Feature - Issues Paper: Young People's Substance Misuse Services : 2008-05-05

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Issues Paper: Young People’s Substance Misuse Services

Positioning our services in the children’s agenda
Martin Moran, Senior Manager, Lifeline Project

INTRODUCTION
This paper was originally intended to consider how young people’s substance misuse services (YPSMS) integrate appropriately into the children’s agenda at local level. However as there have been recent changes in relation to the funding, commissioning, and potential future of some services there is a need to consider wider issues. The paper argues that integrating services effectively and meaningfully still remains central to the survival of YPSMS. It is therefore important for the sector to begin to discuss how to continue to be successful, ensuring sustainability in a complex and changing policy arena. The emerging policy framework is an opportunity to think about these implications and indeed, the direct impact changes may have on the quality and accessibility of provision to children and young people in relation to their substance use. The current national situation is both diverse and complex and taken together, the position for YPSMS is very unclear:

some areas have still had no indication of funding
others are already aware of funding allocations for the coming year(s) and may have been notified of cuts
some services may go out for tender
service level agreements are being revised
services in a number of areas will simply have funding continued until commissioners reconfigure their own roles in relation to the commissioning and planning of substance misuse services for children and young people.

The remainder of the paper is split into two sections. Part one discusses the key themes emerging from the national policy framework in relation to children and young people. Part two highlights a range of issues relevant to YPSMS nationally and regionally. The conclusion is brief. It argues that despite a changing and complex policy arena, the sector must ensure it has the ability to fully integrate into the children’s agenda as this is interpreted at a local level.

PART ONE: background and context
As we are all aware integration is now inherent in most if not all aspects of the children’s agenda. It runs throughout Every Child Matters (2005), Hidden Harm (2003, 2006), Working Together to Safeguard Children (2006) and has been encapsulated in law in the Children Act 2004. Other strategies such as Youth Matters (2005) and Youth Matters next steps (2006), Integrated Youth Support (2007) and more recently the governments new ten year drugs strategy (Drugs: protecting families and communities 2008), all focus on integration. The reason for this is the tragic experiences and fatalities of many children who have been let down by poor coordination of services. One of many children, Victoria Climbiè lost her young life as a result of the lack of an integrated approach by the services she needed and deserved. Although there is an emphasis on integration some children’s services still do not adhere to its principles. There is a need for a cultural shift in thinking, understanding, recognition and commitment to it.

What do we mean by integration?
We talk about integration but what do we mean by it? Is it about positioning our services physically with other services or a strategic process to ensure services work effectively together? We need to develop a clear understanding across services so that it is cross cutting and effective. Statutory services should recognise the importance and vital role of the third sector in the delivery of integrated provision. For example, the Department for Children Schools and Families published ‘Engaging the voluntary and Community Sectors in Children’s Trusts’ (2005) which outlines expectations for the engagement of the Voluntary and Community sector as equal and respected partners. Other aspects of integration also need to be understood. For example, information sharing, safeguarding, identification of lead professionals and implementing the common assessment framework all need to be addressed so that the intention of the children’s agenda does not become empty rhetoric.

Who is going to commission our services?
Services in the main have been commissioned by a strategic, commissioning and coordinating body, the DAT/DAAT, to achieve the national drugs strategy. From April 2008 this commissioning structure may change depending on local infrastructures such as Children’s Trusts and children’s partnership arrangements. The partnership grant that guided the commissioning of children’s substance misuse services was a ‘pooling’ of many funding streams: Department of Health, Home Office, Department for Education and Skills (now Department for Children Schools and Families) and the Youth Justice Board. This will now change. Funds can now go straight to the Primary Care Trust (PCTs), Youth Offending Service and via the Local Authority through Local Area Agreements. For the time being treatment allocations will continue to be ring fenced whereas prevention allocations will not. The DAT/DAAT’s could continue to coordinate the commissioning of our services or the PCTs and the Local Authorities (LAs) may commission services separately. Services may have their funding extended perhaps for one year whilst commissioning arrangements change. Some services may be re tendered. The role of the DAT/DAATs in relation to children’s services may also change depending on local structures. Some DATs/DAATs may keep their children’s commissioners, others may move to children’s trusts or some other agency and others may be lost all together.

