time of arrest.

6.3.2: PPO report

At any given time there are estimated to be around 300 active PPOs in Birmingham,

although they will not all be in the community at any given time. The audit that was

conducted between September and December 2006 focused on cases for which files

existed in the main treatment provider, DSB, supplemented by additional information from

the supervising police officer on patterns of offending. Just over half of the cases (n=159/

299) had files available at DSB representing a combination of existing and active cases,

closed cases, and new cases yet to initiate treatment. At the time of the analysis, 29% of

the 299 PPOs were in prison or custody and 28% were active in treatment (this constituted

85 cases, of which 57 were in contact with DSB).

Of the files identified (n=159), at the time of the audit, 57% were suspended, 16% were

closed and 27% were active in treatment. The majority of PPOs were male (98%) and

white (72%), and they had an average age of 28 years. At the time of initiating treatment,

62% were unemployed and 19% were living in unstable accommodation. Only 90% of

the caseload reported illicit drug histories, and only 18% were daily heroin users and 6%

daily crack cocaine users. Nonetheless, 17% reported an average weekly spend of more

than £500 per week, with the most common crime reported as burglary (46%) followed by

theft (18%) and robbery (16%). In terms of previous involvement with the criminal justice

system, the group averaged a mean of 31.0 previous convictions, and an average of 3.1

convictions in the year before PPO status was established. It is perhaps surprising that the

most frequent length of most recent conviction for the group was between one to four

months (30%).

All but one of the PPOs reported having previously received treatment from DSB, with

46% reporting two or more previous treatment episodes. However, more than half of

the group (56%) had spent a total of less than three months in treatment, and rarely

had any of the PPOs been treated in any agency other than DSB. Just under half of the

clients in contact with DSB had ever received a prescription (46.5%), with methadone and

buprenorphine most commonly used, although other drugs prescribed include naltrexone.

Where care plans were available, the aim of treatment could be classed as stabilisation

or prescribing treatment (in 63.5% of cases) and abstinence in 29.7% of cases. In terms of

attendance, on average clients attended a mean of 7.1 of the 11.3 appointments offered.

The results suggest some promising treatment engagement for this group, although it

does not always happen initially – there are often ‘false starts’ in which clients are assessed

and then drop out of treatment for a period of time. There is also little indication of client

drop-out among the closed cases – only 8.5% of cases closed are because of drop-out,

compared to 54.2% remanded or returned to prison, with the other main reasons being

moving away from the area, transferred to other agencies, or there being no suitable

treatment available. However, the low number of cases active at any given point is

potentially a cause for concern, with limited testing information available on the case files

to detect changes in substance use over the period of treatment engagement.

6.3.3: City-Wide Audit

The City-Wide Audit assessed workers’ perceptions of client engagement and problem

profile for 2,806 clients across the city, of which 344 were in treatment at the four DIP

teams, 165 at the DRR team and 135 at DSB criminal justice services. In other words, 644/

2806 clients accessed in the audit (23.0%) were criminal justice clients. Chapter 10 of the

City-Wide Audit provides a comparison of the client groups accessing criminal justice and

non-criminal justice services. Among the key differences reported were:

● Criminal justice clients were younger (mean age of 30.0 years compared with 33.6

years in the ‘community’ services)

● 29.1% of criminal justice clients and 22.0% of community clients were non-white

– this difference was accounted for by the higher rate of mixed race clients (8.1%

compared with 4.4%) and black clients (7.5% compared with 2.2%)

● More criminal justice clients lived in unstable accommodation (24.5%) than

community clients (20.8%)

● A smaller proportion of criminal justice clients had injected drugs in the previous

month (9.2% compared to 13.3%)

● More criminal justice clients used heroin on a daily basis (20.7% compared with

13.8%). More criminal justice clients were also using crack cocaine on a daily basis

than among community clients (10.3% compared to 5.2 %)

● Clients in community services were much more likely to be receiving opiate

substitution treatment (90.5%) than clients in criminal justice services (70.2%)

● However, clients on methadone in criminal justice services were much more likely

to be on supervised consumption (56.3%) than in the community services (14.3%)

● Clients in criminal justice services were more likely to be in contact with

employment, housing and community psychiatry services but were less likely to be

registered with a GP or attending day care services

● Clients in criminal justice services were more likely to have a care plan (83.5%)

than clients in community services (76.2%)

There were no differences between the groups in the profile of gender, nor in the total

problem severity scores as reported by the workers. It is perhaps surprising that criminal

justice workers typically reported fewer problems with the working relationship with

clients than community treatment staff, but the overall profile is of a slightly younger

group accessing criminal justice services, with heavier use of crack cocaine and heroin.

They also appear slightly more chaotic in terms of unstable accommodation, while the

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31

greater representation of black and mixed race clients in criminal justice teams is consistent

with other evidence sources reported here in indicating that community services have

contact with a less diverse range of problem drug-users than the criminal justice system.

6.3.4: DIP Data Analysis

To gain further knowledge around engagement rates with drug misusing offenders,

information was gathered from Drug Intervention Records (DIR) and activity reports as

recorded on CLIPS (Client Information Partnership System), held and monitored by the

DIP team in the city. Of particular interest for the needs assessment analysis was the flow

of clients through the criminal justice system. The data available was used to assess how

many contacts are made by ARWs and how these translate into client care planning and

the initiation of treatment episodes. To present a more valid, relevant picture of DIP data

the period from which data has been explored was between January 2006 and December

2006, (as opposed to April ‘05-March ’06 for NDTMS data collection). This is to allow for

the improvements of data collection systems and data accuracy that took place during this

time, and to use a more contemporary time frame to reflect recent trends, particularly

those related to the introduction of Required Assessments (in place since April 2007).

The total number of contacts made by ARWs during 2006 was 5646, of these 4096

completed a client assessment, of which 2645 clients went on to be given an initial drug

treatment care plan. This represents a conversion rate of 47% from contacts to initial care

plan. Figure 6 represents this in a graphical form below.

Figure 6: Conversion rate from contacts to careplan (based on 2006 records)

Conversion47%

Total contacts

Total assessments

Initial care plans completed

5646

4096

2645

This suggests that just under half of all contacts with ARWs, primarily referred through the

custody system, but also from probation, prison and other treatment providers, result in

the creation of a care plan for the client. Excluded at this stage will be those cases that are

suspended for criminal justice reasons, clients who are already in treatment and those who

are not perceived to be in need of formal drug treatment. Table 5 below illustrates the

trends in numbers over the course of 2006 of client contacts, assessments and initial care

plans being given. Between May and December there is a marked increase in conversion

rates due to the lower number of contacts and relatively stable number of initial care plans

completed.

Table 5: Annual trends in numbers contacted, assessed, and initial care plan completion in

2006.

