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Cornwall and Isles of Scilly Drug and Alcohol Action Team (DAAT)

Alcohol Treatment Needs Assessment

2009/10

Published 02 July 2010

Alcohol Treatment Needs Assessment 2009/10 2


CORNWALL AND ISLES OF SCILLY

DRUG AND ALCOHOL ACTION TEAM (DAAT)

ALCOHOL TREATMENT NEEDS ASSESSMENT 2009/10

© Copyright The text in this document may be reproduced free of charge in any format or medium providing that it is reproduced accurately and not used in a misleading context.


Acknowledgement of contributors

Bruce Arnot CDAT Manager, Cornwall Partnership Trust Penni Barker 13-19 Commissioning Manager, Children, Schools and Families, Cornwall Council Marion Barton Social Inclusion Lead, Cornwall and Isles of Scilly DAAT

Jez Bayes Alcohol Strategy Co-ordinator, Cornwall and Isles of Scilly DAAT Sam Campbell Information Officer, Criminal Justice Integrated Team

Brian Carrington Service user representative Steve Coad Manager, Gwellheans

Ashleigh Coleman Homelessness Strategy Co-ordinator, Cornwall Council Bob Crossland Manager, Cornwall and Isles of Scilly DAAT

Kim Hager Acting Commissioning Manager, Cornwall and Isles of Scilly DAAT Lynne Kirkham Analyst, Public Health Erika Sorensen Strategic Analyst, Amethyst (CDRP Intelligence Hub) Lucy Stapleton Job Centre Plus

Howard Stevens Drug-related Deaths Co-ordinator, Cornwall and Isles of Scilly DAAT


Contents EXECUTIVE SUMMARY 6 POLICY CONTEXT 8

Aims and objectives 9 GEOGRAPHICAL SCOPE 11 METHODOLOGY AND DATA SOURCES 11 COMMUNITY CONSULTATION 13 WHAT IS CORNWALL? 14 CHAPTER 1 PROBLEM ALCOHOL USE AND TREATMENT 16

Mapping the treatment system – tiers 1 and 2 17 Mapping the treatment system – tiers 3 and 4 18 Key findings 21

CHAPTER 2 HARM REDUCTION 22 Alcohol and harm to health 22 Key findings 25

CHAPTER 3 ACCOMMODATION AND HOMELESSNESS 26 Accommodation need and provision 26 Key findings 27

CHAPTER 4 ALCOHOL AND CRIME 28 Alcohol-related violence 28 Key findings 38

YOUNG PEOPLE 39 Problem substance use (alcohol and / or drugs) 39 Attitudes to drinking and harm to health 41 Key findings 43

Chapter 5 – Commissioning priorities 44 IDENTIFYING PRIORITIES – THE PROCESS 44 APPENDIX 1: 46 APPENDIX 2: 47

Executive Summary


Executive Summary Building on previous work to inform the local Alcohol Harm Reduction Strategy, Cornwall DAAT have now undertaken a comprehensive needs assessment to identify local priorities in relation to alcohol treatment need and to highlight service gaps. This work was done in parallel to the drugs needs assessment process, which has been established for the last three years. The needs assessment aims to facilitate a better understanding of problem alcohol users and the treatment system and informs treatment planning, service commissioning and resource allocation, with the aim that people with alcohol problems will have their needs met more effectively, which in turn benefits the communities that they live in. This needs assessment has also been developed alongside the strategic assessment produced by Amethyst1 for the Crime and Disorder Reduction Partnership (CDRP) “Crime, disorder and substance use in Cornwall” to ensure consistency of key messages and reduce duplication. The full evidence base can be found on the Amethyst website www.amethyst.gov.uk/strataudit.htm.

Recommended focus areas

• Improve opportunities for early identification of problem alcohol use by implementing a set

of screening tools that can be used across all services, and broadening the range of settings where screening can take place.

• Improve the flexibility of support options, including increasing the availability of telephone and drop-in support, mutual aid and recovery groups.

• Increase enrolment in in-patient and residential treatment options, with a long-term goal to reach around 15% of those in treatment, supported by increased capacity to offer services within Cornwall.

• Identify and implement appropriate data collection processes to monitor the level of screening and brief interventions delivered and support future capacity planning.

• Consideration should be given to how existing supported housing provision could meet the needs of problem drug and alcohol users with complex needs and those who lapse or relapse, alongside improving move-on support.

• Alcohol-related violence is concentrated in town centres and is closely linked to the night-time economy. Tackling alcohol-related violence is a key part of the effective management of town centres and should involve a wide range of partners:

o Preventative work with licensed premises (including alcohol retailers), local licensing teams and Trading Standards.

o Targeted interventions and education programmes with young people, including tackling the health impacts of problem alcohol use.

o Reduce re-offending: effective use of Alcohol Arrest Referral Scheme and links to treatment / offender programmes.

o Reassurance and communication: PACT is one route of regular consultation with the community but only reaches a small number of people. Young people (aged 18 to 24 years), who are more likely to perceive problems in their local area and feel less safe, may also be less likely to engage with community safety partners through traditional routes. Communities should be informed about initiatives in their local area and positive outcomes publicised.

o Geographical focus should be on long term town centre hotspots where there is a high volume of recorded crime – Newquay, Penzance, Truro, Falmouth and Camborne.

• The impact of violent crime in terms of injuries sustained and the resource implications for the Ambulance Service and Accident and Emergency remains a significant knowledge gap.

1 Community Safety Intelligence Hub


Cornwall and Isles of Scilly DAAT

Alcohol Treatment Needs Assessment 2009/10

Introduction


Policy context The developing response to alcohol related harm: The process of raising the profile of the response to alcohol related harm began in earnest when the first national Alcohol Harm Reduction Strategy was published in 2004. This had 4 major aims: 1: Better education and communication around alcohol; 2: Improving health and alcohol treatment services; 3: Combating alcohol related crime and disorder; 4: Working with the alcohol industry around responsible marketing; Locally, Cornwall developed an Alcohol Strategy in 2006, before this was a national requirement of all CDRPs. This requirement was outlined in the reviewed and updated National Alcohol Strategy “Safe, Sensible, Social” in June 2007. This is the strategy that is still in place. It addresses 3 themes intended to focus on alcohol related harm, whilst also enabling people to enjoy alcohol safely: 1: Better use of legislation around the alcohol trade and alcohol related disorder: Ensuring that the laws and licensing powers introduced to tackle alcohol-fuelled crime and disorder, protect young people and tackle irresponsibly managed premises are being used widely and effectively. 2: Better focus on drinkers causing harm to themselves and others: Sharpening the focus on the minority of drinkers who cause the most harm to themselves, their communities and their families - young people under 18 who drink alcohol, 18–24-year-old binge drinkers (a minority of whom are responsible for the majority of alcohol-related crime and disorder in the night-time economy) and higher risk drinkers, many of whom don’t realise that their drinking patterns damage their physical and mental health and may be causing harm to others. 3: The promotion of sensible drinking: Working together to shape an environment that actively promotes sensible drinking, through investment in better information and communications, and by drawing on the skills and commitment of all those already working together to reduce the harm alcohol can cause, including the police, local authorities, prison and probation staff, the NHS, voluntary organisations, the alcohol industry, the wider business community, the media and local communities themselves. All of this was summed up in the overall goal: ‘To minimise the health harms, violence and antisocial behaviour associated with alcohol, while ensuring that people are able to enjoy alcohol safely and responsibly.’ In support of these 3 aims, the strategy committed to 8 actions: 1: Sharpened Criminal Justice for drunken behaviour; 2: A review of NHS alcohol spending; 3: More help for people who want to drink less; 4: Toughened enforcement of underage sales; 5: Trusted guidance for parents and young people; 6: Public information campaigns to promote a new sensible drinking culture; 7: Public consultation on alcohol pricing and promotion; 8: Local Alcohol strategies. In the 2 years since this has been in place, there has been an increasing amount of national guidance for local areas in developing and commissioning effective services and policies in response to the problems caused by alcohol. This has led to consultative guidance from NICE about medical treatment, increased criminal justice options connected to alcohol interventions, better data being supplied by NWPHO geared towards a more thorough understanding of alcohol related Hospital admissions in all areas of the country, and finally Department of Health guidance encouraging commissioning of High Impact services addressing alcohol related harm.

Introduction


Alcohol Improvement Programme 2009:

These High Impact Changes are outlined in ‘Signs for Improvement,’ http://www.alcohollearningcentre.org.uk/_library/Alcohol-Signs_For_Improvement1.pdf and they are calculated to be the most effective and practical actions used extensively across the NHS and local government.

The first three High Impact Changes are necessary enabling actions that set the scene for success. The latter four changes are services and activities that are calculated to impact most effectively on alcohol-related harm, and reduce the rate of rise in alcohol related Hospital admissions, as measured by LAA NI39, NHS VSC 26, and PSA 25.

The 7 High Impact Changes are as follows: 1: Work in Partnership; 2: Develop activities to control the impact of alcohol misuse in the community; 3: Influence change through advocacy;

The first High Impact Change, Work in partnership, is a major building block for success as it is unlikely that progress on reducing alcohol harm at any level will be effective without good partnership working in place.

This leads logically to the second recommendation, Developing activities to control the impact of alcohol misuse in the community which involves the spectrum of local partners: the NHS because of the high cost of alcohol related illnesses and alcohol related hospital admissions, Local Authorities because of quality of life and community safety, and the Criminal Justice System because of the link between alcohol, crime and public disorder. All partners need to use their existing powers to make the maximum impact on alcohol-related harm.

This degree of partnership commitment needs championing in various areas, both geographically and in different service areas; hence the need to influence changes through advocacy.

The latter four High Impact Changes are services and activities that can be commissioned, based on proven and emerging evidence of their effectiveness and direct impact on hospital admissions.

4: Improve the effectiveness and capacity of specialist treatment; 5: Appoint an Alcohol Health Worker (in Hospital services); 6: IBA – Provide more help to encourage people to drink less through early advice; 7: Amplify national social marketing priorities.

