The group of NHS providers, NHSSMPA, is looking at new ways to make sure service users stay connected with essential skilled healthcare. ‘Nostalgia isn’t what it is used to be’ goes the quote, but are drug and alcohol services what they used to be? Well no. Historically, before the formation of the National Treatment Agency (NTA), some areas saw two year plus waiting lists for opiate substitution therapy (OST), and investment in alcohol services was severely lacking. While there had since been improvements in these areas, the combination of commissioning by local authorities, the global financial crash and ongoing austerity has conspired to result in devastating disinvestment in our services. Disinvestment and retendering cycles have resulted in changes in the skill mix of services, with fewer nurses, doctors and psychologists (those registered with professional bodies) in teams, and an over-reliance on staff without professional registration or specialist training, and volunteers. There has been a significant loss of knowledge, practice and skills along the way, as provider organisations design services that try to manage the reduction in budgets while still meeting need. The need for high calibre clinical skills and expertise were recently highlighted by two eminent leaders in the field – professors Colin Drummond and Sir John Strang in the Mental Health Times and BMJ respectively. Professor Drummond stated: ‘Without proper care there are serious risks including epileptic fits and hallucinations, brain damage, suicide and risk of overdose. Yet many services do not have doctors or nurses with sufficient specialist training and competence to provide safe care.’ This highlights that registered staff and doctors have been in steady decline, but also that many of those recruited lack the relevant training, supervision and support to ensure high quality provision for complex service users. These experts do exist, but more and more they are in a lead role rather than ‘on the ground’, which can affect their contribution locally. There are only so many hours in a week. A reduction in budgets means cash-strapped services are able only to work the purest interpretation of the service specification, compounding the effect of smaller budgets with a loss of social capital from providers. As a sector we have been eager to seek solutions, usually through collaborative partnerships across health and social care. The significant decline in registered staff, including nurses, social workers, clinical psychologists and doctors means it is harder to achieve improvements even when the willingness has been there. Being able to speak the language of those that you wish to collaborate with has its advantages and enables effective partnership to prosper far more easily. The loss of these posts (and the assurance of the NHS badge) has negatively affected partnerships, most notably with health colleagues. The continued reduction in professionally registered staff in treatment services is diluting the skills and professionalism required to address the needs of our service users. A recent CQC publication reports on serious concerns uncovered in many of the independent detoxification clinics across the country. Furthermore, the reduction in registered staff and the number of NHS providers jeopardises the overall standard of care and the ability to forge meaningful ventures to enhance care pathways. In short, the loss of these providers, practice and skills means some drug and alcohol services are relying on limited clinical expertise, to the detriment of care. Public Health England (PHE) recently commissioned three publications highlighting the importance of the roles of nurses, addiction specialist doctors and psychologists within the drug and alcohol sector (available at www.gov.uk). They are a call to commissioners and providers that these skills and professional contributions are core and essential, and that their loss is having an impact on the overall provision of care as well as putting service users at risk. As a group of NHS providers, NHSSMPA hopes to contribute to changing this. The following examples show innovations by NHS services where good practice has been implemented to improve the wellbeing of our service users. They also illustrate why retaining an appropriately balanced and skilled workforce is essential. STREET SEX WORKER INITIATIVE A low threshold initiative was developed for street sex workers who elected to engage with it, and who were provided with 30mg oral methadone. They could pick up on any or all days, seven days a week, giving them the option of working and a safety net. Two pharmacies were part of the team and would work in partnership, closely monitoring risk. The expectation of the sex worker was that they would attend a three-monthly clinic. Its format was devised by service users and access was available for: • rape crisis intervention • genito-urinary medicine services for smear tests and sexually shared infections, high vaginal swabs and any necessary treatments • family planning for depot contraception injections • midwives for pregnant service users • needle and syringe exchange • condom provision • vaccination for hepatitis A and B Direct referral to colposcopy and appointments was provided at the time of attendance, as well as the ability to dress wounds, listen to breathing to identify respiratory disorders, examine injecting sites, monitor drug use and move into mainstream treatment if that was what the person wanted. Apart from the obvious direct benefits for service users it also improved relationships between services and the sex workers’ access to these. Engaging complex clients Nursing staff learned compression bandaging to work with some difficult-to-engage service users with venous leg ulcers. We worked with people who were not turning up to the dressings clinic, not having doppler studies, continually having breakdown of their ulcers, and suffering widespread infection, cellulitis and venous eczema. We engaged with their GP practice and developed a shared care type approach. We increased outreach to service users and managed their dressings as per the care plan. We would make sure they attended doppler appointments where the GP and nursing staff would manage the dressings. This allowed a relationship to develop between the service user and the nursing team and allowed us to pull back when the service user was fully engaged. Derby’s HIT Derby Healthcare Foundation NHS Trust looked at their care delivery in an effort to address the effect of diminishing resources. They devised a ‘red flag system’ to identify service users most at risk of accidental overdose, through reviewing six years of local mortality data. The common themes that correlated this risk of accidental overdose were largely expected – continued intravenous use of illicit drugs, erratic engagement, poor physical and/or mental health. But less considered was hepatitis C status and the link with those living in isolation. Other risk factors were a hospital admission in the last 12 months and having a physical health condition such as chronic obstructive pulmonary disease or a deep vein thrombosis. Being prescribed additional medication with a sedating effect by their GP was also a marker. Collecting and analysing this data identifying who was at risk led to the creation of a health improvement team (HIT) in Derbyshire. This approach was incorporated into a tender for Derbyshire treatment services at the beginning of 2017, and the new service went live in April 2017. The HIT do not carry a caseload, but instead support key workers with their higher risk service users, and the sole focus is on improving their physical and mental health and preventing drug-related deaths. Those with chronic and deteriorating physical health will have greater priority placed on managing these conditions integrated with their substance misuse treatment. Physical health assessments and advice will be provided by the HIT nurses, including more routine care such as blood-borne virus testing and vaccinations alongside ECG. The role of nurses was central to the success of the Derby approach, and is fundamental to the other examples provided. Over the past decade or so, nursing and other clinical expertise has been lost – meaning that within drug and alcohol treatment, as many of our service users age and require broader health and social care, clinical expertise is less accessible. The multi-disciplinary team, which includes those with clinical expertise working with other disciplines and those with lived experience, has never been more important. NHSSMPA is also part of a national working group led by the Royal College of Psychiatrists and PHE, with third sector colleagues, that is trying to reverse the reduction in addiction psychiatrists – an example of the sector responding to an important workforce issue. It is at our peril that we do not ensure that drug and alcohol services incorporate the correct blend of skills and disciplines, including highly skilled clinicians. Authors are Jon Shorrock, Avon and Wiltshire Mental Health Partnership NHS Trust; Linda Johnstone, Cheshire and Wirral Partnership NHS Foundation Trust; Martin Smith, Derbyshire Healthcare NHS Foundation Trust; Mike Flanagan, Surrey and Borders Partnership NHS Foundation Trust. All are members of the NHS Substance Misuse Provider Alliance (NHSSMPA).