Another key piece of information needing further investigation are the number of DIRs by

status, for example open, closed or suspended. From ‘activity form’ records there appears

to be between 5-10% closure of cases due to completion of care plan or treatment. This

represents an outcome of 5-10% of DIP clients successfully engaged who are subsequently

completing treatment. However this figure could be negatively affected by the number

of closures reported as ‘other’, this category represented 35% of case closures in the last

quarter of 2006. Ongoing work is attempting to improve this system, but at present it is

impossible to be definitive about how these closures should be interpreted.

2006 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total

Contact 667 528 584 435 488 515 304 421 442 422 447 393 5646

Assessed 364 277 333 314 374 368 238 358 376 369 384 341 4096

Careplan 280 193 229 199 240 260 135 228 220 235 238 188 2645

% Conversion 42% 37% 39% 46% 49% 50% 44% 54% 50% 56% 53% 49% 47%

3332



3332

Although there is not precise data to evidence this at present, it appears there are around

400 initial contacts with the ARWs each month, so just under 5,000 per year with indicative

information suggesting that the rate of those not already in treatment is both low and

constant. In other words, there is no suggestion that the overall population of drug using

offenders is being exhausted by either the Required Assessment initiative or by overall

expansions in the drug treatment system. Of these 400 clients each month, typically

around half are closed prior to the care plan stage, either because they are not suitable

for treatment, are already in treatment or are treatment resistant. In an average month,

a further 60 cases will typically be suspended as a result of criminal justice actions (such as

incarceration), and 40 will typically drop out so around 100 (or 25% of the initial pool) will

actually make it as far as initiating contact with the DIP teams. Of this group, around 70

will actually initiate and engage with treatment and between 30 and 40 will be retained

for the 12-week target of the throughcare and aftercare teams. In other words, initial

estimates would suggest that between seven to 10% of all initial ARW contacts will be

engaged and retained in treatment up to the 12-week target window, although ongoing

analysis will both clarify this process and will be needed to assess whether there are

differences by age, gender, ethnicity or drug profile.

There are also ongoing data issues that complicate the overall assessment of effectiveness.

Another issue of information recording is highlighted in drug profiling during assessment,

as 20% of all assessment forms have no drug profile recorded. In other words there is

no information recorded about the clients drug(s) of choice. Therefore a large amount

of potential data through which to profile DIP clients is missing. This is also an issue for

recording housing status, in particular ‘NFA’. DIP teams have a total monthly caseload of

approximately 3000 active cases, however due to a possible backlog of cases requiring

closure it is believed this is more likely to be in the region of a 2000 client monthly

caseload.

6.3.5: Criminal Justice - Overview

From the three sources of local information discussed above it is possible to draw some

conclusions regarding the needs of PDUs and the existing criminal justice treatment

system. Firstly, as highlighted by the ARW analysis, of the clients assessed who were not

already in treatment there was a higher likelihood of them being classed as high risk,

compared to the ‘in treatment’ offenders. This highlights the need to retain high-risk

clients in treatment to reduce the risk of further offending and related risks. This is a

particular need for women offenders, who were more likely to be classed as ‘high risk’.

The small number of female PPOs involved in sex work were not currently engaged in

treatment at the time of arrest and this further highlights the need to provide further

interventions targeted towards female sex workers.

In relation to the needs of BME offenders, analysis draws attention to the significant

proportion of BME clients referred into treatment through the criminal justice route. In

comparison to referral from other sources, this was particularly the case for black and

mixed race clients. The low comparative rates of BME groups in community treatment

highlight a need to assess the systems in place to attract and retain BME clients in

treatment.

In order to retain these clients in treatment and prevent dropout there needs to be

appropriate safety nets and mechanisms in place to prioritise these clients and assist them

in re-engaging with treatment. The implementation of ‘required follow-up’ assessments in

April 2007 may have a positive impact on this need by re-engaging with offenders who fail

to successfully engage in treatment following the initial required assessment.

With regards to housing status, criminal justice clients appear to have higher rates of

unstable accommodation compared to community based clients; this highlights a need

for DIP housing support to work closely with these clients in order to reduce the risk of

treatment dropout due to unstable housing.

6.4: LOCAL DATA SOURCES

6.4.1: Needle exchange data

Some data were available from three different sources – from DAT information on

community needle exchanges, from BSMHT and from Drugline a city-centre specialist

provider.

The first source of data is from community pharmacies across the city, based on a six-month

window of recording by community and collated through the Dug Action Team, based

on a total of 69 pharmacies who have returned data. There were a total of 7,726 packs

distributed, of which 5,794 were 1ml packs, 1,623 2ml packs, 293 5ml packs. No data was

available for the 84 missing cases. Thus, it would be estimated that there are in the region

of 15,000 exchanges conducted in 2006/07 in community-based pharmacies.

Where gender was recorded, 1,345 packs were distributed to women and 6,128 to men.

Thus, of the 7,473 attributable needle exchange packs, 18.0% were distributed to women

and 82.0% to men. This did not differ for 1ml and 2ml packs. The distribution of packs by

age at community pharmacists is shown in Table 6 below:

Table 6: Age breakdown of packs from clients attending community needle exchanges

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AGE GROUP NUMBER PERCENTAGE

Under 20 60 0.8%

20-25 years 1307 17.8%

26-30 years 2145 29.2%

Over 30 years 3833 52.2%

Missing 381

Total 7726

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Ethnicity data were available on the recipients of 7104 of the packs given out in the

six-month target window. 85.8% (n=6096) of the packs were given out to white British

clients, 317 (4.5%) to other white clients, 250 (3.5%) to clients of mixed race, 359 (5.1%) to

Asian clients, 118 (1.7%) to black and 80 to individuals from other ethnic groups.

From the specialist needle exchange service run by Drugline, there were a total of around

6,000 exchanges conducted. This breaks down as an average of 576 exchanges conducted

per month, and this is estimated to represent an average of 259 clients. Thus the rate

of exchanges to clients is calculated for the Drugline service as 2.2 contacts per client.

Additionally, there was activity data on the needle exchange within one of the four

Community Drug Teams, indicating that there were 76 exchanges conducted in 2005/06.

This would represent around 300 exchanges per year across the CDTs, implying a total

number of exchanges of 21,300 in 2005/06.

To date, we do not have any data on the treatment status of those accessing community

needle exchanges, and there have as yet been no attempts to reconcile the data collecting

processes across the three main providers – community pharmacies, BSMHT and Drugline.

This represents a key area where data could be collected to provide more information

about the profile of clients not accessing treatment, by the addition of a single field on

treatment status to the recording form. However, it would be essential that this be agreed

across all of the provider agencies as part of rigorous monitoring of patterns of needle

exchange utilisation.

Conversely, if the majority of needle exchange users are already in treatment, an

alternative needs model arises. If those individuals accessing needle exchange services

are currently engaged in structured treatment, questions arise about the effectiveness of

treatment in the reduction or cessation of injecting drug use. Only by adequately mapping

the overlap of treatment engagement among the needle exchange utilisation group, and

linking this to the demographics captured here, will it be possible to turn this analysis into

actions about capture or intervention effectiveness.

