Health and Wellbeing Board	19^th January 2021
Report of the Consultant in Public Health, City of York Council and Vale of York CCG

Preventing harm and supporting recovery for those using Drugs and Alcohol in York

Summary

1. The health harms, social impacts and economic costs of alcohol and drug use are substantial nationally and in York, with rising rates of alcohol-related diseases, an upward trend in drug-related deaths, clear and enduring links between mental ill-health and substance use, criminal justice and community safety issues relating to drugs and alcohol, and overall costs to society estimated at £21.5bn for alcohol use (PHE) and £20bn for drug use (Home Office).

2. These issues involve multiple partners in our city, ranging from schools and universities to primary care and hospital services, specialist drug treatment and recovery services, the police, housing and probation services, and many more. There are very few parts of civic society in York untouched by drug and alcohol issues.

3. In December 2021 a new ten-year national drugs strategy (‘From harm to hope’ – see Background Paper) was published, alongside significant commitment of investment to tackle alcohol and drug harm to be distributed to local areas. This report summarises the key implications of these announcements for partners in York.

4. One key issue is that of improving support to those who have concurrent mental health issues and addiction issues (‘dual diagnosis’). A local work programme has been set up and partners in North Yorkshire and York are being encouraged to sign a ‘Dual Diagnosis Pledge’ (see Annexe A) committing organisations and professionals to better joint working between addiction and mental health services.

Recommendations

5. The Health and Wellbeing Board is asked to:

1) Note and comment on trends and needs around drugs and alcohol in the City of York

2) Note and comment on the new ten year national drugs and alcohol strategy and its implications for partners in York

3) Note and comment on proposals to work more closely in partnership with North Yorkshire area, including working towards a combined North Yorkshire and York Drugs and Alcohol Strategy

4) Consider signing the North Yorkshire and York ‘Dual Diagnosis Pledge’

Background

Overview of the impact of Alcohol in York

6. Alcohol is widely available and consumed by the majority of adults in England; however its harms are often under-appreciated. The stance of the World Health Organisation, based on extensive global research, is that there is no ‘safe’ level of drinking, with any level of alcohol consumption, regardless of the amount, shown to lead to loss of healthy life at a population level. The UK advice from the CMO focusses on encouraging people to limit their consumption to 14 units of week, with one unit being equivalent to half a pint of regular strength beer or half a small glass of wine.

7. A PHE best practice summary from 2021 highlights that:

· 28% of men and 14% of women are drinking at increased or higher risk of harm (more than 14 units per week).

· Of these, 589,000 adults potentially need specialist treatment for alcohol dependence.

· 24,202 deaths in 2017 were caused by alcohol consumption in England.

· In the UK since 1987 alcohol has become 64% more affordable (NHS Digital, 2019), with successive freezes in UK alcohol duty since 2012 which have led to increased levels of alcohol consumption.

8. Locally, data from the Public Health Outcomes Framework shows that alcohol harm and misuse is a major issue in York, especially considering most of our population generally live in relatively good health and see better outcomes on other health indicators. This can be seen across the whole alcohol ‘pathway’, from our average consumption levels to our hospital admissions and deaths:

· The number of premises licensed to sell alcohol per square km in the city is 3.1 vs 1.3 in England

· In the off-trade (e.g. supermarkets), the amount of alcohol sold per adult per year in York is 6.4 litres vs 5.4 litres in England

· The proportion of adults who abstain from drinking alcohol in York is 11.2% vs 16.2% in England

· The proportion of adults drinking over 14 units per week is 21.4% vs 22.8% in England

· 28.7 per 1000 patients on GP registers in York have a ‘substance misuse’ code

· In 19/20, the admission rate of York residents to hospital:

o  directly attributable to alcohol was 545 per 100,000 in York vs 519 per 100,000 in England;

o  indirectly attributable to alcohol was 1,996 per 100,000 in York vs 1,815 per 100,000 in England

· 21 people in York died in 2020 from conditions directly related to alcohol, and 69 people died in 2020 from conditions indirectly related to alcohol

9. Population level prevention is a key factor in tackling these issues, with PHE’s 2016 evidence review concluding that taxation and Minimum Unit Pricing (MUP) are the most effective and cost-effective approaches to reducing alcohol-related harm. However local action on pricing, marketing, and availability is limited by national legislative barriers.

10. For individuals, as part of our local work to reduce alcohol harm people in York are encouraged to use an evidence-based resource such as the PHE ‘One You’ quiz to assess if their alcohol consumption is within the guidance, with its many helpful links and resources to support for reducing drinking levels.

11. Extensive training has previously been carried out by the council’s public health team (funded by the BCF) on Identification and Brief Advice (IBA) which trains professionals on the use of the AUDIT tool to identify alcohol harm and offer brief interventions. This will be further rolled out across 2022.

12. City of York Council’s Health Trainer service now offer up to six 1:1 support sessions around living healthily, including alcohol use, supporting clients to understand their alcohol use and set goals for reduction using a motivational interviewing approach.