The importance of Local Area Agreements
Local Area Agreements detail how priorities in local areas will be met. They contribute to national priorities. Each local Children’s Plan will have priorities. It is important that we can demonstrate the continued need for our services through our own structures, assessments, care planning and the way we measure and monitor outcomes for the children and young people that benefit from our specialised services. We must also demonstrate that we have contributed and continue to contribute to the success of local priorities, for example, how we positively contribute to the experiences of children being looked after by the local authority and prevent them from being received into the care system, contribute to children continuing to attend school and to their achievement and attainment at school, the reduction and prevention of crime and addressing sexual health and teenage pregnancy issues and those not in education, employment or training (NEET).

Children’s partnership arrangements
All local authorities will have developed their structures for children’s services and are at different stages of development. Some have the necessary infrastructure’s to support the integration of substance misuse services and are able to utilise appropriately the non-ring fenced prevention allocations for the coordination of targeted and prevention services. Others do not. It is important that the prevention allocations do not become consumed to the extent that they become unidentifiable and lost in the LAA pot. Can we have an impact on this? Children and young people need our services and have a right to them.

The new drug strategy acknowledges what works in preventing harm to children and young people.
Compared to adult provision, children and young people’s substance misuse services are in their infancy. The new 10 year drug strategy states that “Since the introduction of the 1998 drug strategy, we have seen reductions in young people’s drug misuse with, for example, sharp falls in the frequent use of drugs by vulnerable young people, which fell from 21 per cent in 2003 to 11 percent in 2006. However, Class A drug use among young people aged between 16 and 24 has remained relatively stable, falling from 8.6 percent in 1998 to 8 per cent in 2006/07”. The strategy continues to state that, for young people, there are strong predictive factors for the misuse of drugs. These factors enable us to identify those at greatest risk of developing substance misuse problems and offer them and their families targeted preventative support.
For example:

young people in families at risk, and where parents or siblings misuse drugs or alcohol;
young people from specific vulnerable groups;
young people at key transitional stages in their lives and young people subject to specific risk factors.

The new strategy recognises what works in preventing harm to children and young people. Specific targeted interventions which have been shown to contribute to reduced substance misuse and improved wider outcomes include:

early intervention targeting those most likely to develop substance misuse problems;
early identification and screening and assessment; drug and alcohol education programmes delivered by teachers;
interventions and intensive support with at-risk families;
Individually-tailored programmes for specific vulnerable groups and reducing absenteeism at school.

After ring fenced funding….what now?
The strategy appears to suggest that the way services have been commissioned have been effective to meet the needs of vulnerable children and young people in relation to substance misuse. The commissioning arrangements and the ring fencing of allocations have been utilised effectively since guidance was made available to DATs in 2001 to begin the development and coordination of substance misuse services focussing on education in schools, targeted prevention and treatment services. These services need to be embedded and continue to develop and evolve. As mentioned the prevention allocations will be un-ring fenced. This could affect YPSMS who already provide targeted services (Tier 2 provision) and raises important questions. If the strategy refers to the success of these services and identifies that importance of targeted provision and the importance of targeting those most vulnerable, then why change systems that have been shown to work? And, are Local Authority structures across the country significantly developed to support changes in commissioning and the positioning of targeted drug and alcohol services?

The strategic importance of Every Child Matters
Integrated Youth Support Systems and Targeted Youth Support aims to address the specific needs of young people within the Every Child Matters framework as outlined in Youth Matters. The four key elements of Youth Matters highlighted areas felt to be crucial to improving the life chances of young people: positive activities, making a contribution, information, advice and guidance and reformed targeted youth support. Integrated Youth Support and Targeted Youth Support are important elements of improving services and outcomes for young people. However, it is important that services are integrated strategically across the children’s agenda and continue to commission substance misuse services and not simply consume previously targeted funding to be used generally by universal services.