6.4.2: Hiddun data

The Hiddun project was a piece of work undertaken by Drug Solutions Birmingham Shared

Care Service in order to attempt to make contact with groups identified by the NTA as

being under represented in drug treatment (as seen in figure 7 below). Another key aim

of the project was to explore potential barriers encountered by individuals attempting

to access Birmingham drug treatment services. The title of the project is an acronym

for Hidden-drug-users-needs. The project consisted of attending a range of activities to

engage with communities, groups and individuals in order to ask questions and administer

questionnaires.

Figure 7: Groups Identified by the NTA as under represented in adult drug treatment services

The four main areas summarised as being key reasons for not accessing treatment were:

1. Lack of information or knowledge of drug services

2. Confidentiality fears

3. Cultural and/or language barriers

4. Accessibility of services

One hundred and thirty three drug users or significant others participated in the study

including 43 structured questionnaires from people not involved with the treatment

system. Of these, 12% reported issues around cultural or language barriers and inadequate

outreach provision for BME groups. Additional comments focused on the lack of

accessibility around services, including issues around opening times. There were significant

comments regarding lack of provision for childcare and the amount of assessment

encountered when accessing services. This was felt to be too lengthy and repetitive.

6.4.3: BRO-SIS community led research

Bro-sis, a community project aiming to raise awareness about sexual health, drug and

crime issues specific to the African Caribbean community, conducted a piece of research to

explore the links between crack-cocaine use and crime in the African Caribbean community

in Birmingham. In conjunction with the University of Central Lancashire’s Centre for

Ethnicity and Health the research had four key aims, namely to engage with individuals:

● Who were on the fringes of committing offences but never been charged

● Arrested and who were screened positive for crack-cocaine

● Arrested and who are now in treatment for crack-cocaine

● Who have been convicted for crack-cocaine possession with intent to supply

Interviews were conducted with 32 individuals (25 black Caribbean and seven white); 20

were current users of crack-cocaine, of these 20 reported lack of sensitivity at initial visit;

lack of cultural awareness, and delays in accessing treatment as barriers to treatment

access, when asked how these barriers could be overcome suggestions included, more

workers from ethnic backgrounds, use of street outreach workers, and employing ex-drug

users as support workers. Twenty four of the respondents wanted positive role models or

mentors to be involved in drug services.

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NTA Identified Groups Under-represented in Drug Treatment

Drug treatment services

Women

Young people

BME Groups

Stimulant Users

People with mental health problems

Homeless people

3736

Key recommendations resulting form this research included:

● Targeted interventions for asylum seekers

● Aftercare that specifically addresses the needs of crack-cocaine and other stimulant

users, especially in regards to prison CARAT, resettlement, and in-reach services

● To provide clear visible, wall mounted care pathway information for crack-cocaine

and other stimulant users who may access services

● Utilise faith groups

6.4.4 Local Data Sources – Overview

The three local data sources available have provided the following key information:

Needle Exchange

● 69 community pharmacies contribute basic needle exchange data to a central database

❍ Although this does not include treatment status

● 7,726 packs distributed, 18% to women and 82% to men (minus non-attributable data)

❍ 75% were 1ml packs



● Approximately 6000 exchanges conducted by Drugline estimated to represent

around 260 clients using the service

❍ Crudely representing an average of 2.2 contacts per client per month or 23

per client per year.

● Data from CDT needle exchanges are largely unavailable due to the reporting

mechanisms in place for BSMHT services

If we assume that there are 4,918 problem drug users in treatment in the last year, then

using the PHO data (17.7% in-treatment current injectors, 04/05 data), there are 870

injectors who are in treatment in the last year. If we infer that around 15,000 packs have

been distributed in the last year in the city (across all three providers), and that treatment

entry will have the effect of reducing injecting, then there is a significant injecting

population not engaged with treatment services, although the size of this group cannot be

estimated with precision for the reasons asserted above.

This cannot be attributed to users of other substances such as anabolic steroids because of

the low rate (4%) of use of 5ml packs, so we are assuming that the majority of exchange

users are either primary opiate or polydrug users. There is also no evidence to suggest

that the injectors who are recruited into treatment fare any worse than non-injectors.

Conversely, if we assume those individuals accessing the 15,000 syringe packs are currently

also engaged in treatment services, this would represent an average monthly pick up of 1.4

packs distributed per person (or 14 syringes based on 10 per pack). This assumed scenario

would then point to a potentially substantial number of injecting drug users not accessing

needle exchange services or structured drug treatment.

‘Hiddun’

● 133 drug users or significant others highlighted four main areas why drug users

might not access treatment:

❍ Lack of information or knowledge of drug services

❍ Confidentiality fears

❍ Cultural and/or language barriers

❍ Accessibility of services

BRO-SIS – Key recommendations

● Targeted interventions for asylum seekers

● Aftercare for crack-cocaine and other stimulant users, especially in regards to

prison CARAT, resettlement, and in-reach services

● To provide clear care pathway information for crack-cocaine and other stimulant

users accessing services

● Utilise faith groups

All three of the analyses above would indicate sizeable out of treatment populations,

although we are not able to assess from this whether they have treatment histories.

The databases would indicate certain under-represented groups – injecting drug users,

stimulant users and individuals from non-white cultural backgrounds.

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6.5: KEY INFORMANT INTERVIEWS

In order to determine and balance the views of local stakeholder’s qualitative research,

methods were introduced to the needs assessment process. Key informant interviews

were conducted with members of the expert group to gain an in-depth knowledge of the

treatment system profile in Birmingham and what gaps and needs may exist within the

current system. Views and experiences of local users and ex-users were also sought through

service user groups. These collective methods provided information and expert knowledge

on the people accessing (and not accessing) local treatment systems, the existing treatment

provision, the needs and gaps within the system, and the emergent needs assessment

findings.

The interview schedule consisted of 15 open-ended questions exploring:1) the treatment

bullseye, prevalence of drug users, and the profiles of PDUs; 2) the static treatment map,

service configuration, and entry and exit from the treatment system; 3) the dynamic map,

flow of clients through the system, blockages and inadequate pathways, and the 2007/08

target for numbers in treatment. The following emergent themes are described below

using key information from the interview responses.

6.5.1 The needs of groups or communities

Sex Workers

It was felt that sex workers were being missed by many treatment services or not accessing

treatment that could best meet their needs, i.e. sex work specific services or women

centred services. Conversely it was also felt that there was a rise in the number of sex

workers attempting to access treatment. It was also felt that there has been a rise in male

sex workers, particularly working in certain areas of the city.

Women

Being a mother was identified as being a barrier to treatment due to the issues and

concerns of children accompanying their mother (and indeed father) to treatment services

or due to the lack of childcare provision while attending appointments. The fear of social

services involvement was also felt to be an issue. Multiple respondents felt that services

were well configured for white males and that other groups were not so well provided for.