Aims and objectives The purpose of a needs assessment is to examine, as systematically as possible, what the relative needs and harms are within different groups and settings, and make evidence-based and ethical decisions on how needs might be most effectively met within available resources. An effective needs assessment for alcohol interventions, treatment, support, recovery and reintegration involves a process of identification of: • What works well, and for whom in the current system, and what the unmet needs are

across the system, in both community and prison settings • Where there are gaps for alcohol clients in the wider reintegration and treatment system • Where the system is failing to engage and / or retain people • Who are the hidden populations and what are their risk profiles • What are the enablers and blocks to treatment, reintegration and recovery pathways • What is the relationship between treatment engagement and harm profiles (LAPE)

Introduction


This will provide a shared understanding by the partnership of the local need for services, which then informs treatment planning and resource allocation, enabling alcohol clients to have needs met more effectively, and ultimately benefiting the communities in which they live.

Introduction


Geographical scope This assessment covers the county of Cornwall and the Isles of Scilly. As a result of the Local Government Review (LGR) the six district councils and the county council within Cornwall have undergone a transition into a unitary authority called Cornwall Council. The Isles of Scilly has remained an independent unitary authority. Following the dissolution of the districts, Cornwall Council now co-ordinates activities at a local level through the Localism Service and 19 community networks, working with elected members, town and parish councils, other key partners and the community. The community networks are arranged into three service delivery areas, West, Central and East, which are managed by community network area managers. This map shows the three service delivery areas and their component network areas. Methodology and data sources National Drug Treatment Monitoring System (NDTMS) data The National Drug Treatment Monitoring System (NDTMS) is the key source of information about problem alcohol users engaged with treatment services. NDTMS is used to capture data on clients who reach the assessment / triage stage at any treatment service agency. It should be noted that NDTMS does not represent the whole client group referred to treatment services. A service user receiving only a brief intervention (such as one-off advice or information) is not usually recorded and also a small proportion of service users do not give consent to be recorded on NDTMS.

Figures are taken from reports drawn from NDTMS data and provided by the NTA, either year-end reports or, where applicable, summary reports provided specifically for needs assessment purposes. The National Treatment Agency (NTA) definition of a problem alcohol user means any service user in treatment for alcohol as the primary problem substance. Offender data Offender data is provided by Devon and Cornwall Probation Area (DCPA) and is a caseload ‘snapshot’ drawn from OASys (Offender Assessment System). The caseload includes adult offenders subject to a court order or released on licence from prison that are being supervised in the community and offenders serving a prison sentence of one year or more. The ‘snap shot’ used for this assessment was drawn on 31 March 2009.

Introduction


Police data Devon and Cornwall Police (Performance and Analysis Department) provide sanitised recorded crime data extracted from the Crime Information System (CIS). Only crime records with accurate co-ordinates for mapping are included within this data set and hence, for violent crime, there is a small shortfall of 3%. Crime data – interpreting maps Wherever possible, maps have been included to provide an understanding of the geographical spread of an issue. Although every care has been taken to ensure that the maps present a clear and accurate picture, it’s important to be aware of the following points when interpreting them: • Maps can exaggerate differences between areas based on class divisions (the range of

values used to determine different colours). Where values are close to a division threshold, there may be very little difference between two areas on either side of the threshold but their different colours may be interpreted otherwise.

• The fact that some geographic units are much larger than others means that their colours can dominate the map. This is a particular issue for the geography of Cornwall because the eye is drawn to the larger geographical areas in North Cornwall and away from smaller, more densely populated areas such as Penzance.

• Aggregating data to a large geographical boundary, such as a community network area, can mask pockets of crime and disorder that are concentrated in only a small part of that area. For this reason, data is also analysed at a small statistical area level, called a Lower Super Output Area (LSOA), which contains an average of 1500 people, and appropriate commentary provided.

Local Alcohol Profiles Key indicators relating to the harms of alcohol has been drawn the Local Alcohol Profile for Cornwall, produced by the North West Public Health Observatory (NWPHO). This includes regional and national comparators which enable us to put measured alcohol-related harms in Cornwall into a wider geographical context. Other data sets A wide range of other complementary data sets were provided by partners and a full list of sources can be supplied on request. Comparing performance To make a meaningful comparison between Cornwall and other areas, it is useful to have a comparative measure and for the purposes of this interim assessment we have made temporal and geographical (regional and national) comparisons:

• Numbers for 2008/09 are compared to the previous year (2007/08). • Rate per 1000 resident population (for example, number of increasing risk drinkers) which

allows comparison with regional and national averages.

Introduction


Community consultation Consultation with communities, which includes service users, their families and carers as well as the community at large, is recognised as an important process in making services relevant and sustainable. The assessment aims to incorporate the views of the community on particular wherever possible, and information has been drawn from a number of sources. Place Survey The Place Survey is the new biennial statutory survey which all lower and upper tier local authorities are required to conduct. It captures local people’s views, experiences and perceptions2 about their local area, rather than the Council specifically, and allows local authorities to understand how residents’ views change over time and how they differ between different demographic groups across the county. It also draws on comparator data, where available, to understand how well the county is performing relative to other local areas. The first survey was conducted in Autumn 2008 and the ratified results were published in August 2009. 6,245 responses were received out of just under 18,000 distributed and the final results have been analysed and weighted3 to take into account proportional representation across a range of demographic variables (such as age, gender and ethnicity). Partners and Communities Together (PACT) With the introduction of the Home Office Neighbourhood Policing Programme, police forces were required to develop a process of engagement with all sectors of the community to improve quality of life by targeting the issues that matter locally. PACT meetings have been successfully established in 63 geographic areas across Cornwall and the Isles of Scilly (defined by police neighbourhood boundaries) and there are 4 PACTs that are countywide and defined by identity rather than place – traveller communities, migrant workers, the lesbian, gay, bi-sexual and transgender (LGBT) community and adults with learning disabilities. A multi-agency panel meets with the community on a regular basis (at minimum quarterly) to discuss the issues that need addressing as priorities in the area, how and when they will be addressed and also how members of the community can get involved. The ‘top 3’ priorities are recorded after each meeting and a quarterly data ‘snapshot’ is provided for this assessment.

2 The Place Survey collects 18 of the 198 national indicators prioritised by the Government, which are common to all areas and must be monitored in order to measure progress made in meeting key quality of life priorities 3 All results provided by Ipsos MORI, crown copyright reserved 2009 ©

Introduction


What is Cornwall? There are many myths and misconceptions about Cornwall. The following statements are based upon facts and figures collated by the Council and challenge the common perceptions of Cornwall. All too often Cornwall conjures up idyllic images of childhood holidays to the seaside; however, there is much more to Cornwall than this. Cornwall is more than… farms, fishing villages and second homes Cornwall has over 250,000 homes, not all of which are occupied by full time by residents. Its population is 530,000 and is growing steadily. The population increases significantly in during the summer months, the peak tourism season. There is a dispersed spread of towns, large and small across Cornwall, with a major city, Plymouth, on the eastern boundary. We have three significant conurbations: Camborne, Pool and Redruth; St Austell, Tywardreath and St Blazey; and Falmouth and Penryn. While these towns are smaller than urban areas elsewhere in the UK, they, along with many other freestanding large and small towns, exhibit similar characteristics.

Cornwall is more than… art galleries and campsites Tourism clearly has a significant influence on the area. Cornwall is a renowned and popular destination across the UK, and increasingly draws in international visitors. However, Cornwall has many other influential sectors, which are often be overlooked.

For example, the better than average economic growth experienced during 2000-2005 was driven by strong performance in the housing market and the retail sector, as well as public sector investment in areas such as educational infrastructure. Furthermore, manufacturing makes up more than 10% of the local economy. 30% of this is food and drink manufacturing, rooted in the farms for which Cornwall is so well known. There are strong sales in cheese, clotted cream, pasties and beer. However, Cornwall still has persistently poor earnings relative to national averages.

Introduction


Cornwall is more than… exclusively poor or wealthy Cornwall has concentrations of real visible wealth in terms of housing, cars, restaurants and hotels. However, there is also significant visible and hidden poverty, as evidenced by high benefits take up, part time and seasonal employment and low incomes.

Cornwall is more than … older people The percentage of older people living in Cornwall is growing, although recent migration trends have seen fewer younger people leaving. In addition to this, the majority of people moving to, or returning to, Cornwall, are of working age and getting younger. What it means to be older is changing as well, with longer working lives and longer retirement time. The rapid growth in the elderly population that Cornwall has experienced over the last 20 years is expected to slow during the next 20 years.

Cornwall is more than … a language Interest and study of the Cornish language is increasing. Cornish history and culture is wider than this, captured by sports, arts, creativity and industrial heritage. For many, Cornwall is a magical spiritual place, with legends and aspirations that add to the sense of belonging and identity. Cornwall is an increasingly diverse area in terms of ethnic backgrounds, national origins and religions, in this the tradition of being a welcoming place, associated with a rich maritime heritage is continued.

Cornwall is more than… postcard pretty Cornwall has a historic built environment to be proud of, with striking remnants of a globally influential industrial heritage designated as a World Heritage Site status. It also has large housing and employment estates that are decaying, some of which were built with little reference to the area in which they are set or the long term needs of the community. Recent developments in the built environment have set higher standards with eco buildings such as Jubilee Wharf in Penryn.

Cornwall is more than... Areas of Outstanding Natural Beauty Cornwall has many nationally and internationally recognised landscapes, including a superb coastline, a variety of moors and hidden valleys, all of which offer valuable recreational opportunities. Cornwall is also making use of its natural resources for energy. It leads the South West counties in terms of renewable energy production, with eight currently operational wind farms, as well as a wide range of other renewable energy technologies. Cornwall also has a number of proposed renewable energy projects, which aim to harness wave energy and to build on pioneering research to extract heat and power from geothermal sources.

Cornwall is more than … a place to live or visit, it’s a place to learn Cornwall has a growing knowledge economy, and there has been significant growth in higher and further education courses and places in Cornwall. The Peninsula Medical School and the University College Falmouth complement the highly regarded courses run by Falmouth College of Arts and the School of Mines (both now part of University College Falmouth). There are now over 2,000 students at the Tremough Campus alone.

Chapter 1 – Problem alcohol use and treatment


CHAPTER 1 PROBLEM ALCOHOL USE AND TREATMENT

Prevalence of problem alcohol use

Problem drinkers are those whose pattern of drinking brings a risk of or actual physical or psychosocial harm or symptoms of dependence – these are categorised as increasing risk, higher risk and dependent. Synthetic estimates for each level of problem drinking were calculated by the North West Public Health Observatory (NWPHO) to inform Local Alcohol Profiles and these have

now been updated to take into account the latest population estimates.