Young People are not PDUs
The drug strategy also highlights the need for services for Problem Drug Users (PDUs) as defined as those using opiates (e.g. heroin, morphine, codeine and/or crack cocaine). We know that adult provision responds in the main to adults who are PDUs but as we are all aware children’s drug use is different and impacts differently. Children and young people continue to use the range of illicit drugs, alcohol, prescribed medication, tobacco and solvents. Most do not understand the nature or the potential effects of the substances they are using. They are in the developing stages of their lives and the transition to adulthood. Services need to respond to the range of substances used and address the complexity of their need, not just in relation to substances defined under a PDU category.

PART TWO: Key priorities
Services need to continue to provide interventions to meet the range of needs that children present with as well as any substance they present as using.

There are a number of steps that need to be considered that will demonstrate that services integrate into the children’s agenda and are valuable local resources in achieving national and local priorities:

Working with commissioners. At a strategic level YPSMS must work with commissioners to ensure that our work is detailed in the Young People’s Substance Misuse Plans and reflected in local Children’s Plans. Children’s plans should highlight how services contribute to the achievements of all five outcomes outlined in Every Child Matters 2005, as well as the priorities for the local area. As the national agenda informs local priorities the following priorities are usually adopted in all local areas:

youth offending
looked after children
attainment and attendance at school
teenage pregnancy; and
sexual health.

Every Child Matters places substance misuse under the ‘be healthy’ outcome. It should however cut across all five outcomes as substance misuse can impact on every aspect of a child’s life. Local Authority children’s plans must reflect this by recognising the impact of substance misuse on all five outcomes and the valuable contribution of YPSMS in assisting children and young people to achieve them.

Area based representation. Where local areas have been divided into districts, localities or other geographical configurations YPSMS must ensure that we have representation in these areas. Multi Agency Teams for children’s services may already be operational in some areas. We must have either a physical presence in these teams or a strategic alignment to them. In Manchester, for example, the city is divided into six districts. Each district has a ‘district commissioning panel’ to begin to consider and understand the specific needs of children and young people in these localities and inform the commissioning process to meet need and address the priorities of the children’s plan. The DAAT young people’s coordinator is a representative on one of the panels. Lifeline Project’s children and young people’s service is a member on another. This is a great opportunity to strategically inform children’s services to meet the needs of children across Manchester. It is also an opportunity for third sector agencies to plan strategically with statutory agencies. There will be opportunities like this in other areas.

Attendance at key forums. In order to have a presence within local areas, develop and maintain partnerships and promote the importance of service, it is vital that we have and sustain attendance in a number of forums. Particularly, Safeguarding forums, integrated youth Support Systems groups, Multi Agency Teams and other third sector forums that feed into the children’ trusts or partnership arrangements.

Protocols with other children’s services and review. There is a need to develop and review, as a measure of good practice, protocols with all children’s services that we work with, in particular, the Youth Offending Teams (Service), Looked After Children’s Services, Pupil Referral Units, Sexual Health, Adult Community Drug Teams (for transitional and family services), CAMHS and so on. Protocols will inform the responsibilities of all services outlining expectations, information sharing, identification of lead professional, risk management and review of the protocol. This will ensure that practitioners understand how and when to make a referral, what the child/family can expect from the services, roles and responsibilities. Monitoring and reporting between services will track referrals and uptake of the service as well as measuring outcomes for the child/young person. Training for practitioners in relation to screening and assessment can be outlined in the protocol.

Targeting vulnerable groups and evidencing outcomes to demonstrate value for money (VfM). There is a need to continue to target vulnerable groups as defined in the drug strategy and the local children’s plans. The target groups remain the same focussing on looked after children (LAC), young offenders, NEET, sexual health and teenage pregnancy. We should be evidencing the outcomes of our interventions and demonstrating how we contribute to local priorities. Increasingly, local authorities are required to demonstrate VfM principles. Commissioned services will therefore need to demonstrate that maximum benefit is being obtained in relation:

Economy – careful use of resources to save expense, time or effort.
Efficiency – delivering the same level of service for less cost, time or effort.
Effectiveness – delivering a better service or getting a better return for the same amount of expense, time or effort.

Policies and operational procedures. We should ensure that our policies and procedures especially those that relate to child protection and safeguarding are ratified by the Local Safeguarding Children’s Board.