Domestic Violence

Another issue for women that became apparent from the key informant interviews was

the effect domestic violence can have on accessing or being retained in treatment. Phoenix

Day Service reported that 85% of women attending the programme in the last 12 months

report domestic abuse as a key factor in their lives. This was also highlighted as an issue for

sex workers who have reported experiences of abuse from both partners and customers.

Asylum Seekers

The asylum seeking population in Birmingham, and particularly those who have been

denied the right to legally remain in the UK, have been highlighted as a group of substance

misusers without specialist services tailored to meet their needs. Nationalities most cited

as presenting a need for drug treatment include Iran, Iraqi, Afghanistan, Somalia and the

Sudan. It was felt that Khat use was a particular problem for East African immigrants and

asylum seekers.

BME Groups

The need for treatment agencies to work more closely with community groups has been

suggested as a need for BME groups, particularly to raise awareness of drug issues among

faith groups and community organisations. It was felt that there has been an increase in

heroin and crack use among BME groups, and that although services can cater for these

groups the services could be configured better in order to attract and retain their clients,

especially, Asian, Black African and Caribbean. It was suggested that information could be

placed at airports and other ‘landing points’ for people coming into the country who have

issues with substance misuse.

Crack and other stimulant users

Stimulant users were identified as not being well catered for within the present

configuration. It was felt that services may not attract or retain clients due to the lack

of substitute medication and there were unclear pathways for crack and other stimulant

users.

NFA and Vulnerably Housed

Housing for drug users was highlighted as a gap in provision and also a problem for

retaining clients who are vulnerably housed. It was also felt that NFA clients were

presenting with more complex health issues than previously recognised.

6.5.2 Systems or process related themes

Referral Processes and Tier 1 services

The pathways into Tier 2/3 services from Tier 1 settings were a cause for concern. Reasons

for this were cited as: lack of awareness of substance misuse services, lack of awareness

of stimulant use and the treatability of this group of drug users, and issues with referral

mechanisms and assessment paperwork.

Cultural Sensitivity

A need for services to be more culturally aware of the needs of drug users from different

ethnic groups was discussed together with the need for a variety of translated written

information and interpreter services.

Joint Working/Throughcare

A major area of discussion were the blockages within the treatment system, particularly

for clients needing to be moved from specialist Tier 3 services to GP prescribing and vice

versa, the need to move suitable individuals through the system towards Tier 4 services or

successfully exiting the system drug free. Transferring assessment paperwork between

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services was highlighted as a recurrent issue particularly from Tier 1 services into Tier 3 and

Tier 2/3 to 4.

Inpatient/Residential Services

Key informants felt that inpatient services posed difficulties for access and that more

people should be moving through the system in this direction. It was also thought that

there would have been more clients moving through inpatient and residential than

the data suggested. It was felt that the process of accessing these services was lengthy,

unrealistic, and that having no local residential services made this option unattractive for

some clients.

Aftercare and Outreach Services

In terms of safety nets, the interviews elicited many suggestions around the provision

of outreach services to draw in clients who have dropped out of the system. This was

particularly the case for sex working drug users and BME clients. It was felt these outreach

services could target the drop out within the first three months of treatment and also the

point further into established structured treatment where people may be again susceptible

to dropping out of treatment.

6.6: Expert group involvement

A total of 26 people were invited to attend the three expert groups – three each from the

two main provider agencies (DSB and BSMHT), six from a range of other provider services,

two service user representatives, data analysts from the police, DIP and the Public Health

Observatory, and the remainder as key figures from the commissioning teams and the NTA

and Government Office for the West Midlands. Each of the three groups was held prior to a

Treatment Function Group to ensure attendance and to create a monthly structure for the

meetings. Between 15 and 25 people attended each of the three meetings.

Expert Group 1: The initial presentation overviewed the NTA data in relation to the

Glasgow estimates and discussed the implications of the marked increase from the prior

estimate (based on the Hickman-Frischer study) to the Glasgow estimate. Concerns were

expressed by members of the expert group about whether there were in fact more than

11,000 problem drug-users, prompting debate about the definition of ‘problematic’

and the extent to which all of this population would benefit from treatment. There was

also discussion about the consistency of the PDU population, with some concern about

migratory populations and their under-representation in the data. In particular, there was

discussion about the role of the prison population and the effects of prison release both on

the size of the population and the adequacy of ongoing care for individuals coming out of

prison (although it was acknowledged that the introduction of IDTS should have an effect

on this). Additional under-represented populations raised in the meeting were asylum

seekers, groups who attend for initial assessments and do not return and some ethnic

minority groups believed to be under-represented in adult treatment services.

Expert Group 2: The initial discussion was a review of the process of identification of

underutilised groups and its reconciliation with existing data sources. Among the key

data sources discussed was the City-Wide Audit, with concerns raised about the incidence

and management of alcohol problems among drug-users in treatment. Two key under-

represented groups discussed in detail at the meeting were BME groups (in particular

black clients) and homeless groups. The second part of the discussion involved the low rate

of IV drug use indicated by NDTMS and by the PHO analysis – with agreement that it will

not be possible to assess the extent of the out-of-treatment population of injectors until

changes are made to data collection in needle exchanges establishing both frequency of

attendance and treatment status of users of community needle exchanges. There was also

discussion of the utilisation of other needs assessment process – with links to both the

Hiddun project and to Bro-Sis work, linked by their concerns around barriers to treatment.

Expert Group 3: The presentation at the start of the meeting overviewed the data

collecting process to date and the outstanding tasks required, and provided the expert

group with initial conclusions and recommendations. To discuss these in full, three

discussion groups were convened on the following topics:

● Accessing hidden populations: the key groups identified were around mental

health and co-morbidity, young people and the provision of services for women.

This group also suggested the development of ‘super exchanges’ for provision

of injecting equipment but that would also deliver harm reduction advice,

that would permit secondary distribution of needles and that would act as a

bridge to structured treatment provision

● Targeting and retaining under-represented groups: targeted interventions and

pathways were suggested for asylum seekers, satellite and outreach services

for crack and other stimulant users, partnership working with the city council

around homeless populations, more effective education and joint working with

young people’s services, women only provision in structured services with

additional provision for female sex workers and greater continuity of care for

prison release populations

● Modelling the options for increasing the numbers in treatment for 2007/08: the

key under-pinning assertion was the need for a culture shift to move away from

maintenance and stasis to a culture promoting change across client groups.

As part of this culture change it was suggested that there needs to be a

significant investment in training for service managers and for commissioners

in effective communication and liaison around treatment planning and delivery.

