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road to recovery

2006/07 Birmingham Adult Drug Treatment Needs Assessment


Birmingham Drug Action Team

BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

ACKNOWLEDGEMENTS
The 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.

Authors Jessica Loaring David Best

Birmingham Adult Drug Treatment Needs Assessment

CONTENTS
1. Executive Summary 1.1. Background 1.2. Aims and methodology 1.3. Key findings 1.4. Recommendations 2. Background 3. Aims and objectives, the national context 4. Aims of the Birmingham Needs Assessment 5. Methodology 5.1. The local context 5.2. Testing the resulting data 6. Findings 6.1. Epidemiological needs assessment and treatment bullseye 6.1.1. What can we learn about the characteristics of those not engaged satisfactorily from the bullseye method? 6.1.2. Section Overview 6.2. Treatment system maps 6.2.1. Initial Treatment system map 6.2.1.1. City-Wide Audit 6.2.2. Dynamic system map 6.2.3. Section Overview 6.3. Drug Interventions Programme (DIP) systems map 6.3.1. Arrest referral worker (ARW) analysis 6.3.2. PPO Audit 6.3.3. City-Wide Audit 6.3.4. DIP data Analysis 6.3.5. Section Overview 6.4. Local data sources 6.4.1. Needle exchange data 6.4.2. Hiddun Project 6.4.3. Bro-Sis community led research 6.4.4. Section Overview 6.5. Key informant interviews 6.5.1. The needs of groups or communities
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5 5 5 6 8 10 10 11 13 13 14 16 16 18 20 21 21 22 23 25 27 28 29 30 31 33 34 34 35 36 37 39 39

BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

6.5.2. Systems or process related themes 6.6. Expert Group Involvement 7. Projection Map 2007/08 Numbers in Treatment Targets 7.1. Model 1: Increased turnover model 7.2. Model 2: Increased capacity model 8. Overview, Conclusions and Key Recommendations 8.1. Key Findings 8.2. Recommendations 9. Appendix 9.1. Linking the Treatment Plan to the Needs Assessment Process

40 41 44 44 46 48 48 49 52 52

1. EXECUTIVE SUMMARY
1.1 Background A core component of the National Treatment Agencys 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 Governments 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 doesnt 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 PDUs, 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

BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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.

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

BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07
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. 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. 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. 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. 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. 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. 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. 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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6.

7.

8.

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.

BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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 datadriven 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 Governments 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 doesnt 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:

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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.

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

Ethnicity White Asian/Asian British - Indian - Pakistani - Bangladeshi Black/Black British - Black Caribbean - Black African Mixed ethnicity Chinese & other ethnic group

Number 687386 190761 55774 104052 20847 59784 47798 6191 27928 11198

% 70.4% 19.5% 5.7% 10.6% 2.1% 6.1% 4.9% 0.6% 2.9% 1.1%

England Average % 90.9% 4.6% 2.1% 1.4% 0.6% 2.3% 1.1% 1.0% 1.3% 0.9%

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.

Age Group Aged 15 to 24 Aged 25 to 44 Aged 45 to 74 Aged 75 or over

Number 132543 276803 270745 68155

% 37% 28% 28% 7%

England Average % 31% 29.4% 32.1% 7.5%

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 Englands 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 Trusts 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:

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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.

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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 Minus - in treatment now Minus - in treatment last year Minus - known to treatment but not treated in last year Total estimate for population unknown to treatment 11865 - 3474 - 1444 - 846 = 6101

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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.

410 846 1444 3474

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)

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

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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: Sex - % Male clients Ethnicity - % BME

74% 77% 75% 85% DIP

25% 28% 26% 34% DIP

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

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. 18

Gender1

Age Group1

Injecting Status1

Main Drug2
(within opiates and/or crack cocaine users)

Main Drug3
(within all drug types recorded)

Female Treatment (Tx) Status

15-24yrs

25-34yrs

Current

Former

Opiates

Crack -Cocaine

Opiates

Crack

In Tx (On 31.03.06)

26%

23%

48%

13%

21%

97%

29%

53%

16%

In Tx during past year

23%

25%

49%

11%

17%

90%

37%

44%

18%

Known to Tx but not treated in last year Known to DIP but not Tx series

25%

23%

47%

15%

16%

90%

33%

53%

19%

15%

35%

46%

Currently Unknown

85%

40%

54%

26%

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 Birminghams 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

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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 Treatment Primary Care Self CJIP Other Bham n= 224 446 803 1027 125 Bham % 8.53 17 30.6 39.1 4.8 National % 11.7 11.3 40.7 24.1 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: 11,865 is the prevalence estimate for opiate and crack cocaine users in Birmingham 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 From the bullseye method of analysis we can see that: Male PDUs have a poorer retention in treatment than females BME groups 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 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.
Tier 1 Tier 2 Tier 3 Tier 4

PRIMARY CARE /PSYCHIATRY

NEEDLE EXHANGE

DIPS TEAMS Total=344


HoB N=126 North N=38 South N=178 East N=102

DSB
Shared Care N=1101 Criminal Justice N=135
DAYCARE

HOUSING SERVICES

OUTREACH

CDTs Total=761
PROBATION/ COURT/ POLICE CARAT/ INREACH

DRUGLINE

Aftercare

Slade Rd N=203 Barker St N=143

Azaadi N=239 Mary St N=176

EXIT

Total Across Service n=119

INPATIENT

PRISON

INFORMATION & ADVICE SERVICES

BRO-SIS
ADDACTION

INCLUSION

SAFE

OTHER

Movement through system in both directions

Figure 3: Initial treatment system map for Birmingham

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07
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.