• Increasing risk drinking4 is defined as consumption of between 22 and 50 units of alcohol per week for males, and between 15 and 35 units of alcohol per week for females (previously described as hazardous)

• Higher risk drinking is defined as consumption of more than 50 units of alcohol per week for males, and more than 35 units of alcohol per week for females (previously described as harmful).

• Dependent drinking refers to people who are drinking above ‘sensible’ levels (less than 21 units for males and 14 units for females) and who are experiencing harm and symptoms of dependence.


• Using this methodology, 23% of the population or 101,000 people are estimated to have an alcohol problem in Cornwall.

• 2.4% or just over 10,000 are estimated to be dependent drinkers. • The figure below shows the estimates of need against the range of

alcohol treatment interventions for each level of severity.

Severe

Moderate

Harmful8,7462.0%

Hazardous81,85518.6%

Not yet developedNot yet developed

Increasing Risk81,85518.6%

Higher Risk (not dependent)8,7462.0%

Moderatelydependent

Severelydependent

Public health education programmes

Simple brief interventions in mainstreamhealth or other, non-health settings (eg GP)

Extended brief interventions in mainstreamhealth or other settings

Specialist treatment in generalist or specialistsettings (eg detox at home, with counselling)

Intensive specialist treatment(eg detox in hospital combined with residential rehab)

Dependent10,6902.4%

Source: adapted from Broadening the Base of Treatment for Alcohol Problems, Institute of Medicine (1990)

Cornwall South West England Level of problem % Number % % Dependent 2.4% 10,690 2.4% 2.8% Harmful (not dependent) 2.0% 8,746 2.0% 2.3% Hazardous 18.6% 81,855 19.6% 20.1% Total 23.0% 101,291 24.0% 25.1% Number in treatment 2008/09 1,884 12,820 104,104 % in treatment* 9.7% 6.8% 5.0% *of harmful drinkers estimate, including dependent

4 World Health Organisation



PROBLEM ALCOHOL USE AND TREATMENT


Prevalence of problem alcohol use (continued)

• The table shows the estimates for Cornwall compared with those for the South West and England. Any apparent differences between the estimated percentage in each type of problem drinking for Cornwall and the regional and national estimates are not significant.

• Specialist structured treatment relates to those at the top of the pyramid – higher risk and dependent drinkers. In 2008/09 1,883 service users in Cornwall engaged with structured treatment services for alcohol as primary problem substance, accounting for 9.7% of the estimate of higher risk (including dependent) in the county.

• This is notably higher than both the regional and national averages. Mapping the treatment system – tiers 1 and 2

Identification and brief advice (Tier 1)

• The National Alcohol Strategy highlights the importance of early intervention – if consistently implemented across the UK, simple alcohol advice would result in 250,000 men and 67,500 women reducing their drinking from increasing or higher risk to low risk each year.

• Screening is already provided in GP surgeries and a specialist substance use screening tool (SUST) is available for all services in contact with children and young people.

• Probation staff are being trained to screen offenders and some screening is carried out in Courts.

• The main priority for development is to identify and agree a set of screening tools, with a common training and implementation policy across a range of services, including Accident and Emergency, community midwives, Adult Social Care and targeted community agencies such as Housing and employment and advice centres.

• In Cornwall, initial assessment and extended brief interventions are provided through the GP-based service from Addaction and structured groups. Addaction also offer support via a telephone helpline.

• The homeless can access services through the outreach at St Petroc’s and Health for Homeless.

• Support is also available across Cornwall from Alcoholics Anonymous.

• Priorities for development include providing more flexible access to support, including improved telephone help and drop-in services, and providing extended brief interventions in Accident and Emergency. Consultation to inform the needs assessment process has also identified a need for more mutual aid and recovery groups and post-detoxification community support pathways.

• Tier 2 activity is not consistently monitored, in terms of numbers of people accessing services and those who subsequently move into the structured treatment system. Tier 2 treatment is often a ‘gateway’ into structured treatment for problematic users and improved monitoring of activity would enhance our understanding of how service users move into the treatment system.

Open access, non-care planned interventions (Tier 2)

AA Meetings in Cornwall: Bodmin (2) Fowey Newquay (3) St Ives

Bude Hayle (2) Penzance/Newlyn (4) St Mawes Callington Helston (2) Perranuthnoe (2) Truro (2)

Camborne (4) Launceston Polperro Wadebridge Camelford Liskeard (2) Redruth (2) Cawsands Looe Saltash Total: 42

Falmouth (2) Lostwithiel St Austell (2)




Mapping the treatment system – tiers 3 and 4

Service provision in Cornwall

• Tier 3 interventions available in Cornwall include structured psychosocial therapies and support, community detoxifications (Home and Dry), prescribing interventions to reduce the risk of relapse, structured day programmes and post-detox programmes (PoDs).

• Tier 4 includes in-patient interventions and residential rehabilitation. In-patient interventions are offered via a specialist bed at Treliske Hospital and through 3 community hospitals supported by GPs (CHADs) but many people have to be sent out of county to access treatment at specialist centres such as Broadreach in Plymouth. Residential rehabilitation is offered by Bosence Farm and Chy Colom.

Numbers in treatment 2008/09

• All figures for 2008/09 are based on data provided by NDTMS; all service users recorded with alcohol as their primary problem substance. The figures published in the Strategic Assessment 2007/08 related to adult service users only and were drawn from NDTMS record level data. This data was not available this year and figures have instead been drawn from year-end summary reports, which include young people. 2007/08 figures have been updated accordingly for comparison.

• Due to the range of Tier 4 providers (many of whom are out of county), however, the information relating to Tier 4 treatment through NDTMS has proved to be inconsistent.

• 1,883 service users engaged with structured treatment services in 2008/09, an increase of 16% compared with last year.

• This equates to 5.6 service users per 1000 population (aged 15 to 64 years), more than twice the regional and the national average.

• The majority of the growth was with the main service provider, Addaction, who treated an additional 297 people in the year (an increase of 29%), compared with 2007/08.

Service user profile

• The gender split in 2008/09 was 58% male and 42% female. There was a slight increase in the proportion of females accessing treatment (+1%). There is a higher representation of females in the alcohol treatment population than in the drug treatment population (where it is around 30%).

• The age profile of service users engaged with alcohol treatment services is much older than the drug treatment population (as shown in the chart below).

0

100

200

300

400

18 to

19

20 to

24

25 to

29

30 to

34

35 to

39

40 to

44

45 to

49

50 to

54

55 to

59

60 to

64 65+

AlcoholDrugs

• Consistent with last year, the majority of the alcohol treatment

population is aged 40 or over (59%, age based on year mid-point), indicating that treatment is not being sought until a problem is well-established.





Service provision in Cornwall

• Completion of the ethnicity field substantially improved over the course of the year, with only 3% omitted (compared with 29% last year). 94% of the alcohol treatment population was White British. 1% was from a non-white ethnic group, which based on the latest population estimates5, indicates that there is an under-representation of non-white ethnic groups in alcohol treatment.

• The majority of the alcohol treatment population (86%) presented with alcohol as their only problem substance. The most common secondary substance was cannabis (9%), and this shows a slight increase of 2% compared with last year.

Getting into treatment

• There were 501 new presentations to treatment in 2008/09.The majority of service users are referred to Addaction for structured alcohol interventions.

• Based on the information available6 waiting times for alcohol treatment were considerably longer than for drug treatment. On average 62% of waits were less than 3 weeks, compared with around 80% for drug treatment. The latest performance data, however, shows that local initiatives have been successful in bringing waiting times down, with very few service users waiting longer than 3 weeks to access treatment.

In treatment

• A breakdown of service users in treatment by type of treatment is not currently available from NDTMS. We do know, however, that the majority are receiving structured psychosocial interventions, which include regular planned therapeutic sessions with a key worker, addressing alcohol problems alongside mental and physical health needs, offending behaviour (if relevant) and social functioning.

• The NTA estimate that 10% of people in drug and alcohol treatment require in-patient interventions and a further 5% require residential rehabilitation.7 Tier 4 service provision can provide effective responses to problem use of drugs and alcohol in treating people whose use has been long and heavy, and people with complex needs, and can enable people to move towards long-term abstinence when and where appropriate. The NTA and National Institute for Health and Clinical Excellence (NICE) have published guidance relating to provision of Tier 4 services, highlighting the effectiveness of appropriate residential options.

• In-patient detoxification for alcohol can be accessed locally through one bed on the Liver Unit at Treliske hospital and through 3 community hospitals supported by GPs. The former is restricted to people with liver and gastroenterological problems and the latter is limited in the degree of complexity that can be managed. In-patient detoxification is also available out of county in specialist centres such as Broadreach House in Plymouth.

5 The latest figures from the Office for National Statistics (mid-2007) estimate that 3% of the population are from a non-white ethnic group 6 Three quarters were available for review – third and fourth quarters 2008/9 and first quarter 2009/10 7 NTA (2008), National Needs Assessment of Tier 4 Drug Services in England





In treatment (continued)

• There were 31 out-of-county in-patient interventions in 2008/09 and 27 referrals to residential rehabilitation services. Numbers are not available for the bed at Treliske but is estimated at 40 detoxifications per annum, and 60 community hospital detoxification placements are commissioned per annum.

• Taken together, in-patient interventions accounted for 7% of the total number in treatment in 2008/09 and residential rehabilitations accounted for 1%, falling short of the expected 10% and 5% respectively.

• Demand for in-patient assisted withdrawal from alcohol in Cornwall considerably outstrips provision and many clients perceive it as being protected and inaccessible. Bringing the level of enrolment in in-patient alcohol detoxifications up to the target level of 10% requires additional capacity building locally, as well as additional funding for out-of-county interventions.

• Locally a Tier 4 project is being developed with Bosence Farm, a non-statutory service that provides residential treatment to drug and alcohol users based on abstinence, through a partnership of the independent sector, Primary Care services and Cornwall Partnership Trust.

• This would provide much needed capacity for in-patient interventions in the county, and also provide the potential for specialist placements for young people (who will have no in-patient options at all following the closure of Middlegate Lodge, the only specialist centre nationally for young people) and particular vulnerable groups such as those with dependent children. Funding is being sought through the Local Area Agreement.