Assessments and Care Plans. We should also ensure that the Every Child Matters outcomes, Treatment Outcome Profile, Risk Management, Safeguarding and Risk and Protective Profile Domains are within our assessments. Care plans need to reflect the issues identified in assessments and that risk management is maintained throughout all our interventions, care plans and care plan reviews. Where necessary we will need to review our operational systems relating to the achievement of the care plan so that we can reflect planned discharges appropriately. The NTA had stated that they expected treatment services for 2008/09 to demonstrate 80% in planned discharges. This may be lowered. We need to continue to provide screening and assessment training tailored to the needs of individual children’s services and correspond it to their own assessment processes. This will provide a unique screening, assessment and referral system for each service.

Common Assessment Framework (CAF). We should work with our commissioners or CAF leads to negotiate a question on substance misuse in the CAF. All practitioners using CAF should also have training in relation to screening, assessment and referral relating to substance misuse.

Reporting to NDTMS. We should continue to provide information on all case work that corresponds with the definition of treatment as defined by the NTA to the NDTMS. This could include tier 2 individual casework as treatment.

Reports to Contract Monitoring meetings. All aspects of our work and our contributions to local priorities should be presented at contract monitoring meetings. Quantitative information should be presented together with information relating to the achievement of outcomes for young people relating to their substance use/misuse. This information should be fed from commissioners to the children’s trust or children’s partnerships.

Working to achieve PSA 14 and 25. PSA 14 aims to ‘increase the number of children and young people on the path to success’. PSA 25 to ‘reduce the harm caused by alcohol and drugs’. This can also be presented at contract monitoring meetings.

Mental Health. There is evidence of a direct correlation between substance misuse and mental health. We should ensure that our services work in partnerships with CAMHS and/or other mental health services for children and young people and addresses transitional arrangements into adult mental health systems. This needs to be planned for strategically and translated into practice. The NTA has published a draft paper ‘The role of CAMHS and addiction psychiatry in adolescent substance misuse services’. The paper states that ‘many of the adolescents presenting to child and adolescent mental health services show significant substance-related problems. The presence of co-existing substance misuse complicates the clinical course, treatment compliance and prognosis for these young people and is the single most important factor for increasing the risk of suicide, psychosis or depression in young people (Mirza, 2002). The converse is also true: substances exacerbate and maintain psychiatric disorders’. The paper continues to state that ‘as a group, psychiatrists and their commissioners have not yet grasped that substance misuse should be a key focus of treatment’. The National Service Framework for Children, Young People and Maternity Services (2004) Standard 9: ‘The Mental Health and Psychological Well-being of Children and Young People’ states that all children and young people, from birth to their eighteenth birthday, who have mental health problems and disorders have access to timely, integrated, high quality multidisciplinary mental health services to ensure effective assessment, treatment and support, for them, and their families.

There are potentially significant benefits to children and young people who receive joint provision from CAMHS and treatment services.

Sexual Health. The Independent Advisory Group on Sexual Health and HIV published its review and seminar findings of the impact drugs and alcohol have on young people’s sexual behaviour ‘Sex, Drugs, Alcohol and Young People’ (2007). The seminar was called to seek a way to address risky sexual behaviour in young people, and in particular what part drugs and alcohol play in this. The seminar established an indisputable link between alcohol, drugs and risky sexual behaviour. The implications for young people engaging in risky sexual behaviour are well documented: greater risk of contracting an STI; becoming young parents; failing at school; building up longer-term physical and mental health problems; and becoming addicted to alcohol and drugs. The seminar findings state that ‘local authorities and PCTs should ensure there is sufficient funding for charities and voluntary organisations to be able to work effectively with young people and advise on good practice and creative use of funding’. Young people are the group least likely to use a contraceptive or a condom or access sexual health advice, thus putting them at high risk of a sexually transmitted infection or becoming pregnant.

Accident and Emergency. There are increasing admissions of children and young people toaccident and emergency departments in relation to their substance misuse. Many are admitted as a result of alcohol use to the point of collapse and unconsciousness. There will be safeguarding issues that will need to be addressed by the hospital. Treatment services can assist the children and young people as well as hospital staff to address substance misuse and respond to safeguarding issues. We should ensure the we address elements of the The National Service Framework for Children, Young People and Maternity Services (2004) which include promoting the health, safety and well-being through the identification of needs and early intervention.