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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.

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

Tier 1

Tier 2

Tier 3

Tier 4

PRIMARY CARE /PSYCHIATRY

NEEDLE EXHANGE

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

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

HOUSING SERVICES

OUTREACH

DAYCARE n=70

CDTs
PROBATION/ COURT/ POLICE CARAT/ INREACH New & Retained n=300 New Transfered INFORMATION & ADVICE SERVICES Dropped Out Continuous n=1200 n=250 n=50 n=600 New

DRUGLINE
n=400 n=100 n=200 n=50 n=100 Continuous Drop Out Complete Transferred

Aftercare

EXIT

INPATIENT Admitted n=250 Completed n=150

PRISON

New & Retained n=50

BRO-SIS

INCLUSION

SAFE

OTHER

ADDACTION

Movement through system in both directions

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:

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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

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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 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 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 threequarters 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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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.

Referral Routes

CJ Treatment Services DIP Outreach NORTH

Non-CJ Tier 3 Services

Tier 4 Services

SHARED CARE SOUTH


BIRMINGHAM PRISONS CARAT TEAMS

DSB

CRIMINAL JUSTICE TEAM PPOs

DSB

INPATIENT/ RESIDENTIAL

TIER 4

SLADE RD AZAADI CDTs

Movement through system in both directions

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

exit

27

exit

exit

COURTS RENSTRICTION ON BAIL, PROBATION PRE-SENTENCING REPORTS

DRUG REHABILITIATION REQUIREMENT PPOs

DRR

TERRACE MARY ST

Tr e a t m e n t E x i t

POLICE ARREST REFERRAL WORKERS (TOUGH CHOICES)

DIP HoB 12 wks EAST

Aftercare

BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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 PPOs 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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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,

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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

30

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.

5646
Conversion 47%

Total contacts Total assessments Initial care plans completed

4096 2645

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

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07
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.

2006 Contact Assessed Careplan

Jan 667 364 280

Feb 528 277 193 37%

Mar 584 333 229 39%

Apr 435 314 199 46%

May 488 374 240 49%

Jun 515 368 260 50%

Jul 304 238 135 44%

Aug 421 358 228 54%

Sep 442 376 220 50%

Oct 422 369 235 56%

Nov 447 384 238 53%

Dec 393 341 188 49%

Total 5646 4096 2645 47%

% Conversion 42%

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.

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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

33

BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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:

AGE GROUP Under 20 20-25 years 26-30 years Over 30 years Missing Total

NUMBER 60 1307 2145 3833 381 7726

PERCENTAGE 0.8% 17.8% 29.2% 52.2%

Table 6: Age breakdown of packs from clients attending community needle exchanges 34

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.

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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 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 Lancashires 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. 36

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 21% were 2ml packs 4% were 5ml 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.

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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 stakeholders 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

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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.

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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 underrepresented 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 peoples 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

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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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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 nave 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:
Tier 1 recruitment of 2500 clients, 2000 through CJ Tier 2 recruitment of 1500 clients through care planned care and new services, plus re-engagement NEEDLE EXHANGE -targeted translation rate for contacts structured interventions Tier 3 Increased recruitment through more turnover of planned care cases and planned treatment exits in each year Tier 4 Treatment exits to be augmented through more planned use of community and residential detox and external stage 1 rehabilitation

PRIMARY CARE /PSYCHIATRY

DIP TEAMS
New Retained for 12 weeks (85%) n=1500 New Continuous n=2000 n=500 Continuous

DSB
n=1200 n=1000 n=1000 n= 200 n=1000 n=250 New & Retained Dropped Out Completed Transferred

HOUSING SERVICES

OUTREACH

PROBATION COURT/POLICE (5,000 contacts per year 2,000 new engagements)

CDTs
CARAT/ INREACH
Targeted completers n=500 New n=500 New

DRUGLINE
n= n=200 n= n= n= n=50 Continuous Dropout Complete Transfer New & Retained

Aftercare

DAYCARE OR COMMUNITY DETOXIFICATION n= 1000

EXIT

Transferred from DIP n= 1500

INPATIENT Admitted n= Completed n=

PRISON

INFORMATION & ADVICE SERVICES

Dropped Out Continuous

n=400 n=800

BRO-SIS

INCLUSION

SAFE

OTHER

ADDACTION Possible site for delivery of care planned care through BTEI

Movement through system in both directions

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

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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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Tier 1

Tier 2 delivery of 30 new care planned care slots per month

Tier 3 the remaining 110 new structured care places will be delivered here

Tier 4

PRIMARY CARE /PSYCHIATRY

NEEDLE EXHANGE

DIP TEAMS
New cases around 40 new treatment slots will have to be found each month

DSB

HOUSING SERVICES

OUTREACH

CDTs
PROBATION COURT/POLICE CARAT/ INREACH Within the extended CDT System around 60 new places will have to be located each month

DRUGLINE
Around 10 new slots for structured treatment will be required each month

Aftercare

DAYCARE

EXIT

INPATIENT

PRISON

INFORMATION & ADVICE SERVICES

BRO-SIS

INCLUSION

SAFE

OTHER

ADDACTION

Movement through system in both directions

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.

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

8. OVERVIEW, CONCLUSIONS AND RECOMMENDATIONS


8.1: 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 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

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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 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 highrisk 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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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

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. 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)

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Planning Grid 5 Harm Reduction Strategy 1.6 To create a reporting mechanism to collect data and to ensure baseline reporting of:

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

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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07

(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 Womens 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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BIRMINGHAM DRUG ACTION TEAM Adult Drug Treatment Needs Assessment 2006 / 07
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

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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