Leaving treatment • 535 service users exited the treatment system in 2008/09. 59% left in a care planned way and 6% were referred on to another provider.




Key findings

Problem alcohol use and treatment

• 23% of the population in Cornwall (101,000 people) are estimated to drink at a level that puts their health at risk, of which 4.4% or 19,500 people are causing themselves actual physical or psychosocial harm or experiencing symptoms of dependence.

• The level of higher risk drinking is not significantly different from the regional or national averages but we are more successful in attracting higher risk drinkers into treatment. 10% of the estimated number of higher risk drinkers received specialist treatment for alcohol dependency in 2008/09; twice the national average and 43% above the regional average.

• National research shows that early identification and intervention, such as providing targeted advice, plays a crucial role in helping those with an alcohol use problem to reduce their drinking to a lower risk level.

• The age profile of dependent drinkers in specialist treatment indicates that treatment is not sought until a problem is well-established (the majority are aged 40 and over).

• Currently there is no common assessment tool or tools for screening individuals for problem alcohol use in Cornwall. If agreed, this would facilitate screening in a wider range of settings (not just GPs and services in contact with young people).

• Service mapping and consultation indicates that there is a need for more flexible access to support, both at the start (advice and brief interventions) and at the end (mutual support and recovery groups) of the treatment journey.

• A particular service gap has been identified in Accident and Emergency departments – both at the screening stage and the capacity to offer brief interventions.

• 8% of people who received specialist treatment in 2008/09 were in in-patient (7%) or residential rehabilitation (1%) services. This falls far short of the anticipated need of 15% (National Treatment Agency). Historical perceptions of the inaccessibility of these services, compounded by a lack of capacity locally, were highlighted as key factors.

• The majority of people who received specialist alcohol treatment in 2008/09 (59%) completed treatment successfully.

Chapter 2 – Harm reduction


CHAPTER 2 HARM REDUCTION Alcohol and harm to health

The Joint Strategic Needs Assessment (JSNA) is one of the major requirements of the Our Health Our Care Our Say white paper and the government’s aim is to ensure that the local health community

and local government are using the same analysis of population need for health and social care services to determine local commissioning priorities.

The JSNA made the following key findings in relation to alcohol-related harm in Cornwall: • Cornwall’s Health profile, 2007 points out that the rate of admission to hospital for alcohol specific

conditions is higher than the England average. • In 2005/06 there were 1401 hospital stays due to alcohol; this was a directly age sex

standardised rate of 275.5 people /100,000 compared with 247.7/100,000 in England. • Up to 140,000 working days are lost in Cornwall and the Isles of Scilly each year due to alcohol

related sickness.

Information relating to the harms of alcohol has been drawn previously from the Local Alcohol Profile for Cornwall, produced by the North West Public Health Observatory (NWPHO) in 2007. Indicators

have subsequently been updated for 20098 and the key points are summarised here.

Hospital admissions for alcohol-related harm (NI39)

• The Department of Health has improved the way it estimates alcohol-related harms and the way it tracks progress to address them in the NHS. Previously just three principal blocks of data on alcohol-related admissions were counted – alcohol liver disease, acute toxic effect of alcohol and alcohol-related mental health disorders. These data alone significantly underestimate the extent to which patients with alcohol-related disease and injury are presenting for treatment within the NHS.

• A new indicator was introduced on 1 April 2008 (NI39), as part of the national indicator set, which considers a range of diseases and injuries in which alcohol can play a part and estimates the proportion of cases that may be attributed to the consumption of alcohol.

• There were 1,401 hospital admissions for alcohol-related harm per 100,000 population (around 7,500 admissions) in 2007/08 and the number is projected to rise by 23% over the next three years.

• Reducing the rate of increase is a priority for Cornwall and the rate of admissions is a key indicator within the Local Area Agreement. This is a joint indicator with Health (Vital Signs Indicator VSC26). The target is to record a maximum of 1,617 admissions per 100,000 population in the year to March 2011 – which is an increase of 15% from 2007/08 compared with the projection of 17%.

• Cornwall was ranked 191 out of 354 local authorities (where 1 is the worst) for hospital admissions for alcohol-related harm in 2007/08. The local rate was in line with the regional average but significantly lower than the national average.

• The new indicator is not directly comparable with the previously published measure of alcohol-specific hospital admissions although the two are, inevitably, very strongly correlated. Alcohol-specific hospital admissions continue to be measured and the table below shows the directly standardised rates per 100,000 population for males and females (2007/08) and the crude rate per 100,000 for young people under the age of 18 (2005/06 to 2007/08) compared with the regional and national averages.

8 NWPHO from Health Survey for England, using Hospital Episode Statistics, ONS mid-year population estimates and mortality data and the Census 2001.



HARM REDUCTION

Alcohol and harm to health

Hospital admissions for alcohol-related harm

Area Males

DSR per 100,000

Females DSR per 100,000

Under 18s, crude rate

per 100,000 LA Rank 203 204 256 Cornwall 364.5 185.9 96.9 South West 331.7 178.9 78.6 England 373.7 189.5 72.3

• The rate for males is significantly higher than the regional average,

although the difference from the national average is not significant. The rate for young people is significantly higher than both the regional and national averages and this finding is consistent with last year.

• Previously this data has been available at former district level and has shown that the problems are in Central and West Cornwall (Carrick and Kerrier were ranked within the worst 10% nationally).

Mortality linked to alcohol

• Alcohol-specific refers to conditions that are wholly related to alcohol, such as alcohol liver disease or alcohol overdose. Alcohol-attributable conditions include alcohol-specific conditions plus conditions that are caused by alcohol in some, but not all, cases (e.g. stomach cancer and unintentional injury).

• The rates of deaths from both alcohol-specific and alcohol-attributable conditions in Cornwall are not significantly different from the regional or the national average.

• The next table shows the number of alcohol-specific deaths9 (all ages), shown as a directly standardised rate (DSR) per 100,000 population and the national local authority rank. Rates for females in both cases are more highly ranked than males.

Alcohol-specific Alcohol-attributable Area Males Females Males Females LA Rank 165 125 213 152 Cornwall 10.7 4.5 37.8 13.9 South West 11.6 4.9 33.7 13.2 England 12.7 5.9 36.1 15.2

Deaths from land transport accidents

• Data from the Local Alcohol Profiles shows that the estimated number of deaths attributable to alcohol from land transport accidents10 is significantly higher in Cornwall than the regional and national average.

Area DSR per 100,000

(all ages) LA rank 248 Cornwall 2.5 South West 1.9 England 1.8

• Previous figures provided at former district level indicated that the

main issues were in the East of the county.

9 NWPHO from ONS mortality data and mid-year population estimates. 10 Directly standardised rate per 100,000 population, NWPHO from Compendium of Clinical and Health Indicators, National Centre for Health Outcomes Development 2005-07 pooled and Office for National Statistics mid-year population estimates 2005-2007. The Strategy Unit's alcohol-attributable fraction was applied to obtain the estimates.



HARM REDUCTION


Claimants of Incapacity Benefit due to alcoholism

• Figures from the Department of Work and Pensions (see chart below) show that whilst the proportion of the population claiming Job Seekers Allowance has remained fairly in line with the regional average over the last 5 years, the proportion claiming Incapacity Benefit (now including Employment and Support Allowance) has consistently been considerably higher.

• Over the last few years we have seen the number of claimants of Incapacity Benefit steadily increase, whilst Job Seekers allowance claimants dropped. The rising trend peaked at the beginning of 2007/08 and has shown some decline in the last two years (a reduction of 3% by February 2009).

• The impact of the recession on the number claiming Job Seekers Allowance can be clearly seen in the latter half of 2008/09.

3.1

7.6

2.9

6.2

012

3456

789

Feb-04

Jun-0

4

Oct-04

Feb-05

Jun-0

5

Oct-05

Feb-06

Jun-0

6

Oct-06

Feb-07

Jun-0

7

Oct-07

Feb-08

Jun-0

8

Oct-08

Feb-09

Rat

e pe

r 100

0 w

orki

ng a

ge

Cornwall Job Seeker Cornwall Incapacity / ESASouth West Job Seeker South West Incapacity / ESA

• Figures published by the NWPHO for claimants of health-related

benefits specifically due to alcoholism show that the Cornwall has a significantly higher rate than the national average, although the apparent difference from the regional average is not significant.

155.8

142.7

130.6

England upper bound

115120125130135140145150155160

Cornwall South West EnglandCru

de ra

te p

er 1

00,0

00 w

orki

ng a

ge

• Rates at a sub-Cornwall level are no longer available but historical figures have shown that rates are significantly lower than average in the East of the county, whereas rates in the former local authority areas in Central and West Cornwall were ranked within the worst quartile nationally.



HARM REDUCTION

Key findings


• At 1,401 admissions per 100,000 population (2007/08), the rate of hospital admissions for alcohol-related harm is in line with the regional average and significantly lower than the national average.

Comparison with regional and national indicators indicates that performance in Cornwall is significantly worse than the regional and / or national average in the following areas: • The rates of admissions for alcohol-specific conditions for males

(all ages) and under 18s • Deaths from land transport accidents attributable to alcohol • The rate claiming health-related benefits specifically due to

alcoholism. The proportion of the working age population who are claiming health-related benefits (any reason) is consistently higher in Cornwall than average for the South West.

Chapter 3 Accommodation and homelessness


CHAPTER 3 ACCOMMODATION AND HOMELESSNESS

Accommodation need and provision

Housing need

• Where accommodation status was recorded, 31% of people who started new treatment journeys in 2008/09 presented for treatment with accommodation problems, of which 8% were homeless.

• Comparison with last year and with the regional average remains problematic due to continued low recording rates for this information (only 78% of service users locally and 71% in the South West and this is an improvement on last year). Based on the information that was recorded, however, the proportion of service users presenting with accommodation problems is in line with the regional average and not much changed from last year.

Existing provision

• Obtaining suitable accommodation and accommodation-related support is a critical factor in ensuring access to the treatment system and in supporting treatment outcomes for clients throughout and after their treatment journey.

• There are 126 units of accommodation in Cornwall11 specifically designated for people with drug and / or alcohol problems. People with drug and alcohol problems are also accommodated in units primarily designated for other client groups, in particular rough sleepers, single homeless and ex-offenders. The majority of housing provision requires the client to be ‘misuse free’ (not drinking or using illicit drugs).

