This year’s NHSSMPA conference was dedicated to creating lasting behaviour change, as DDN reports.
Read the full report in October’s DDN Magazine
‘How can we give the best chance of long-term behavioural change?’ This was the question 13 NHS trusts gathered to discuss at the NHS Substance Misuse Providers Association (NHSSMPA) conference in London.
The context for this debate was not easy, said NHSSMPA chair Danny Hames. There were many challenges – loss of expertise, disinvestment and diminishing resources, and increasing needs from all areas of the population.
‘As a sector we really need to think about how we do stuff and the quality of what we do,’ he said. While the sector had ‘held up pretty well’ against recession, we should not be measuring success by successful completions.
We needed to address the critical loss of expertise right the way through the workforce – from addiction psychiatrists, to recovery workers, to commissioners. Add to this the loss of many small valuable organisations and it gave a ‘bleak picture’ and many separate challenges. ‘We need to up the ante and be more dynamic,’ he said. We had lost ‘vital capital’ so we needed to understand how to use investment to the best effect.
‘One of the things we could be doing better is finding allies and forming alliances,’ he suggested. We needed to think about how we worked with commissioners, improved influence in local authorities, and sought out meaningful partnerships with service users. Our culture should focus on being transparent – making the effort to understand where risk is, focusing on evidence and ‘sharing what works more openly’.
Cutting the numbers of specialists was a backward step, agreed Dr Luke Mitcheson, a consultant clinical psychologist at South Maudsley NHS Foundation Trust, who said that the loss of clinical psychologists was one of the biggest challenges faced by the sector.
Psychosocial interventions (PSI) contributed significantly to positive treatment outcomes, but delivering them effectively depended on highly trained staff and good governance, he said. Cutting down on the level of supervision and on skills such as motivational interviewing undermined our capacity to use PSI effectively.
Many clients had experienced trauma and abuse – in fact ‘we should start from the premise that clients have trauma,’ he suggested. The skills to deal with this had to go hand in hand with a flexible approach – the capacity to do different things at different times and ‘step things up or down’.
It was important to keep the perspective of delivering PSI as part of an integrated service that included opioid substitution treatment (OST) and other harm reduction initiatives, said Mitcheson. ‘Some recovery services don’t understand harm reduction, and that’s a problem.’
Another major challenge was the ever-changing drugs market – how was the sector meant to keep abreast of new information? Since 2009 there had been 803 new substances identified by the UN, said Dr Dima Abdulrahim, of the Central and North West London NHS Foundation Trust. She was the main author of guidance for NEPTUNE – the Novel Psychoactive Treatment UK Network – which had been developed to improve knowledge around club drugs and NPS and was funded by the Health Foundation.
Many clinicians lacked confidence in dealing with the rapid growth in new substances, she explained. A panel of experts, including experts by experience, had developed a system to simplify guidance to new drugs by categorising them into stimulants, depressants, hallucinogens and synthetic cannabinoids. This framework had proved effective in helping clinicians to orientate themselves when they came across a drug they were not familiar with.
More than 70,000 downloads over the past two years had confirmed the need for this information, leading to an e-learning course evaluated by the Royal College of Psychiatrists, to disseminate the information more widely. As well as increasing their knowledge, participants had reported improvements in their confidence and morale through being able to identify NPS.
Another area of the sector where information and support were needed urgently was for problematic gambling, and Dr Henrietta Bowden-Jones shared her expertise as a doctor, neuroscience researcher and founder/director of the National Problem Gambling Clinic. With half a million problem gamblers and 2m people at risk, there were ‘many organic reasons why people gamble,’ she said. ‘It’s not all about the bookmaker around the corner.
‘Gambling was something I came across by chance in my research on alcohol dependency and I became obsessed with understanding the illness,’ she explained. People used to wait years to come forward, but it was now becoming recognised as a condition to be treated.
‘Most people will walk away from a table when they are losing,’ she said, describing the pattern of behaviour that could become a preoccupation from first thing in the morning and escalate into lies and deceit.
Cognitive Behavioural Therapy (CBT) was being used to treat gambling – very successfully in many cases. For those who didn’t respond to CBT, naltrexone (as used to reduce cravings for alcohol) had been trialled successfully. Bowden-Jones had written guidelines on naltrexone and found that it ‘gives an opportunity’ if CBT had been ineffective.
The National Problem Gambling Clinic was the only multidisciplinary treatment centre in the UK for problem gambling and had been inundated with referrals since opening ten years ago. With a gambling culture that was rife – including in prisons, where inmates could inherit a bunk with debts – NHS England really needed to take the problem on board, she said.
Another extremely valuable – and under-used resource – was families, according to Vivienne Evans OBE, chief executive of the national support service Adfam. There was still a culture of seeing family members as part of a patient’s problems, but in fact they could be agents for change, she explained.
Commissioning family support should also be viewed as an investment, rather than an ‘add on’ to recovery services. The effects of substance misuse were a high factor in incidents of domestic violence, family break-up and divorce so it made sense to commission strategically: ‘They should be seen as more than supporting an individual’s recovery and receive the support they deserve in their own right,’ she said.
Throughout the conference there had been frequent mention of the need to harness the power of service user involvement – in his opening speech Danny Hames talked about the value of a ‘strong and equipped service user voice’.
In the final session Rob Eyres, founder of the Telford After Care Team (TACT), demonstrated what that could mean. Caught up in a destructive cycle of drug dealing and addiction, he served time in young offenders’ units and then prison. He carried on using drugs and drink after he was released, right through his relationship and break-up of his family, until a new key-worker confronted him with the responsibility of changing his attitude to his addiction, telling him ‘it’s your addiction – I’m here to support you’.
Committing himself to treatment (which involved a subutex script) Eyers discovered the support of SMART Recovery meetings, then decided to begin his own support group. He rented a room in a leisure centre and for 12 weeks no one came – ‘the cleaner used to hoover around me’. Then people started to join him and when the group began to become more established, they began a gardening project, alongside regular meetings.
Seven years on, their blossoming project had its own premises and works on four NHS projects, running social enterprises that include a café, a landscape gardening company and a printing business. With 28 full-time staff and more than 40 volunteers, they had around 100 people accessing their services each day.
The peer support was an essential element; staff all formerly had problematic substance use and now worked with people at all stages of recovery. ‘If people turn up and are intoxicated, we will talk to them and get them to come tomorrow and try again,’ said Eyres. ‘We don’t turn people away – it’s a recovery centre, not a recovered centre.’