13. At the start of 2022, a new service commissioned by public health will be launched, ‘Changing Habits’, a pilot of an intensive primary-care based intervention for those with harmful drinking levels not reaching the threshold for treatment and recovery services.

14. At the higher-impact end of alcohol consumption around 400 adults require specialist alcohol treatment in York at any one time, through the York Drug and Alcohol Service provided by Changing Lives, including clinical interventions around managing withdrawal, psycho-social interventions, and access to day recovery and inpatient detox if required, as well as a positive and flourishing recovery community (York in Recovery).

Overview of the impact of Drugs in York

15. Addiction to drugs and substances is a chronic health condition responsive to treatment and support, from which many people recover and in the long term live substance-free. It can however cause severe health, social and mental health harm, and often exacerbates other conditions and multiple complex needs being experienced by the user.

16. A PHE best practice summary from 2021 highlights that:

· An estimated 314,000 people in England are dependent on heroin and crack cocaine, a rise of 4.4% from 2014-15 to 2016-17.

· Increasing numbers of people are reportedly having problems with other drugs such as cannabis, new psychoactive substances and image and performance enhancing drugs. Concern is also growing about misuse of, and dependence on, prescribed and over-the-counter medicines (PHE, 2019).

· Injecting drug use continues to be a risk factor for blood-borne viruses such as HIV and hepatitis C, and prevalence in England has remained high among people who inject drugs.

· Drug-related deaths (DRDs) have risen significantly in recent years, with heroin deaths doubling since 2012. There were 2,917 drug misuse deaths recorded in 2018, an increase of 17% from 2017 and the highest number on record (ONS, 2018).

· Around 45% of acquisitive offences are committed by heroin and crack users.

· There are signs that drug use is increasing among young people. The last two national surveys of drug use among school children in England showed a large and statistically significant increase in use among 11- to 15-year-olds.

· Parental alcohol and drug use were present in over a third of serious case reviews within social care.

· People who experience homelessness and rough sleeping also experience some of the most severe health inequalities and experience much poorer health than the general population. Many have co-occurring mental ill-health, substance dependence and poor physical health, and have experienced significant trauma in their lives.

17. Around 600 people in York are in treatment for drug use, including clinical interventions around opioid substitution, managing withdrawal, psycho-social interventions, and access to day recovery, as well as a positive and flourishing recovery community (York in Recovery). It is estimated that half of crack cocaine and opiate users are not currently in treatment nationally, meaning there is likely to be significant unmet need in our population.

Overview of the National ten year drug strategy

18. On the 7^th December 2021 the government published its 10 year national drugs strategy (‘From Harm to Hope’). It aims to delivering on the findings of both parts of the Dame Carole Black Review into the supply of drugs and prevention, treatment and recovery. It includes a commitment of £900m investment over 3 years, across criminal justice and public health.

19. The new strategy represents a combination of strengthened criminal justice actions around the supply and use of drugs, and actions to strengthen treatment/recovery for substance misusers. It recognises that addiction is a chronic health condition which requires higher quality / better funded support and treatment, but also takes a strong line against decriminalisation and a more punitive stance than current drugs policy especially around recreational drug use.

20. The plan sets out three strategic priorities:

· Break drug supply chains

· Deliver a world-class treatment and recovery system

· Achieve a generational shift in demand for drugs

21. Every area of this strategy has implications for York, ranging from enforcement, education, community safety and partnerships with the criminal justice system, and of course the public health responsibilities around harm from alcohol and drugs and commissioning of prevention, treatment and recovery services.

22. Total funding for prevention, treatment and recovery services is an extra £780m over 3 years, meaning a total of £2.8bn will be spent through the public health grant in total over 3 years, effectively a 40% increase in funding for treatment. The phrase 'rebuilding what was lost' references the fact that even with more recent uplifts in cash terms, the public health grant in 2021/22 was 24 per cent, or £1 billion, lower per head in real terms compared to 2015/16.

23. This funding will be distributed to the 50 local authorities with the greatest need in 2022/23, a second 50 in 2023/24, and the last 50 in 2024/25.

24. However 2021/22 additional funding (£80m nationally, £243k for York) will stay as a baseline for all areas. This year, this has been spent locally on work relating to drugs and the criminal justice system, including:

· Criminal justice workers offering liaison services in custody and with probation, including as part of out-of-court disposals which require people to engage with treatment services

· Harm reduction initiatives e.g. naloxone, needle exchange

· Support for the York recovery community

· Advocacy work with York MIND around Dual Diagnosis.

25. Beyond public health, money in the national strategy will be provided for criminal justice system work including:

· Expansion of drug testing on arrest

· Extra liaison and diversion capacity

· Work to tackle recreational drugs use

· £145m for an upgraded county lines programmes

· Extra regional organised crime unit support to confront middle-market drug supply issues

26. Other relevant schemes in the strategy include

· A £15m expansion of the rough sleeper treatment grant

· £21m on the Individual Placement and Support (IPS) scheme (employment), now covering the whole country

· Links to the Supporting Families programme

27. At the time of writing, key outstanding issues include confirmation of funding envelope over the next 3 years for York, the grant conditions including if the money can be planned over 3 years (which would enable much better recruitment and quality), what schemes will be supported for public health and other partners to commission using the new resource, and given the focus of the strategy on drugs, and how much of the extra investment can be used to tackle alcohol-related harm.