• Research to inform the needs assessment has identified the highest levels of unmet need amongst people with drug and alcohol problems who have complex needs, those who lapse or relapse and those who are required to move on from supported accommodation.

• The housing needs of people with drug and alcohol problems, and the degree to which they are adequately met, are considered in Cornwall Council’s Homelessness Review 2009,12 which includes consultation with people accessing current housing services.

• Key themes emerging from the consultation are a need for better and more accessible information relating to housing, legal issues, support and treatment options (including addressing fears about loss of tenancy and / or children) and a perceived lack of tolerance and understanding amongst current supported housing providers.

11 Latest data available to the DAAT 12 The review is currently in draft. The findings will provide the foundation of the Homelessness Strategy for Cornwall, which will be published by April 2010.

Chapter 3 Accommodation and homelessness


ACCOMMODATION AND HOMELESSNESS

Key findings

Key findings

• 31% of people starting new treatment journeys in 2008/09 had accommodation problems, of which 8% were homeless. Obtaining suitable accommodation and accommodation-related support is a critical factor in ensuring access to the treatment system and in supporting treatment outcomes for clients throughout and after their treatment journey.

• In Cornwall, those with the highest levels of unmet need are problem drug and alcohol users with complex needs, those who lapse or relapse and those who are required to move on from supported accommodation.

Chapter 4 – Alcohol and crime


CHAPTER 4 ALCOHOL AND CRIME

Alcohol-related violence

Alcohol-related violence is discussed in detail in the annual strategic assessment produced for Cornwall CDRP, which can be downloaded from the Amethyst website

www.amethyst.gov.uk/strataudit.htm The main tables and key findings only are included here.

A violent crime is categorised as alcohol-related if the offence is recorded as taking place on a licensed premises and / or the offender was perceived to be under the influence. Alcohol markers may be recorded with any type of violent crime – homicide, violence against the person, sexual

offences and robbery.

050

100150200250300350

Apr-06

Jul-0

6

Oct-06

Jan-0

7

Apr-07

Jul-0

7

Oct-07

Jan-0

8

Apr-08

Jul-0

8

Oct-08

Jan-0

9

Num

ber o

f crim

es

All recorded crime by month with moving annual average (red line)

Change since 2007/08

Service area Rate per 1000 Crimes Change

(crimes) Change

% General trend

East 4.4 740 -65 -8.1% Flat / reducing Central 4.8 983 -252 -20.4% Reducing West 6.2 975 58 6.3% Rising / flat Cornwall 5.1 2,698 -259 -8.8% Reducing

Extent and trends

• 47% of violent crime was recorded as linked to alcohol. Alcohol-related violence reduced by 9% compared with 2007/08 and the trend was reducing to the end of the year. The majority of the reduction was in assaults with injury.

• 29% of all alcohol-related violence was recorded as domestic. The trend for alcohol-related domestic violence was rising throughout the year, predominantly in offences of actual bodily harm. Excluding domestic violence, alcohol-related violence showed a stronger downwards trend.

• Alcohol-related violence follows a seasonal pattern, with higher levels of recorded crime during the summer months. On average there are 13% more crimes per month between June and August (based on 3 years crime numbers).

• The impact of seasonality is stronger in popular holiday areas, with Newquay seeing the most significant average rise (around 50%) per month during this period.

• Comparable rates per 1000 population for alcohol-related violence are not currently available through iQuanta.

• The British Crime Survey 2008/09 found that nationally the offender was perceived to be under the influence in 47% of all violent incidents. This relates to surveys of actual experience, rather than the percentage shown in recorded crime data but does indicate that the local picture may be similar to the national.



ALCOHOL AND CRIME


Extent and trends (continued)

• In April 2008 the Home Office introduced a number of changes in the counting rules for grievous bodily harm (GBH – see the strategic assessment for full details), which has resulted in an apparent rise in more serious offences. The impact of this should settle within the coming year.

• The next table shows the breakdown of violence against the person by type (using the new rules) and shows the substantial rise in the number of serious assaults.

• There was also a rise in offences categorised as other violence, the majority of which relate to possession of weapons in a public place and is likely to reflect increased proactive behaviour of the police in response to strong focus nationally on this issue.

• Total assaults with injury (serious and other assault), which make up 58% of alcohol-related violence, saw the greatest overall reduction but all other types of violence reduced.

Breakdown of alcohol-related violence by crime type in Cornwall 2008/09

Crime Type Crimes 2008/09

% of alcohol-related

Crimes 2007/08

% of alcohol-related

Change (crimes)

Change %

Homicide 1 0.0% 2 0.1% -1 -50.0% Serious Assault 89 3.3% 43 1.5% 46 107.0% Other Assault 1,466 54.3% 1,682 56.9% -216 -12.8% Common Assault 555 20.6% 617 20.9% -62 -10.0% Harassment 423 15.7% 431 14.6% -8 -1.9% Other Violence 75 2.8% 56 1.9% 19 33.9% Violence against the person 2,609 96.7% 2,831 95.7% -222 -7.8% Sexual offences 76 2.8% 104 3.5% -28 -26.9% Robbery 13 0.5% 22 0.7% -9 -40.9% Total alcohol-related 2,698 2,957 -259 -8.8% Source: Devon & Cornwall Police

Extent and trends (continued)

• The estimated cost of alcohol-related violence in 2008/09 was £43.3 million, of which £4.6 million are health-related costs, which includes A&E, ambulance, medical staff time, treatment for injuries and aftercare (such as physiotherapy).

• Data relating to ambulance call-outs and presentations to A&E for assaults, despite being included within the minimum data sets prescribed as a duty to share by the Home Office13, is not currently provided to the Crime and Disorder Reduction Partnership, thus the impact of violent crime in terms of injuries sustained and the resource implications for health remains a significant knowledge gap.

Day and time

• The day / time profile for alcohol-related violence is similar to that for all violence in that the level of crime builds throughout the day to a peak late at night / early hours of the morning.

• Alcohol-related violence is more concentrated, however, around the peak times associated with the night-time economy than all violence (see next chart).

13 Delivering Safer Communities, A guide to effective partnership working (Home Office, 2007)



ALCOHOL AND CRIME


Victim

• Young males were most likely to be victimised in non-domestic alcohol-related violence, with those aged 18 to 24 at highest risk. Victims of alcohol-related domestic violence were more likely to be female and, although the age profile is weighted towards younger victims (aged 20 to 24 years), the peak was less pronounced and there was a wider spread of victimisation by age.

5.5

12.3

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

0-4 5-910

-1415

-1920

-2425

-2930

-3435

-3940

-4445

-4950

-5455

-5960

-6465

-69 70+

DomesticNon-domesticAverage DomesticAverage Non-domestic

• Excluding domestic violence (where the ACPO definition is limited

only to offences where the victim and offender are adults), in 14% of recorded alcohol-related violence the victim was under 18 years of age. In 2008/09 alcohol-related violence against under-18s reduced by 32% compared with the previous year.

Offender (continued)

• Offender data linked to crimes is not currently made available for this assessment. Some useful information is available for offenders aged over 18, however, from Probation caseload data.

• Probation data does not show whether the offender was perceived to be under the influence at the time that the crime was committed but some general details of problem alcohol use are recorded as part of the comprehensive offender assessment – whether problem alcohol use is linked to their offending or presents a risk of serious harm.

• Previous research into offenders and problem alcohol use in the South West14 found that nearly two thirds of prisoners had an alcohol use disorder, of which roughly half were increasing risk / higher risk drinkers and half were alcohol dependent. The South West had a higher proportion of offenders with needs around problem alcohol use than the national average.

• The same research reported that problem alcohol use was recorded as linked to offending for 52% of offenders on the South West Probation caseload. Locally in 2008/09, problem alcohol use was recorded as linked to offending for 57% of offenders; this is consistent with previous years and indicates that problem alcohol use may be more of an issue in Cornwall than in the region as a whole.

• Violent offenders are more likely to have identified problem alcohol use – 69% were recorded as having an issue linked to their offending and 51% were considered to be at risk of serious harm.

• Violent offenders with an identified alcohol use problem are also more likely to be / have been a perpetrator of domestic violence – 52% compared with 31% for the offender caseload as a whole.

• The age profile for violent offenders with an alcohol use problem is weighted towards younger offenders with 34% aged under 25 years.

14 Walsh A. (2007), A Needs Assessment of Alcohol Treatment Services for Offenders in the South West Criminal Justice System, commissioned by Government Office for the South West



ALCOHOL AND CRIME


• Cornwall has an established adult substance (drugs and alcohol) misuse referral scheme. The Criminal Justice Integrated Team (CJIT) is a multi-agency team that provides needs-based drug and alcohol treatment and interventions, addressing physical and mental health, social care and housing as well as criminal and anti-social behaviour. There are good working practices in place in Cornwall to allow offenders to be referred across different criminal justice strands such as Arrest Referral and the Drugs Intervention Programme. The Drug (DIP) conditional caution and the Alcohol Conditional Caution are both provided in Cornwall, with the Substance Misuse Arrest Referral team within the CJIT providing the relevant assessments and interventions.

• Current developments include: o Training all Probation staff to use the AUDIT15 tool to

undertake alcohol assessments and make appropriate referrals for all offenders on the Probation caseload.

o Increasing the use of the Alcohol Short Programme16 (ASAR) for offenders with violent index offences (including domestic violence) committed when “in drink”. This is a low intensity alcohol model and suitable for offenders who have an alcohol problem but are not dependent (thus traditional specialist treatment is not appropriate); the 14 session group programme is delivered by Probation and Addaction covering a range of issues including taking responsibility, understanding the consequences of behaviour and alcohol awareness.

o Probation and Alcohol Treatment providers have just commenced delivery of the Alcohol Treatment Requirement in Cornwall, which is a 6 month Court Order Requirement, geared towards offenders dependent on alcohol, with an AUDIT score of 25 or above.

15 AUDIT is the Alcohol Use Disorders Identification Test. It has been developed by the World Health Organisation as a simple screening tool to pick up the early signs of hazardous and harmful drinking and identify mild dependence. 16 ASAR is currently only for offenders referred from the courts through a Specified Activity Requirement within a community sentence and thus not accessible to the wider Drugs Intervention Programme / Alcohol Arrest Referral population.