More radical suggestions were also advanced including a re-classification of

existing clients according to their treatment needs, and improved utilisation of

existing capacity by re-drawing treatment pathways for clients based on their

goals and immediate needs. The suggestion was to move away from service-driven

treatment models to client-propelled models of change. More practical

suggestions for improving uptake and retention included improved flexibility

around opening hours, targeting of DNA appointments for review and weighting

of caseloads by severity of client needs and problem profiles. It was agreed

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that there would be a need to balance increased capacity with improved client turnover

including delivery of interventions at Tier 1 and 2, improved utilisation of Tier 4 and better

change management to detoxification in community settings. Finally, there was

general agreement that services’ commitment to improved data management was an

essential under-pinning to this change process

7. PROJECTION MAP FOR 2007/08 NUMBERS IN TREATMENT

The treatment target for 2007/08 is for 7,000 individuals to enter treatment within the

year, this represents a significant uplift from the 2006/07 target. To achieve this target,

two key milestones will need to be achieved. The first will be increased movement within

the treatment system to ensure that clients are not discouraged from accessing treatment

because of system blockages and to enable treatment journeys to be completed. The

second requirement for this target to be met is that a new cohort of individuals will have

to be recruited into treatment combining those with previous treatment contact who

have dropped out and those who are new to treatment. The section below outlines two

putative models for how these numbers may be achieved. This is a modelling approach

based on the question of ‘how would the treatment system have to look to make this

target attainable?’ The two models can be broadly classed as the increased turnover model

and the increased capacity model.

7.1: Model 1: Increased turnover model

The model outlined below makes the assumption that, of the 3,500 clients in Tier 3

treatment at present, 1,500 will complete their treatment journeys within the year, 1,500

will be retained in treatment throughout the course of the year and 500 will drop out of

treatment. This model will then require a further 3,500 individuals to be recruited into

treatment in the course of the year, predicated largely on four populations:

● Contacts with the criminal justice system (including prison releases, ARW contacts

and court referrals)

● Contacts with Tier 2 treatment services successfully engaged in structured

treatment either within the Tier 2 service providers or by transfer to specialist

services

● Re-engagement of those who have had contact within 2005-2007 but are not

engaged in treatment at the start of the year

● New treatment populations self-referring or accessed through Tier 1 agencies

The primary objective for this new population will be around increasing the translation

rate for contacts obtained through criminal justice. The evidence available would suggest

that this pool is not being exhausted by the Required Assessment process and this is

the primary group among whom the increase in overall local prevalence occurred. This

will require an increased translation rate from contact with ARWs to engagement with

structured treatment services of close to 50% if the current rate of 5,000 contacts is

maintained of whom 1,000 are either already in treatment or are suspended as a result of

criminal justice interventions. This would target around 2,000 new entrants into treatment

for criminal justice. This will require two things to happen – more efficient flow of

clients through DIP to more specialist forms of treatment supplemented by the option of

delivering structured interventions in a more flexible range of contexts, which is rendered

possible by the new care planning approach adopted in the city.

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4544

This would then leave a targeted strategy of 1,500 clients to be recruited via Tier 1 and 2

services and through the re-engagement of treatment dropouts in the last two years. These

approaches will overlap as the re-engagement approach is likely to require assertive and

targeted outreach and more effective links between community needle exchange providers

and structured Tier 3 services to enable the effective targeting of out of treatment

populations. The basic breakdown of this group would be to aim for 1,000 re-engagements

from the 2,290 treatment drop-outs known in the last two years and 500 successful

treatment recruitments among ‘treatment naïve’ populations primarily recruited from Tier

2 services and through increased links with Tier 1 providers. However, this has significant

ramifications for the overall treatment systems model as shown in Figure 7 below:

Figure 7: Projected increased turnover model to enable 7,000 treatment cases

What this will do is to create a significantly enhanced burden within structured treatment

provision requiring two additional mechanisms if the 7,000 individuals are to be effectively

managed within the treatment system above – the first is that structured interventions

will have to be delivered in a wider range of contexts, in line with the Models of Care

presumption that tiered delivery refers to the intervention and not to the location. For that

DSB


HOUSING SERVICES

PROBATIONCOURT/POLICE(5,000 contacts

per year 2,000 new

engagements)

PRISON

OTHER

NEEDLEEXHANGE-targeted

translation rate for contactsstructured

interventions

OUTREACH

CARAT/INREACH

INFORMATION&

ADVICESERVICES

ADDACTIONPossible site fordelivery of care

planned carethrough BTEI

EXIT

DAYCARE ORCOMMUNITY

DETOXIFICATIONn= 1000

INPATIENTAdmitted n=Completed n=

Aft

erca

re


DIP TEAMS

CDT’s DRUGLINE

Retained for 12 weeks (85%) n=1500

New n=2000

Continuous n=500

Targeted completers n=500

New n=500

Transferred from DIP n= 1500

Dropped Out n=400

Continuous n=800

New n=

Continuous n=200

Dropout n=

Complete n=

Transfer n=

New & Retained n=50

Tier 1recruitment of2500 clients,

2000 through CJ

Tier 2recruitment of

1500 clients throughcare plannedcare and new services, plus

re-engagement

Tier 3Increased recruitment through more

turnover of planned care cases and plannedtreatment exits in each year

Tier 4Treatment exits to

be augmented throughmore planned use of

community and residentialdetox and external stage 1

rehabilitation


New n=1200

New & Retained n=1000

Continuous n=1000

Dropped Out n= 200

Completed n=1000

Transferred n=250

reason it will be imperative that care-planned care and managed treatment pathways are

effectively delivered in Tier 2 treatments as standalone pathways – including those within

the criminal justice system and through the new Tier 2 provider. The second requirement

will be far greater movement through structured Tier 3 services with plans required for

around 1,500 completed treatment journeys (with the target of 85% retained in treatment

for 12 weeks or more for 2007/08) for new entrants to structured services. This will require

a treatment planning approach that aims for far more movement and transition in

treatment journeys than is currently achieved. This will be achieved by increasing the focus

on managed detoxification in the community, more efficient utilisation of Tier 4 provision

– which may require interim utilisation of external stage 1 detox and rehab – and

increased planned care closures for stimulant users engaged within the treatment system.

Although this model will place a significant burden on teams to create greater movement

of clients through tiers and on the delivery of care-planned care in a broader array of

services, it will avoid significant increases in caseloads as the mechanism for increasing

annual numbers. The increased number is based on two strategies – higher conversion

rates for Tier 1 and 2 contacts (requiring better mapping of this population in needle

exchange services to map progress) and the delivery of care-planned interventions in a

wider range of low threshold services including, but not restricted to, needle exchange

provision.

7.2: Model 2: Increased capacity model

The second map used to illustrate the possible shape of the system for 7000 clients in

treatment is based on a much more limited flow model, instead assuming that the increase

can be absorbed by increasing the amount of activity within each service, primarily

through increasing caseloads rather than moving clients through the system.