28. There will be increased accountability / scrutiny on the spending of the new money, including a new commissioning quality standard being developed and an encouragement to work in strengthened partnerships with all the relevant organisations and key individuals, and to provide a single point of contact for central government. This partnership could cover one local authority or several.

29. Currently, partnership work on the drugs and alcohol agenda happens both at the city level and as part of North Yorkshire and York. This reflects the fact that some of our needs in the city of York are specific to our denser and urban population, for instance around alcohol, the night-time economy and licensed premises, but many of the partners, for instance Police and Probation services, and TEWV NHS Foundation Trust, operate at a North Yorkshire and York level, and the treatment provider services overlap significantly. Health and Wellbeing Board members are asked to comment on proposals to work more closely in partnership with North Yorkshire area, including working towards a combined North Yorkshire and York Drugs and Alcohol Strategy to take forward our respective areas’ response to the nation plan and new commissioning responsibilities.

North Yorkshire and York Dual Diagnosis Pledge

30. One of the groups who suffer the most inequalities and health impact in our city are those who have mental health problems and addictions to drugs and/or alcohol (this is referred to as ‘dual diagnosis’). It has been long recognised that not only do these two issues exacerbate one another for the individual, but also see historic barriers between mental health and addiction services, such that people with addictions often struggle to get adequate mental health support (and vice versa).

31. In North Yorkshire and York, a Dual Diagnosis Strategic Group has been working on a Dual Diagnosis pledge, a copy of which can be found in Annex A. Individuals and organisations are being invited to sign this as a display of commitment to this agenda.

32. There are a number of key principles to the approach embodied by the pledge:

· ‘The person comes first’, including a joint care approach where the ‘which came first’ debate will be set aside, and both co-occurring difficulties being addressed as a presenting problem that affect the other

· ‘Let’s talk’, which focusses on communication between services and effective joint-working between agencies

· ‘Commitment to learning, sharing expertise and good practice’, through support, advice, training and shadowing opportunities to other specialist services

33. As part of their commitment to both mental health agenda and the drugs and alcohol agenda, the Health and Wellbeing Board are invited to sign the pledge and to take back into their own organisations the principles and values within it, acknowledging the fact that some member organisations of the Board may already have signed (for instance, Tees Esk and Wear Valley NHS Foundation Trust).

Consultation

34. There has been no formal consultation on the contents of this paper regarding information on drug and alcohol impacts in York and the new national drugs strategy. The North Yorkshire and York Dual Diagnosis pledge has been developed following service user input.

Health and Wellbeing Board Strategy

35. This report aligns with the York Health and Wellbeing Strategy 2017-2022, including priorities on:

· Focus on recovery and rehabilitation

· Ensure that York is a mental health friendly environment

Implications

· Financial

There are no direct financial implications of this report, however when the new drug strategy funding is announced individual agencies will need to make decisions through their own governance arrangements on the spending of this resource.

· Human Resources (HR)

There are no direct HR implications of this report

· One Planet Council / Equalities

Drug and alcohol issues disproportionately impact those from marginalised communities and more deprived areas, and future efforts to tackle their impact should be targeted to ensure that health inequalities are reduced.

· Legal

There are no direct legal implications of this report

· Crime and Disorder

Efforts to tackle drug and alcohol issues in the city have a strong overlap with criminal justice and community safety. There is much debate over the criminalisation of drug use and the effectiveness of a punitive approach to possession. Some major aspects of a public health approach to substance misuse (e.g. opioid consumption rooms and heroin-assisted treatment) are missing from the national drugs strategy. However locally, there is strong partnership working between criminal justice and other agencies to support the optimal use of treatment and recovery and reduce drug/alcohol-related crime in the city, which the strategy will enable us to build on through the Community Safety Partnership and other fora.

· Information Technology (IT)

There are no direct IT implications of this report

· Property

There are no direct property implications of this report

Contact Details

Author: Peter Roderick Consultant in Public Health City of York Council / Vale of York CCG	Chief Officer Responsible for the report: Sharon Stoltz Director of Public Health City of York Council
Report Approved	√	Date	[4/1/22]
Specialist Implications Officer(s)  List information for all Financial:-                                        Legal:- Name                                               Name Title:                                                 Title Tel No.                                             Tel No.
Wards Affected:  [List wards or tick box to indicate all]					All
For further information please contact the author of the report

Background Paper

‘From Harm to Hope’: 10 year National Drugs Strategy

https://www.gov.uk/government/publications/from-harm-to-hope-a-10-year-drugs-plan-to-cut-crime-and-save-lives

Annexe

Annexe A - North Yorkshire and York Dual Diagnosis Pledge