ALCOHOL AND CRIME

Alcohol-related violence Cornwall Arrest Referral:

2008-09 2009-10 up to 06/12/09

All Contacts 1135 675Avge no. of contacts per

month 94.58 c. 82

Primary Alcohol 707 62.29% 475 70.37%Secondary Alcohol 44 17

Tertiary Alcohol 8 1Total Alcohol 759 66.87% 493 73.04%

63.25 per month 60.12 per monthSignpost/referrals

to Addaction 136 12% of contacts 53 7.9% of contacts

11.33 per month 6.46 per month

Of which Drug and Alcohol Exit Risk

Assessment referrals 604 53.22 542 67.41%


Camborne 20 3.3% 79 14.0%Launceston 511 84.6% 362 66.8%Newquay 76 12.5% 88 16.2%

Other 9 1.4% 13 2.4%

Alcohol Exit Risk Assessment referrals 476

78.81% of Exit

RAs358 78.68% of Exit

Ras


Arrest Referral

• There is evidence of a fall in overall recorded Arrest Referral contacts of around 12 per month in the last year, but the number of alcohol contacts has only reduced by 3 per month.

• The proportion of alcohol contacts within the caseload has increased by 4% to 73%.

• Exit Risk Assessment referrals are increasing. Newquay and Camborne’s proportion of referrals is increasing, despite the number of referrals from Launceston still rising from 42.6 per month, to 44.1.

• This suggests that the physical cover of custody by Arrest Referral workers is reducing, and the Custody Centres are making more referrals on paper through the Exit Risk Assessment system.

• Alcohol cases make up 78% of Exit RA referrals, with the overall number of alcohol Exit RAs increasing by 4 to 43.6 per month.

• These figures demonstrate that a thorough Arrest Referral Scheme needs to continue to cover Alcohol cases, as well as Drugs.

Location

• The next table shows the rates and volumes of recorded alcohol-related violence by community network area.

• The principal hotspot for alcohol-related violence was Newquay, where crime was concentrated around pubs and clubs in the town centre. In 2008/09 crime in the town centre saw a significant drop compared with last year. Crime in Newquay is highly seasonal and additional resources are allocated every summer.

• The other main hotspots were the town centres of Penzance, Truro, Falmouth, Camborne and Launceston, where the level of crime is more constant throughout the year.



ALCOHOL AND CRIME


Change since 2007/08

Network area Rate per 1000

% violent crime

linked to alcohol

Crimes Change (crimes)

Change %

Newquay 10.0 60% 269 -114 -29.8% Penzance, Marazion and St Just 8.7 55% 342 49 16.7% Bodmin 6.8 45% 130 -14 -9.7% Hayle and St Ives 6.4 52% 165 19 13.0% Camborne and Redruth 6.0 40% 355 -18 -4.8% Launceston 6.0 50% 107 25 30.5% Falmouth and Penryn 5.9 46% 242 -11 -4.3% Liskeard and Looe 5.2 46% 172 -11 -6.0% St Austell 5.0 42% 153 -47 -23.5% Saltash and Torpoint 4.3 48% 136 -36 -20.9% Truro and Roseland 4.0 43% 175 -36 -17.1% Bude 3.8 54% 64 -4 -5.9% Wadebridge and Padstow 3.5 52% 72 2 2.9% Helston and the Lizard 3.5 54% 113 8 7.6% St Blazey, Fowey and Lostwithiel 2.7 38% 53 -19 -26.4% China Clay 2.3 40% 59 -1 -1.7% Callington 2.1 30% 38 0 0.0% St Agnes and Perranporth 1.8 43% 32 -24 -42.9% Camelford 1.7 25% 21 -27 -56.3% Cornwall 5.1 47% 2,698 -259 -8.8%

Location (continued)

• The next maps show alcohol-related violence mapped to small areas17 within the East, Central and West service delivery areas.

• The maps clearly show that alcohol-related violence is a town centre issue; the rates of crime outside the town centres are generally low.

East Cornwall

17 Statistical boundaries known as Lower Super Output Areas, home to approximately 1,500 people – see page 11 for more information.



ALCOHOL AND CRIME

Alcohol-related violence Central Cornwall

West Cornwall

Community perceptions

• Community perceptions of issues linked to alcohol are more focused on the anti-social aspects of drinking behaviour, such as drunk or rowdy behaviour in public places, rather than the threat of actual violence. Overall in Cornwall, the Place Survey found that 27% of residents thought that drunk or rowdy behaviour was a problem in their local area, which is an improvement of 5 percentage points compared with the last survey (2006/07) and in line with national and regional averages.



ALCOHOL AND CRIME


Community perceptions (continued)

• Network areas where drunk or rowdy behaviour was seen as a bigger problem than average, such as in Bodmin, Newquay, St Austell, Penzance and Camborne and Redruth, also saw a higher proportion of residents feeling unsafe outside after dark in their local area.

• A snapshot of community priorities identified through PACT (June 2009) shows that 25% of neighbourhoods identified an alcohol-related issue (alcohol-related disorder, street drinking or under-age drinking) as a priority in their area. Of these 16 areas, 7 chose it as their top priority - Newquay town centre, Penzance town centre, Camborne North (Tuckingmill) and West (town centre), Arwenack (Falmouth town centre), Callington and Calstock. With the exception of Penzance, alcohol-related disorder was not a priority for these communities a year ago, when the PACT snapshot was last reviewed for this assessment.

• Newquay has hit the headlines in recent months following the tragic deaths of two teenagers from cliff falls after they had been drinking. A public meeting in July organised by Newquay Residents’ Association saw the council and police come under strong criticism for problems with anti-social behaviour, noise and vandalism and alcohol-related crime and disorder in the town.

• Particular focus has been drawn to the influx of under 18s coming to Newquay unaccompanied in the summer, especially in the period post-GCSE exams. Although it is difficult to quantify the actual number of partygoers descending on Newquay in the summer months, a recent report18 quoted approximately 2,500 post-GSCEs students arriving in the first two weeks of July. The report also cited the town’s popularity as a destination for ‘stag’ and ‘hen’ weekends and drinks promotions as particular issues of concern.

• There has been a significant drop in the level of actual recorded crime in Newquay, including involving under 18s as victims, and although the latest figures (to July 2009) indicate that violent crime numbers this summer are slightly up on last year, they remain lower than the previous two summers. Anti-social behaviour in the police beat area that covers the town centre has remained fairly stable for the last couple of years but there was a higher level of reports in June 2009 compared with previous years.

• Anecdotal local reports suggest, however, that whilst there may be fewer problems in the immediate town centre (around the pubs and clubs), anti-social behaviour and excess noise has become more of a problem in residential areas near the town centre, particularly in and around budget accommodation such as ‘surf lodges’.

• Although the risk of becoming a victim of alcohol-related violence has significantly reduced in Newquay, this is only part of the picture in terms of the impacts of problem alcohol use and the night-time economy. Other factors, such as the levels of anti-social behaviour, the high visibility of revellers in the town centre, the high density of licensed premises, including lap dancing bars (which are not found anywhere else in the county) and concerns over the safety of young binge drinkers, may have a stronger influence on public opinion.

• For young people (under 18s) the risk of becoming a victim of crime is lower in Newquay than in most of the other large towns, such as Truro, Camborne, Penzance, Falmouth and St Austell. Other risks relating to personal safety, problem alcohol use and involvement in anti-social behaviour, however, remain major concerns.

18 Newquay Safe – Executive Report, Cornwall Council, August 2009



ALCOHOL AND CRIME


Tackling alcohol-related violence

• The Alcohol Strategy for Cornwall and the Isles of Scilly was launched in 2006 and identified gaps in service provision and considered the development and improvement of alcohol policy and services throughout Cornwall. It covers all aspects of problem alcohol use including the social use of alcohol and the night-time economy, crime, public safety, health and social care, young people, treatment for addicts, housing and homelessness and alcohol at work.

• A dedicated Alcohol Officer is short-term funded by the CDRP to oversee the implementation of the Strategy.

• Measures from the Strategy to reduce crime and disorder linked to alcohol include:

o Increasing the number of designated public place orders, which restrict the consumption of alcohol on the streets and in public places;

o Expansion of the PubWatch Scheme to counter under-age drinking and serving people who are already drunk;

o Increasing the number of alcohol test-purchasing operations to reduce under-age sales of alcohol;

o A specialist Pubs and Clubs worker, employed by Addaction who works closely with police, DAAT, the Licensing Authority, the licensed trade and other organisations such as PubWatch, and provides targeted multi-site training county-wide to promote good practice, reduce the competitive pressure (such as around underage sales) and trains staff on drug and alcohol awareness

• Street pastors, volunteers from local churches who provide night-time economy patrols to help vulnerable and intoxicated people with the aim of preventing incidents occurring, were launched as a pilot in Camborne and consideration is being given to extending this to Newquay and other key towns (Truro, St Austell, Bodmin, Falmouth).

• Tackling assault with injury, which makes up 60% of alcohol-related violence, is an on-going priority for CDRP, and activity has been focused on interventions with young people, who are most at risk of becoming involved in violence, both as victims and as offenders.

• Projects over the last couple of years have included education (such as the Blitz theatre project in secondary schools, which uses theatre to raise awareness about the impact of problem alcohol use, amongst other key issues such as anti-social behaviour and sexual health, and promote positive attitudes to drinking and responsible behaviour), physical activity programmes (football, boxing, street dance) and creative programmes (creating street art and graphic novels). The group has also funded a dedicated part-time youth worker for the Gwavas Estate in Newlyn.

• Many of these projects have engaged directly with young people either already involved in offending or identified as at risk. As well as providing positive activities, projects also aim to provide mentoring opportunities, build self-esteem and raise awareness about the impact of negative behaviour.

• Although formal evaluations have not been undertaken, targeted activities in the East of the county are believed to have contributed to the measurable impact seen on violent crime in this area, including alcohol-related violence (which dropped by 30% amongst under 18s) and there are positive indications in other areas, such as Falmouth.