Although many of the same assumptions would apply as in Model 1 about increasing the

range of services providing care planned care and so incorporating some of the traditional

Tier 2 providers within the definitions of care planned care delivery and so expanding

the number of engagements by shifting the delivery point for structured treatment,

the primary unit for this change is the worker and the assumption that, if turnover of

clients cannot be increased from the current level of around 500 per year, then increased

numbers will have to be seen within all of the services. The calculations are much simpler –

of the 3,500 existing Tier 3 clients we can assume that around 500 will complete treatment

within the year, with a further 500 dropping out at some point in the year. Of the targeted

3,500 new clients that will have to be recruited, assuming that no more than 1,000 of

them will complete or drop out in the course of the year, there will be an additional 300

new clients (approximately) per month compared to around 160 completions or drop-out

per month. In other words, with no marked changes in turnover, there will have to be an

average of an additional 140 slots located within the Birmingham treatment system per

month, delivering structured care-planned care.

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4746

Figure 8: Projection of the increased capacity model to achieve 7,000 treatment slots

The model would require fundamental re-thinking of the way Tier 2 and Tier 3 services

are structured to enable the target to be met. This would necessitate gradual increases

in caseloads particularly in the DIP teams and in the CDTs (accounting for the impact of

the new CDT being developed). There is no point in accounting for Tier 4 services in the

capacity model as we are making no assumptions about the increased movement of existing

or new clients, and few clients would enter the system at this point. Over the course of the

year, this would necessitate providers to either increase their key working capacities (and

related medical provision) or would necessitate a significant reduction in the level of care

provided to each client.

Overview of the modelling approach: Both of the above models and projected methods of

targeting increase either by utilising a model based on increased movement of clients across

services and within treatment journeys or by increasing the load within each team. Both are

predicated on the assumption that the delivery of structured interventions are extended

beyond the existing parameters and both rely on increased front-end recruitment of clients

and successful engagement and mapping of dropped out cases.

DSB


HOUSING SERVICES

PROBATIONCOURT/POLICE

PRISON

OTHER

NEEDLEEXHANGE

OUTREACH

CARAT/INREACH

INFORMATION&

ADVICESERVICES

ADDACTION

EXIT

DAYCARE

INPATIENT

Aft

erca

re


DIP TEAMS

CDT’s DRUGLINE

New cases around40 new treatment

slots will have to be foundeach month

Tier 1 Tier 2delivery

of 30 new careplanned care

slots per month

Tier 3the remaining 110 new structured care

places will be delivered here

Tier 4


Within the extended CDT System

around 60 new places will have to be

located each month

Around 10 new slotsfor structured

treatment will berequired

each month

4948

8. OVERVIEW, CONCLUSIONS AND RECOMMENDATIONS

8.1: Key Findings

Overall data, prevalence and patterns


based on the Glasgow estimate, based on a broader and more inclusive definition

than previous estimates

● Of this number, 5,764 PDU’s (49%) are in treatment, have been in treatment, or are

known to treatment, between 2004 and 2006 (based on NDTMS) data returned to

the NTA)

● 6,101 (51%) are unknown to treatment at present, i.e. they can be classed as the

‘hidden’ or target treatment population


❍ Male PDUs have a poorer retention in treatment than females

❍ BME groups, particularly black and mixed race drug-users, have a higher

representation in DIP services, and poorer capture rate in community services


❍ Women are under-represented in criminal justice when compared to

treatment capture rates

❍ There is an under-representation of 15 to 24 year-olds in structured treatment

when compared to those identified through criminal justice

● A large proportion of the treated group in the last two years are no longer in

contact with structured treatment services

Patterning of risks and identified populations

● Low rates of injecting were evidenced among those in treatment (City-Wide Audit

-13% in community services and 9% in criminal justice services; New presentation

data – 14%), this proportion is substantially lower than the national rate (36.5%),

and is much lower than a number of local areas

● Christo Inventory scores identified that the main problems for clients in treatment

were a lack of meaningful occupation, on-going substance use, and limited social

support

● Shared care service clients were more likely to be in treatment for four months to

two years, in contrast to specialist services who were more likely to treat clients for

five years or more

● Low levels of structured therapeutic interventions were delivered across the city

● There are high rates of unstable accommodation (22% in ‘unstable’

accommodation) particularly women, black, and mixed race drug users



4948

Treatment process, engagement and retention issues

● 2,635 new structured Tier 3 treatment journeys started in 2005/06, as measured by

NDTMS treatment journey information

● Of these 1,162 were unplanned discharges, equating to 44.4% of total new

presentations (including those still in treatment) and 71.3% of total discharged

client episodes. Of the 2,635 new treatment episodes, 76.9% were retained for 12

weeks or more


followed by self referral with 803 referrals. The smallest referral source was from

within the treatment system with 224 referrals coming from treatment services.

There is a lack of referrals from Tier 1 services other than Criminal Justice, and little

evidence of planned treatment exits via Tier 4

● Crack use was especially high amongst black clients (36% primary crack users), with

high number of referrals from criminal justice sources for black clients

● ARWs are in contact with high risk vulnerable drug users who are hard to retain in

treatment

● Female sex workers and particularly PPOs or offenders who are classified as high-

risk in ARW matrices are poorly engaged and retained in treatment

● Of 299 clients identified as PPOs, there was evidence that 159 had had some form

of contact with DSB. However, rates of engagement and retention in treatment in

this population were variable

● There is inadequate provision for asylum seekers

● There is low utilisation of inpatient and day care services, reflecting limited success

in completing and exiting treatment careers in a planned way. Less than 250 clients

had a planned exit from treatment

● Needle exchange data is currently fragmented; this is particularly true for

community needle exchange services. There is an area of monitoring that

could be utilised if more information were to be collected on clients accessing

needle exchange services, and in particular if treatment status was a standard

recording practice. The key question to be addressed is whether needle exchange

users are a hidden population or are users of structured treatment with ongoing

treatment needs around injecting drug use

8.2: Recommendations

1. To improve pathways into treatment for key criminal justice populations identified

in custody, and to increase the translation rates from initial contact into structured

treatment episodes for those seen through Arrest Referral

2. To examine options for delivering care planned care interventions in a wider range

of contexts – in particular through Tier 2 provision and through engagement with

Arrest Referral Workers

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3. To develop appropriate aftercare provision for clients aiming to leave structured

treatment and who require a period of continuing drug-related and non drug

-related support, as part of a new ‘end of treatment journeys’ Tier 4 treatment

pathway

4. To reconfigure the assessment procedure and entry points into inpatient

detoxification and develop rehabilitation provision to increase the numbers flowing

through Tier 4 services. Within this reconfigured system, we need to develop a

method of data recording that will enable the monitoring of outcomes from these

services and the continuing client treatment journey out of structured drug

treatment

5. To explore potential safety-nets and increased outreach provision to engage drug

users in treatment and re-engage clients who have recently dropped out of

treatment. Services must focus on re-engaging clients who have dropped out of

treatment and target those who fail to engage adequately with treatment

6. To increase the retention of clients vulnerable to dropping out of treatment with

particular focus on BME (principally black and mixed race clients), non-criminal

justice 18-24-year-olds, vulnerably housed clients and female sex workers

7. Build Tier 1 and Tier 2 links and awareness to increase referrals and translation into

treatment episodes. Clear training programmes for Tier 1 providers and training

for Tier 2 workers to enable them both to deliver structured interventions and to

improve their links to Tier 3 services

8. Improve early identification of young people misusing substances outside criminal

justice and structure links between YP and adult services more effectively

9. To develop and improve the treatment journeys for particular under-represented

groups in an attempt to improve engagement, retention, and completion for:

● Women

● Asylum Seekers

● BME Groups

● Sex workers

● Homeless drug users

● Crack-cocaine and other stimulant users

Possible ways to tackle this could be:

● To provide extended opening times or a renegotiation of service

opening hours

● The provision of childcare support for parents attending appointments or

therapeutic sessions



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● The development of language specific leaflets and information including

clear pathway information and interpreter services, possibly including Urdu,

Hindi, Bengali, Punjabi, Kurdish, Arabic, and Somali

● Providing further services specifically for the needs of sex workers

● Provide awareness raising among workers to target the needs of women

who are thevictims of domestic abuse/violence

10. To develop a mechanism within needle exchange data collection for recording the

treatment status of clients using these services, and for linking data collection

and collation across community pharmacies, Drugline and BSMHT. This will

improve the quality of data available for the 2007/08 needs assessment process

particularly for profiling the ‘hidden’ population of problem drug users and

for determining the need to target needle exchange users for more structured

interventions. Conversely it would enable the development of targeted

interventions and service development towards clients in structured drug

treatment who also access needle exchange services in the continuation of

injecting drug use, i.e. the group amongst whom injecting use has not been curbed

as a consequence of treatment engagement. However, the initial task is the

development of a coherent information strategy for needle exchange utilisation

and linkage to structured care planned care.

11. To utilise DIR data to create a method for linking initial criminal justice contacts

with client treatment status to enable clearer profiling of the criminal justice

population against their engagement with the wider treatment system. To also

have clear data for profiling the outcomes and onward treatment journeys for

criminal justice clients.

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9. APPENDIX

9.1 Linking the Treatment Plan to the Needs Assessment Process

The final key task of the planning process is to assess the identified needs above in the

context of the treatment planning process. This process will map links between the needs

identified through each stage of the needs assessment with the relevant area to be

targeted in the treatment plan. Although there have been overlaps in the genesis of each

document, the analysis below – identify those areas of common ground and discontinuity

between the planning grids and the areas highlighted. Each key grid is summarised in terms

of overlap, and then a synopsis of areas of difference will be included.

Planning Grid 1 – Commissioning a local drug treatment system

7.2 To commission services informed by the needs assessment that are accessible to drug

users and that meet the needs of specific groups and communities:

● Asylum seekers and refugees (identified within local data sources and key informant

interviews)

● Asian communities (identified from the data driven exercise and as possible hidden

populations in key informant interviews)

● African and African Caribbean communities (shown to be under-represented in

population analysis and a high risk group through criminal justice analysis and

City-Wide Audit)

● Women (no clear under-representation through bullseye but a key target population

through the criminal justice analysis; key informant interviews indicate that this group

are not provided with sufficient specialist provision; DAT project group identified poor

levels of specialist provision and childcare)

● Sex workers (key finding of ARW analysis was poor capture of sex workers into

treatment)

● Rough sleepers and homeless (clear evidence from quantitative data sources of

increased risk among homeless drug users and lower rates of treatment engagement)

● Crack and stimulant use

● Domestic violence

● Dual diagnosis (not prioritised in the key informant interviews, mentioned only twice in

interview, and no local evidence available locally)



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7.6 To review effectiveness of service provision:

● Tier 4 service provision (as highlighted in the key informant interviews and by the low

numbers of clients passing through Tier 4 services indicated in NDTMS data and lack of

clear local information regarding flow through these services)

● Tier 3 and 4 services for young people

● Evaluation of needle exchange effectiveness (including a need to explore further the

relationship between injecting rates of those in treatment and needle exchanges

taking place in the community, there is a suggestion that the latter signifies a large

group of injecting drug users not accessing further structured treatment. There is

also a need to reconcile this against the rate of BBV transmission to obtain information

on effectiveness of harm reduction initiatives)

7.7 To develop an information, audit and evaluation framework around criminal justice

system. Assessment of process in DIP/DRR

● Assessment of effectiveness of DIP/DRR treatment

● Evaluation of objective testing of clients in DIP/DRR

● Evaluation of prescribing processes in DIP/DRR

● Evaluation of impact of Tough Choices (focus on burglary)

(The systems within DIP, particularly DIP activity have been targeted and improvement

processes are ongoing, there is a need to develop the data available to link treatment

status at the point of ARW contact in order to provide linked analysis for the 2007 needs

assessment).

9.4 To communicate and engage with diverse communities through media and marketing

campaigns in a format and language used by specific communities. (Particularly, as

indicated in local data sources and the need to provide increased access to interpreter

services and multilingual written information and advice)

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● Through recruitment and retention

● By reflecting cultural diversity in opening times and accessibility (as highlighted by

local data, key informant interviews and DAT project group, particularly around

opening times, also a theme for the wider treatment seeking population)

● Skills and knowledge held by workers in understanding and being able to discuss

issues of race and culture (key informant interviews and local research raised the

need for cultural sensitivity and increased confidence of workers in this area)

1.12 To create and develop a workforce that works with the community in local

partnership, that reflects local action groups, support groups and hidden populations

of drug users. To encourage development of volunteering and support systems and

to empower communities to take responsibility for substance misuse in their area.

(This area was identified by the needs assessment through local research and key

informant interviews, particularly the contribution of mentors and positive roles

models to attract and retain people in treatment)

2.4 To continue the development and implementation of training programmes:

(Of particular note from the needs assessment were the following two areas within

this objective)

● Specialist crack and stimulant (high numbers within black and mixed race clients using

crack cocaine identified from national and local data supporting this need and in

addition from key informant interviews)

● Domestic Violence (the need to raise awareness of these issues as a priority to engage

and retain female drug users in treatment was identified from key informant

interviews)

2.10 To liaise with specialist training schemes and further education establishments to

develop appropriate aftercare services connected to recreational, leisure and

vocational activities in the community.

(This has been highlighted in various areas of the needs assessment, for example

the need to have clear and sufficient aftercare services that are accessible and

valuable to clients at the delivery and completion stage of their treatment journey)



Planning Grid 2- Workforce Development

1.11 To create a culturally competent workforce that reflects the communities and diversity in which treatment services are delivered.

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● Drug related deaths

● Tier 1 referrals (in order to improve the needs assessment process this has been

highlighted as a source of data with which to gain further information on the flow of

clients into the treatment system)

● Housing status and outcomes (the evidence from quantitative data supports the need

to quantify and gain further knowledge of housing issues in order to plan and provide

suitable housing for the vulnerably housed and homeless drug users)

● General health assessments and outcomes

● Needle exchange (as highlighted previously, to attempt to understand the

effectiveness of needle exchange schemes, particularly in reducing BBV transmission,

DRDs, and other injecting risks there is a need improve the data available for analysis.