Standard 1: Promoting health and well-being, identifying needs and intervening early: The health and well-being of all children and young people is promoted and delivered through a co-ordinated programme of action, including prevention and early intervention wherever possible, to ensure long term gain, led by the NHS in partnership with local authorities.
Standard 2: Supporting parenting: Parents or carers are enabled to receive the information, services and support which will help them to care for their children and equip them with the skills they need to ensure that their children have optimum life chances and are healthy and safe.
Standard 7: Children and Young People in Hospital: Children and young people receive high quality, evidence-based hospital care, developed through clinical governance and delivered in appropriate settings.

We should also seek to establish and maintain partnerships with accident and emergency departments to forge effective working relationships and develop protocols between services so that we can provide interventions to children and young people who present at hospital. Screening, assessment and referral training should be provided to all A+E nursing staff as well as doctors and other key personnel. Discussions should take place with commissioners to identify funding where possible to develop specific substance misuse posts for accident and emergency departments.

Hidden Harm. The new drug strategy has a focus on working with families. This can either be done directly by our own family/parents teams where they exist or by strategically and operationally working in partnership with existing family provision and adult drug and alcohol teams. Each should have a parenting strategy that our services should link in with.

Modalities in line with NICE guidance. There has been a number of NICE guidance notes that informs delivery of services: ‘Community based interventions to reduce substance misuse among vulnerable and disadvantaged children and young people’ (NICE Guidance 2007) – advocates small scale programmes in community settings such as schools and youth services. The guidance suggests the development of local strategic partnerships to develop a strategy for any child or young person under the age of 25 who is vulnerable and disadvantaged;

to screen, assess, identify and refer any child or young person under the age of 25 who are misusing – or who are at risk of misusing – substances and who is vulnerable or disadvantaged;
offer a family based programme of structured support over 2 or more years to vulnerable and disadvantaged children and young people aged 11-16 years and assessed to be high risk of substance misuse and to their parents/carers;
offer children group-based behavioural therapy over 1 to 2 years for children aged 10-12 years who are persistently aggressive or disruptive and assessed to be at high risk of substance misuse and
to offer 1 or more motivational interviews to vulnerable and disadvantaged children and young people who are problematic substance misusers.

‘Interventions in schools to prevent and reduce alcohol use among children and young people NICE Guidance 2007) – shows how to link these interventions with the community initiative: for example:

education to be an integral part of the national science, PSHE and PSHE education curricula in line with DSCF guidelines.
education to be tailored to different age groups for children and young people who are thought to be drinking harmful amounts of alcohol.
Where appropriate, offer 1 – 1 advice on the harmful effects of alcohol
referrals to external services as appropriate
develop strategic and operational partnership arrangements with other services and partnerships.

Treatment services need to plan to address these recommendations. There will also be implications for the commissioning and delivery of services in light of extended age ranges above 19 years. Additional funding may be available to allow the recommendations of the guidance to be developed within services.

Transitional Arrangements. It should not be the sole responsibility of young people’s treatment services to negotiate transitional arrangements between the services. We should encourage commissioners to take a lead on ensuring the dialogue between young people’s treatment services and adult services begins and is maintained. The adult services (drugs and alcohol) should recognise the important role that the young people’s treatment services have in assessing and care planning for young adults and their transition into adult provision. Importantly, all guidance continues to recognise that adult treatment services should be separate to young people’s treatment whilst ensuring that arrangements are in place for transition.

CONCLUSION
Children and young people’s drug and alcohol services have seen considerable growth over the last six years. Services have been developed in line with an evolving agenda. Ensuring that our services fully integrate within the children’s agenda may be the driver for continued investment, continued and increased confidence in our services and ensuring that changes in commissioning are in the best interest of children, young people, their families and communities.

There are many uncertainties about the continued commissioning and indeed the composition of children and young people’s treatment services. This coming year will be a testing time for many local authority areas considering the placement and integration of our services and what that will mean for the quality and accessibility of provision to those that need them.

There are many steps that we can take to demonstrate to local authorities that specialist treatment services are invaluable in providing quality services, achieving positive outcomes whilst contributing to local priorities within their own strategies, most notably their Children’s Plan.