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A national survey of inpatient drug services in England

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A national survey of inpatient drug services in England
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  June 2005 >> Research briefing: 12 Anational survey of inpatient drugservices in England Dr Ed Day, Julie Ison, Dr Francis Keaney, Dr Neena Buntwal and Prof John Strang, University of Birmingham  A national survey of inpatient drug services in England 3 Contents Executive summary............................................................................................................................4   Background and aims....................................................................................................................4   Main findings.................................................................................................................................4   Recommendations for commissioners............................................................................................4   Recommendations for national standards.......................................................................................5   Background........................................................................................................................................6   Aims..................................................................................................................................................6   Method..............................................................................................................................................6   Definitions and inclusion criteria.....................................................................................................6   Exclusion criteria............................................................................................................................7   Phase 1: Identification and recruitment of units..............................................................................7   Phase 2: The survey......................................................................................................................7   Results..............................................................................................................................................8   Identification and recruitment of units.............................................................................................8   The service and its activity.............................................................................................................8   Buildings and staff.........................................................................................................................10   Practice, policy and procedures....................................................................................................10   Clinical interventions and outcomes..............................................................................................12   Overall opinions............................................................................................................................13   Overview and discussion...................................................................................................................14   The survey process.......................................................................................................................14   Number and range of services......................................................................................................14   Buildings and staff.........................................................................................................................15   The clinical picture........................................................................................................................16   Opinions of staff completing the questionnaire..............................................................................16   Recommendations for the Tier 4 project............................................................................................16   Capacity.......................................................................................................................................16   Standards.....................................................................................................................................17   Inpatient standards.......................................................................................................................17   Integration....................................................................................................................................17   Data collection..............................................................................................................................17   Further research...........................................................................................................................17   References.......................................................................................................................................18   Appendix 1: Tables...........................................................................................................................19   Appendix 2: Services providing inpatient detoxification for drug users................................................28   Reader information............................................................................................................................34    A national survey of inpatient drug services in England 4 Executive summary Background and aims Little empirical information exists on the trends in inpatient services for stabilisation or detoxification of patients who have substance misuse disorders. This project aims to establish the level of provision and provide a snapshot of current clinical practice, in terms of number of services, location, availability of beds, types of cases managed, available resources, types of services and ranges of outcomes. Phase 1 of the survey constructed a database of inpatient services based on commissioning records, treatment services directories and specialists in the field. Units identified from this were then asked to complete a written survey, which formed phase 2. Main findings     The survey estimated that there were 10,771 admissions in the year 2003/4 into beds purchased for drug detoxification in English services   The results show that the three broad service groups – termed “specialist”, “non-dedicated” and “rehab” – differed in all aspects of their treatment provision   Inpatient provision in England is extremely variable in terms of its scope, physical location, staffing and clinical practice   Most inpatient services are aimed at 18– 64-year-olds, with very few admitting people under 16 or over 64 years of age   Very few services make specific provision for minority groups   Beds are located in a variety of physical settings, which are not always suitable for the client group   There are huge disparities between services, in terms of input from specialist staff. Staff shortages are also a significant problem   There is no uniformity across the country in terms of patients’ access to inpatient services   Once admitted, the range of services on offer is equally variable and the average length of admission for detoxification ranges from four to 77 days   Services tend to be geared around opioid misuse and there is a lack of provision for poly-substance and stimulant misusers   Patients are likely to experience differences in the amount and variety of structured psychosocial treatment on offer   Established harm reduction interventions – such as screening and vaccination services for blood-borne viruses and training for managing drug overdoses – are not provided routinely in most services   Very few services could provide good-quality audit or research data on their work   One-third of services do not require patients to have an aftercare plan in place prior to admission. Only one-third are discharged to residential or day care rehabilitation services. Recommendations for commissioners Inpatient services   More beds are needed to treat drug users, particularly as only one-fifth of services offered detoxification only if the patient was entering a longer-term rehabilitation programme and nearly 20 per cent of responders were commercial organisations   Beds on a psychiatric ward do not appear to provide the comprehensive service available from more specialist units and commissioners should be made aware of this   Detoxification in rehabilitation units should be encouraged, provided the appropriate level of medical care can be provided to ensure safety and optimum clinical practice. These beds should not be seen as an alternative to specialist inpatient provision, as they have a limited goal and are not available to everyone Mapping provision   Regular mapping of the extent of inpatient provision is necessary in order to ensure even provision across the country   A directory of inpatient services should be produced that covers both statutory and non-statutory agencies. This should be available on the NTA website and each unit should regularly update their information   More comprehensive information should be available for patients regarding the current choices available and how to access them.   