ALCOHOL AND CRIME


Tackling alcohol-related violence (continued)

At a local level, police and partners (including the licensing trade) are working together to respond to persistent hotspots, identify problem premises and implement both preventative and enforcement measures to reduce the level of alcohol-related crime and disorder. • The licensing authorities in Newquay, Penzance and Truro have

succeeded in securing Cumulative Impact Zones (CIZ) in the town centres – an agreed defined area in which there is evidence of an accumulation of crime due to a high concentration of licensed premises in that area. A CIZ gives the licensing authority greater powers but also switches the responsibility from the licensing authority to the licensee, when a request for a new or extended license is submitted, to show that the new license will not have an accumulative effect on crime. This makes it much more difficult for new or extended licenses to be introduced and therefore prevents the escalation of crime.

• Additional police and partnership resources are provided every summer in Newquay, to minimise risk, provide a safe environment for people to enjoy themselves and optimise opportunities for early intervention if issues do arise. Initiatives include restricting discounted alcohol sales, rigorous policing of under-age drinking, additional high visibility patrols (police and partners), providing help to vulnerable people found on the streets (StreetSafe) and alternative night-time activities for under 18s. In July 2009 the Newquay Safe Partnership19 was set up, which includes a multi-agency Steering Group to plan and oversee future activities for the town.

19 For more information the Newquay Safe Executive Report can be downloaded from http://www.cornwall.gov.uk/default.aspx?page=20418



ALCOHOL AND CRIME

Key findings

Key findings

• 47% of violent crime was recorded as linked to alcohol. Alcohol-related violence reduced by 9% compared with 2007/08 and the trend was reducing to the end of the year. The majority of the reduction was in assaults with injury.

• 29% of all alcohol-related violence was recorded as domestic. The trend for alcohol-related domestic violence was rising throughout the year, predominantly in offences of actual bodily harm. Excluding domestic violence, alcohol-related violence showed a stronger downwards trend.

• The day / time profile for alcohol-related violence was more concentrated around the peak times associated with the night-time economy than all violence.

• Young males were most likely to be victimised in non-domestic alcohol-related violence, with those aged 18 to 24 at highest risk. Victims of alcohol-related domestic violence were more likely to be female and, although the age profile is weighted towards younger victims (aged 20 to 24 years), the peak was less pronounced and there was a wider spread of victimisation by age.

• 70% of violent offenders on the Probation caseload have been identified as having a problem with alcohol and a large proportion are aged under 25 years. Regional research indicates that problem alcohol use is more prevalent amongst offenders in Cornwall than the regional average.

• The principal hotspot for alcohol-related violence was Newquay, where crime was concentrated around pubs and clubs in the town centre. In 2008/09 crime in the town centre saw a significant drop compared with last year. Crime in Newquay is highly seasonal and additional resources are allocated every summer.

• The other main hotspots were the town centres of Penzance, Truro, Falmouth, Camborne and Launceston, where the level of crime is more constant throughout the year.

• Community perceptions of issues linked to alcohol are more focused on the anti-social aspects of drinking behaviour, such as drunk or rowdy behaviour in public places, rather than the threat of actual violence. Network areas where drunk or rowdy behaviour was seen as a bigger problem than average, such as in Bodmin, Newquay, St Austell, Penzance and Camborne and Redruth, also saw a higher proportion of residents feeling unsafe outside after dark in their local area.

• The impact of violent crime in terms of injuries sustained and the resource implications for the Ambulance Service and Accident and Emergency remains a significant knowledge gap.

Chapter 5 – Young people


YOUNG PEOPLE

Problem substance use (alcohol and / or drugs)

There is a separate comprehensive substance use needs assessment for young people. The assessment is available at http://www.cornwall.gov.uk/default.aspx?page=19543 YP Substance Use Needs Assessment: http://www.cornwall.gov.uk/idoc.ashx?docid=293cf548-6c36-49c3-a24b-bced4264d9c0&version=-1 YP Substance Use Treatment Plan: http://www.cornwall.gov.uk/idoc.ashx?docid=47ce48a2-8e9a-455f-87be-4b685d289357&version=-1

The information in this section is a summary drawn from NDTMS reports containing data for clients aged under 18 years at midpoint of the year in tier 3 and 4 structured treatment, including where the primary presenting substance is alcohol. Young people receiving a brief intervention only (such as

advice and information) are not recorded on NDTMS.

Yz-Up is Cornwall’s integrated drug and alcohol service for young people and includes all aspects of delivery from prevention to specialist treatment. Although the service is primarily for under 18s, Yz-Up

works with young people up to the age of 24 years.

This section also looks at attitudes to drugs and alcohol and their use amongst under 18s (taken from recent surveys carried out in schools), underage drinking and harm to health.


• 140 young people under the age of 18 received treatment for problem substance use in 2008/09, an increase of 16% or 19 service users compared with last year.

• The increase in number comes from young people referred for a drug as primary problem substance, which increased by almost 50% compared with 2007/08.

• 21% (30 young people) have been in treatment for two years or longer.

• A further 138 young people aged 18 to 24 received treatment through Yz-Up during 2008/09 (50% of the caseload).

• Treatment mapping to support the adult needs assessment process has highlighted the high proportion of young adults retained in the young people’s drug treatment service and the lack of referrals into adult services, indicating that there is a problem locally with transition.

Primary substance Rate per 1000 2008/09 2007/08 Change

(number) Change

% Alcohol 2.2 56 64 -8 -13% Drugs 3.4 84 57 27 47% Total 5.6 140 121 19 16%


• 74 young people were referred into 142 new treatment episodes over the course of the year. The most common route of referral was via children and family services at 69% (the majority coming from universal education).

6%

10%

11%

15%

18%

36%

4%

0% 10% 20% 30% 40%

Substance misuse services

No referral source recorded

Criminal Justice

Self, family or friends

Health and mental health services

Other

Children and family services



YOUNG PEOPLE

Problem substance use (alcohol and / or drugs)


• The majority of young people received some kind of structured psychosocial intervention but other services included harm reduction services and access to residential treatment.

• Cornwall and Isles of Scilly DAAT make on average 2 referrals for detoxification each year to Middlegate Lodge, the only in-patient unit nationally specifically for young people.

• Middlegate Lodge is in the process of closing, which means that there will be nowhere to stabilise and assess young people on an in-patient basis. Young people’s treatment services estimate that there is a requirement for at least 2 in-patient placements per annum. Local specialist provision for young people is proposed as part of the development of the Bosence Farm Tier 4 project, but is at risk if funding cannot be secured.

• 36 young people were discharged from treatment in 2008/09 and most left treatment in a care planned way (89%).

Service user profile

• The service user profile for adult services users is strongly weighted towards males – 70% are male and 30% are female. Consistent with previous years, the gender split is much more even for young people; 54% of young service users are male and 46% are female.

• Two thirds of young people were aged 16 and over at year mid-point (the average age was 16 years).

• Of the young people starting new treatment journeys in 2008/09, almost three quarters of were living in stable accommodation with their parents or other relatives when they presented for treatment. 16% (12 service users), however, were in unsettled accommodation or of no fixed abode.

Substance profile

• NDTMS can record up to three substances per treatment episode. The primary substance is described as the main drug, although poly use (where the problem is with multiple drugs) is not uncommon.

• Cannabis and alcohol are the dominant primary substances at 49% and 40% respectively. Compared with 2007/08 there are more service users presenting with primary cannabis problems and fewer presenting with alcohol problems.

• The term ‘problem drug user’ or PDU is used to define users of opiates and / or crack cocaine. Problem drug users are rare in this age group and there are no injecting drug users.

• 60% of young people presented for treatment with two or more problem substances, the most common combination being alcohol and cannabis. The most common third substance, if stated, was ecstasy.

Primary substance Number %

Cannabis 69 49% Alcohol 57 40% Other stimulants 10 7% Other 5 4% Opiates 1 1% Crack 0 0% Total 142



YOUNG PEOPLE

Attitudes to drinking and harm to health

Attitudes to drinking

• The TellUs Survey, carried out in September 2008, asked children and young people aged 10 to 15 years across England for their views on a range of topics covering the five Every Child Matters outcomes. Drug and alcohol use were covered within the outcome “Be Healthy”.

• The majority of children said that they had tried alcohol (78%) and 43% had experienced being drunk.

Have you ever had alcohol? Cornwall National Never had an alcohol drink 14% 25% Have never been drunk 35% 35% Have been drunk but not recently 21% 17% Drunk once or twice in last 4 weeks 15% 10% Drunk 3 or more times in last 4 weeks 7% 6% Prefer not to say 9% 8% Have tried alcohol 78% 68%

• Compared with the last survey, nationally a higher proportion of children have tried alcohol, although the proportion that has experienced being drunk has remained fairly stable.

• The same is true in Cornwall, although the proportion saying that they had never tried alcohol was significantly lower than the national average and the proportion who said that they had been drunk once or twice in the last 4 weeks were significantly higher.

• Contrary to the TellUs findings, a national study20 on substance use found that the proportion of 11 to 15 year olds who reported having never had an alcoholic drink has increased gradually in recent years. The study also found that young people are becoming less tolerant of drinking and drunkenness among their peers.

• Purchasing alcohol from pubs, clubs, off-licences and supermarkets has become less common. Just under half of the young people who said that they did drink, did not buy alcohol, instead obtaining it from friends, parents or asking someone else to buy it. Those who did buy alcohol were most likely to buy it from friends or relatives.

• The proportion who drink in licensed premises has more than halved since 1996; instead young people are more likely to drink at home or in a friend’s home or outside.

• Findings in the study relating to levels of drug use were broadly similar to the indications from TellUs. There has been a decline in drug use amongst this age group since 2001 and, of those who reported using drugs, cannabis is the most common.

• Only a small proportion take drugs regularly (3%, at least once a month) and frequent drug use is more common amongst young people who truant or have been excluded from school.

• Drug and alcohol consumption was shown to be related to each other and to other risk-taking behaviours, including smoking and playing truant from school.

• For helpful information on alcohol, young people were most likely to cite parents (74%) or television (73%). Whereas for information on drugs, television and teachers (65% and 64% respectively) were the most commonly chosen sources.

20 NHS Information Centre (2009), Smoking, drinking and drug use among young people in England in 2008, carried out by the National Centre for Social Research and the National Foundation for Educational Research



YOUNG PEOPLE

Attitudes to drinking and harm to health

Drinking and harm to health

• The NHS study stated that there are serious risks for teenagers who drink to excess. Young people who drink to excess are more likely to take other drugs, adversely influence their relationship with alcohol as an adult, trigger or exacerbate mental disorders, and increase their risk of liver damage. Previous research also shows a close relationship between alcohol use and low educational achievement and adult criminal behaviour. Young people under the age of 15 are thought to be particularly vulnerable to these risks.