This is also a key factor in the needs assessment process in order to estimate the

‘hidden’ population, i.e. those accessing community needle exchange schemes but no

other treatment services)

5.1 To conduct needs assessment to identify additional capacity required to meet the

needs of homeless drug-users

5.2 Explore the options for crisis intervention for homeless drug/alcohol users

(Particularly as the data analysis revealed a high proportion of those in treatment were

in ‘unstable’ housing)

5.3 Develop and implement protocol with A&E departments for referral into specialist

services, through Drug and Alcohol Liaison Nurses (To address the gaps in locally

available quantitative data this is an area that could be utilised for analysis in the next

round of the needs assessment process).

5.4 Develop existing partnerships with housing services to ensure emergency/medium and

long term housing services for homeless drug users:

● Birmingham City Council Rough Sleeper Team

● Birmingham City Council Homeless Unit

● Housing Associations and Registered Social Landlords

Planning Grid 5 – Harm Reduction Strategy

1.6 To create a reporting mechanism to collect data and to ensure baseline reporting of:

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(A key area evidenced from quantitative data, key informant interviews, and local research

for the need to address the issue of access to housing for drug users. Lower rates of

treatment engagement and the identification in the City-Wide Audit of 22% of those in

treatment being vulnerably housed are key factors)

Planning Grid 6 - Drug-related information and advice, screening and referral to specialist

drug services

3.1 To engage at a local level with Tier 1 services to establish and develop networks for

Improved multi-agency working (a need for partnership and community working was

highlighted in order to improve client journeys into treatment)

3.7 To target specific partner agencies for improved partnership arrangements:

● BCC Housing teams (a significant target area discussed in key informant interviews, as

a gateway to housing and support)

● Anti-social behaviour units

● Local policing

● Learning and Skills offices ● Neighbourhood offices ● Youth Service

Planning Grid 7 – Open Access Drug Interventions

5.2 To identify inconsistencies and discrepancies across treatment providers and

treatment modalities with regards to:

● Caseloads and throughput ● Workforce numbers

● Pathways (as identified through the mapping processes and as a running theme throughout key informant interviews stressing the need for clearer pathways to engage, retain and enable people to exit the treatment system)

● Criteria

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6.2 To ensure through recommendations and results of the needs assessment that

treatment providers employ a competent workforce that reflects the problematic drug

user population but also represent the communities in which services are based.

6.3 To ensure services meet the needs of women (as a group clearly identified as needing

increased specialist provision of services, local research and key informant interviews

have particularly identified the need for increased accessibility of childcare and

services developed to address domestic violence)

● Development through Women’s Forum

● Provision of child care arrangements

● Increased local access to services

● Development of pathways to services for women suffering domestic violence

6.4 To ensure services meet the needs of different cultures and religions (the six key

points in this objective were all evidenced within the qualitative aspects of the needs

assessment as applicable needs for this group of drug-users)

● Provision of services that are flexible in opening and closing times

● Exploring the viability of provision of services that cover Saturday and Sundays

● To develop a 24/7 out of hours helpline building on DIP 24/7 model

● Competence of workers to understand and work within different religions and cultures

● Provision of information for those drug users and parent/carers whose first language is not English

● Ensuring that providers make provision for interpreting services for engagement and treatment of service users whose first language is not English.

Planning Grid 8 - Structured community based drug treatment interventions

1.1 To operate a care co-ordination model working with treatment providers and partner

agencies to ensure appropriate care pathways are in place and are being used. (Care

co-ordination and the need to improve ‘parallel working’ and ‘cross-tier involvement’

was identified through key informant interviews. The City-Wide Audit and local

NDTMS data illustrating the inadequate flow of clients through the systems support

the need for increased or improved care-coordination methods)

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● To ensure all clients are able to move through the Treatment System.

1.4 To ensure services are competent to meet the needs of drug users who have mental

health issues:

● Appropriate staff training to deliver Tier 3 interventions that are appropriate to

drug-users with dual diagnosis issues (there was little indication from the key

informant interviews that dual diagnosis clients are heavily represented in the

current treatment population, however of these clients who do have a current

diagnosed or undiagnosed mental health issue it was identified in two interviews

that greater partnership working was needed with community mental health teams to

provide comprehensive treatment packages).

6.1 Through the needs assessment, to map the estimated distribution of clients through the

treatment system to meet the expected number in treatment target.

6.2 To identify inconsistencies and discrepancies across treatment providers and treatment

modalities with regards to:

● Caseloads and throughput

● Workforce numbers

● Pathways (as stated previously, this was a running theme throughout key informant interviews stressing the need for clearer pathways to engage, retain and enable people to exit the treatment system)

● Criteria

Planning Grid 9 – Residential and Inpatient drug treatment interventions

1.1. To operate a care co-ordination model working with treatment providers and partner

agencies to ensure appropriate care pathways are in place and are being used.

(The provision of appropriate Tier 4 services and timely access to these services has been

identified through local data and key informant interviews, the need to move people

through the system who are stably engaged in treatment has also been identified therefore

the need for improved care-co-ordination, partnership working, and Tier 4 provision).

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Planning Grid 10 – Drug Interventions Programme

Objective 3 - To deliver treatment interventions to drug users and to work in partnership

withall Tier 2 and 3 service providers

Within this objective there are unidentified needs to:

● Increase focused working with vulnerably housed or homeless drug users to

engage and retain this high-risk group in treatment

● Target female sex working offenders to engage and retain this high risk group in treatment

4.3 To agree performance indicators and performance targets as part of SLA as required

in order to meet DAT targets.

● DIP COMPACT targets

● RoB and RA targets

● Numbers of drug users in treatment

● Waiting times for rapid prescribing

● Attrition rates

● Retention targets

● Completion/discharge targets

● DRR commencements and completions

● LPSA target

● To increase the translation rate of contacts to structured treatment episodes (50%)

in order to reach the target numbers in treatment for 2007/08

For the DIP data management team and the Performance Management team to meet on a

regular basis and work seamlessly to understand and improve:

● Monthly reporting to the Home Office

● Monthly activity across DIP Home Office returns, NDTMS and CLIPs

● COMPACT data

● SLA process and performance management

● The treatment status of drug using offenders at point of arrest and how this can

be included in DIP data analysis and the needs assessment process

Birmingham Drug Action Team

part of Birmingham Community Safety Partnership

Gee Business Centre, Technology Block, First Floor

Holborn Hill, Birmingham B7 5PA

Tel: 0121 465 4930 Fax: 0121 465 4931

www.birmingham-dat.org.uk

www.birminghamdatdirectory.nhs.uk

Documents

Needs Assessment - Final