The need for staff with specialist skills to work in inpatient services should be recognised and reflected in the process of developing occupational standards and any revisions to the pay structure, within the NHS and other organisations   Steps need to be taken to tackle the shortage of nursing staff in many inpatient services.  A national survey of inpatient drug services in England 5 Inpatient standards   Inpatient services should be encouraged to provide a full range of treatment services and not just detoxification   All specialist services should provide treatment for patients with crack and benzodiazepine dependence   The importance of providing systematic education for service users about reduced tolerance and the risk of relapse, to reduce the risk of overdose on discharge should be emphasised. Integration   The Tier 4 needs assessment exercise should be used to inform the level of provision of both residential and non-residential aftercare   All inpatient services must be integrated into the wider treatment system and aftercare should be considered and planned prior to admission   Stronger links need to be developed between providers of inpatient detoxification and services providing day care and residential rehabilitation. Recommendations for national standards Mapping provision   Minimum standards for inpatient units should be described. All units should be regularly inspected with reference to these minimum standards Inpatient standards   Data from this survey should be used to inform an expert advisory group in producing recommendations for model inpatient services   Consideration should be given to producing medical guidelines for inpatient detoxification and other treatments (similar to the “Orange Book” for community services) Data collection   The formation of a national network of specialist inpatient services would allow relevant clinical and non-clinical data to be collected   Information from the expert advisory group and the national network should be used to create a national clinical audit program, to improve standards of care and clinical practice   The NTA should highlight examples of good or innovative practice in inpatient services. Further research   Outcome research is needed on the effects of different coexisting technologies, e.g. detoxification for abstinence and detoxification for stabilisation   Outcome research is needed on the different models offered in rehabilitation and their links to inpatient services   An evaluation of patient preferences around treatment modalities would be useful, including the needs of women and children, the role of gender-specific and dual diagnosis units   Consideration should be given to services not included in this study, e.g. general hospital and prison beds.  A national survey of inpatient drug services in England 6 Background Dependence on drugs is a major health and social issue in the UK and the provision of treatment has a large influence on the reduction of harm to the individual and the community. The National Treatment Agency for Substance Misuse (NTA) has established a broad framework for delivering such treatment, 7  and the provision of inpatient services is incorporated within this. Many people with substance dependence have difficulty achieving abstinence in the community and inpatient programs are intended for those drug misusers whose needs require supervision in a controlled medical environment. Such programs provide medically supervised withdrawal (detoxification) and most regard this as an induction pathway into a short-term residential program of psychosocial counselling and support, aimed at relapse prevention. This program can continue in the community as aftercare, or else a referral can be made to a residential rehabilitation program. 7  Alternatively, inpatient beds may be used for periods of assessment or stabilisation when this is not possible in a community setting, due to polydrug use, complex social factors or coexisting severe mental illness. Little empirical information exists on the trends in inpatient services for stabilisation or detoxification of patients who have substance misuse disorders. 1  There is no clear information on the number of dedicated inpatient beds for drug misuse treatment in the UK, or the type of care offered in each one. Models of care   provides recommendations based on a developing evidence base for detoxification procedures, 2–5  but it is not clear that best practice is being followed consistently across inpatient units. Furthermore, it is recognised that inpatient provision is often in designated drug misuse beds in psychiatric wards, rather than specialist units. 8  This presents a range of other difficulties, including a lack of suitably trained staff, difficulties in organising planned admissions due to pressure on beds and difficulties in maintaining a drug-free environment. All of these factors are likely to undermine the effectiveness of designated beds compared with specialist units and there is some evidence that admission to a specialist unit results in better retention in treatment and other outcomes. 9  Two major pieces of work have touched upon some of these issues in recent years, 8,10 but neither has provided a definitive answer to the questions raised above. This project aims to establish the level of provision of inpatient beds for drug treatment in England, and to provide a snapshot of current clinical practice. Aims   The aim of the study was to answer the following questions:   How many services provide inpatient drug detoxification treatment in England?   Where are these services located?   How many beds are available?   Which types of cases do these treatment services manage?   What resources (buildings and staff) do they have available?   Which clinical services do they provide?   What outcomes are achieved? Method Definitions and inclusion criteria The term “inpatient treatment” covers a variety of services in a range of clinical settings. For the purpose of this project, an inpatient treatment service was defined as any service located in England that has offered at least one planned, medically assisted detoxification to a person using prescribed or illicit drugs (and excluding alcohol) in the previous year. “Planned” meant that the bed was recognised as providing a Tier 4a a  service prior to the detoxification taking place (as opposed to somewhere that provided ad hoc detoxification secondary to other medical or psychiatric care). “Medically assisted” meant that medication was prescribed to the patient and dispensed in the unit in order to assist the detoxification process. This definition could encompass beds within specialist detoxification units, beds in psychiatric wards and general hospitals, and residential rehabilitation services providing “front-end” detoxification. The unit could be either an NHS managed service or a non-statutory private agency. Detoxification was felt to be the “common denominator” of all inpatient services, although it was anticipated that many would offer other services such as stabilisation or assessment. a   Tier 4a: Residential drug and alcohol misuse specific services  Tier 4 services are aimed at individuals with a high level of presenting need and include inpatient drug and alcohol detoxification or stabilisation services, drug and alcohol residential rehabilitation units and residential drug crisis intervention centres. Tier 4a services may be abstinence-oriented programmes, detoxification services or services which stabilise patients (e.g. on substitute drugs).
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