• Previously, data from the North West Public Health Observatory (taken from the Local Alcohol Profiles21) has shown that alcohol-specific hospital admissions for under-18s in Central and West Cornwall were significantly higher than both the national and regional averages (Carrick and Kerrier were ranked within the worst 10% nationally).

• This refers to admissions for conditions that are wholly related to alcohol (e.g. alcoholic liver disease or alcohol overdose).

• The table below shows alcohol-specific hospital admissions for under 18s in Cornwall for the period 2005/06 to 2007/08, compared with the regional and south west average. The national rank is out of 353 local authority areas, where 1 is the best (lowest rate) and 353 the worst.

Area Under 18s, crude rate

per 100,000 LA Rank 256 Cornwall 96.9 South West 78.6 England 72.3

21 North West Public Health Observatory 2009. Under 18s admitted to hospital due to alcohol specific conditions (under 18s), crude rate per 100,000 population, 2004/5-2006/07. NWPHO Hospital Episodes Statistics and ONS mid-year population estimates. Does not include attendance at A&E.



YOUNG PEOPLE Key findings

Problem substance use

• 140 young people under the age of 18 received treatment for problem substance use in 2008/09. Cannabis and alcohol are the dominant substances. Unlike the adult drug treatment population, which is strongly weighted towards males, the gender split for young people is fairly even (54% male and 46% female).

• There are a further 138 people in young people’s treatment services, however, who are aged 18 and over, and an absence of referrals into adult services. This is consistent with previous years and indicates significant issues with transition for young adults. This was highlighted in the drug and alcohol needs assessments and will be addressed in the coming year.

• Cornwall and Isles of Scilly DAAT make on average 2 referrals for detoxification annually to Middlegate Lodge, the only in-patient unit in the country specifically for young people. This service is in the process of closing, leaving a significant gap in specialist provision.

• National research shows that young people are becoming less tolerant of drinking and drunkenness amongst their peers. Those who do drink are increasingly less likely to obtain alcohol from licensed premises (on or off), instead obtaining alcohol from family or friends and drinking outside in public places or in someone’s home. There has also been a decline in drug use amongst under 18s and only a small minority take drugs regularly.

• Findings from the TellUs survey in schools, however, indicate that alcohol use amongst young people in Cornwall is significantly higher than the national average.

• The rate of alcohol-specific hospital admissions for under-18s remains significantly higher than the national and regional averages.

Chapter 6 – Commissioning priorities


Chapter 5 – Commissioning priorities Identifying priorities – the process The Cornwall Alcohol Strategy 2006-2009 was published in January 2006: “Action and Awareness on Alcohol: A Better Quality of Life for Cornwall & Isles of Scilly.” Connected to this was the Alcohol Action Plan, which was designed to allow the strategy to live in the real world, in different delivery arenas owned by practitioners. These arenas were 1: Accommodation; 2: Employment; 3: Children and Young People; 4: Criminal Justice; 5: Licensing; 6: Health; and 7: Reintegration and Aftercare. These documents are available on the DAAT website: http://www.cornwall.gov.uk/Default.aspx?page=19538 The process of beginning to update this strategy was progressed in February 2009 with the publication of the Cornwall Public Health ‘Alcohol Health Equity Audit’ available on the same DAAT webpage. This thorough piece of research is designed to assess the ease of access to alcohol services across the County compared to evidence of alcohol related harm, both geographically and demographically. As such, it is not a complete Alcohol Needs Assessment, but forms a very strong basis for the process of compiling one. Amongst its 15 recommendations for addressing alcohol related harm in Cornwall, these had a direct bearing on the direction of alcohol service commissioning: • To increase and embed early identification and brief advice services for alcohol; • To identify and develop the best tools for these services; • To develop these interventions in A&E; • To develop clearer care pathways through the treatment journey; • To develop more equitable distribution of alcohol services for young people; • To increase partnership work to reduce alcohol related domestic abuse; • To ensure that the routes to accessing mental health services, alcohol misuse prevention

and treatment services are clear and accessible, particularly to vulnerable people; • To work to develop effective employer policies around alcohol; • To support the development of a strategy addressing the housing needs of those with

alcohol problems; • To ensure that the impact of alcohol misuse is taken into account in the mental health

agenda and the strategic work around suicide prevention. In the commissioning process following this new Alcohol Needs Assessment, both the national guidelines, such as the ‘High Impact Changes,’ and these local priorities are being taken into consideration.

The items of particular importance which are resulting in commissioning actions are:

1. Improve the effectiveness and capacity of specialist treatment (AIP/HIC): Analysis has led to the conclusion that our specialist treatment services need to focus more on Tier 4, and that services need to be repositioned accordingly. Better routes are also being developed from Criminal Justice into treatment, including an Alcohol Treatment Requirement for dependent drinkers.

2. Identification and Brief Advice (AIP/HIC and AHEA): This is being increased in Primary Care, although there are still opportunities to develop this level of intervention further outside of Health settings.

Chapter 3 – Priorities


3. To identify and develop the best (assessment) tools for these services (AHEA):

Best practice guidance as developed by the World Health Organisation, and evidenced by Alcohol Concern, is being followed, as we increase the use of AUDIT-C and AUDIT in Primary Care and Probation, and identify which method to use in A&E. At present, FAST has is the preferred tool, but other screening tests have been used successfully elsewhere.

4. To develop clearer care pathways through the treatment journey (AHEA): Work is in progress to better define criteria for different treatment services, and easier referral pathways between them.

5. To increase partnership work to reduce alcohol related domestic abuse (AHEA):

Partnership work on this gap has commenced, and training will be delivered to relevant agencies in 2010, geared towards better assessment, communication and referral between alcohol and domestic abuse services.

6. A strategy for the housing needs of those with alcohol problems (AHEA): The County is currently updating its Homelessness Strategy, and a tiered approach to supported housing for Drug and Alcohol clients has been trialled in parts of the County. The items of particular importance which still need to be addressed are:

1. Appoint an Alcohol Health Worker (in Hospital services) (AIP/HIC) and 2. To develop Identification and Brief Advice interventions in A&E (AHEA):

This remains a major area of need, with issues around resources, but there is a will to address this priority. Young Peoples’ services may be available in A&E before an adult service; the role of the alcohol/psychiatric liaison nurse within Treliske needs better definition.

3. Amplify national social marketing priorities (AIP/HIC): Cornwall Public Health now has a Social Marketing lead worker, and the DAAT will liaise with them to develop better alcohol messages in the County. There has been some effort to develop an impactful campaign around the Night Time Economy in Newquay, which will be repeated in 2010, and then evaluated.

4. To develop more equitable distribution of alcohol services for young people (AHEA):

This is another area in need of attention, especially in connection with schools, antisocial behaviour teams, YOS, and Parenting interventions. Each of these final 3 points are priorities that have not yet been addressed more than minimally:

1. To ensure that the routes to accessing mental health services, alcohol misuse prevention and treatment services are clear and accessible, particularly to vulnerable people (AHEA)

2. To work to develop effective employer policies around alcohol (AHEA) 3. To ensure that the impact of alcohol misuse is taken into account in the mental

health agenda and the strategic work around suicide prevention (AHEA)



Appendix 1: Full text of recommendations of Cornwall Public Health Alcohol Health Equity Audit:

1: Support the development of the LES specification for identification and brief advice and its extension to further groups of patients and the extension of patient support such as Addaction Cornwall. 2: Work to extend the DES to more practices in Cornwall and the Isles of Scilly and the LES to Practices where there has not been initial take up. 3: Work with Cornwall Partnership Trust to develop appropriate identification tools and take forward implementation. 4: Work with A&E to develop work for identification and brief advice 5: Develop Care pathway to enable a more robust commissioning of service to prevent harmful drinking and to support those in treatment and post treatment 6: Undertake further work to improve data information concerning ethnicity of people drinking harmfully in Cornwall and the Isles of Scilly 7: Support the work of the Community Safety Partnership (CSP) and the Health and Well Being Partnership in driving progress to reduce hospital related admissions which is included in the Local Area Agreements in both Cornwall and The Isles of Scilly. 8: Develop work with young people to provide more equitable distribution of services 9: Increase partnership work to reduce alcohol related domestic abuse 10: Advocate for changes in national funding to allow greater funding for offenders released from prison with an alcohol misuse problem. 11: Ensure that the routes to accessing mental health services, alcohol misuse prevention and treatment services are clear and accessible particularly to vulnerable people. 12: Work to develop effective employer policies around alcohol 13: Support development of strategy for housing needs of those with drinking problems 14: Ensure that alcohol-related harm and the impact of alcohol misuse is taken into account in the mental health agenda and the strategic work around suicide prevention 15: Provide a report to the PCT board in June 2010 on the progress made on implementing the recommendations outlined.



Appendix 2: Alcohol Improvement Programme 2009 – High Impact Changes:

The first three High Impact Changes are necessary enabling actions that set the scene for success. The latter four changes are services and activities that are calculated to impact most effectively on alcohol-related harm, and reduce the rate of rise in alcohol related Hospital admissions, as measured by LAA NI39, NHS VSC 26, and PSA 25.

The 7 High Impact Changes are as follows: 1: Work in Partnership; 2: Develop activities to control the impact of alcohol misuse in the community; 3: Influence change through advocacy; 4: Improve the effectiveness and capacity of specialist treatment; 5: Appoint an Alcohol Health Worker (in Hospital services); 6: IBA – Provide more help to encourage people to drink less through early advice; 7: Amplify national social marketing priorities.

The High Impact Changes in Cornwall so far:

1: Work in Partnership:

National guidance states that PCTs and their local partners should investigate their alcohol-related needs within their Joint Strategic Needs Assessment (JSNA) and reflect their plans within the NHS Operational Plan using the Vital Signs alcohol indicator (VSC26) and the Local Area Agreement (LAA) indicator (NIS39). This involves having an agreed vision for an area, which describes what an area will look like as a result of their partnership activity, without becoming target-focussed or disconnected from each other.

Local multi-agency groups such as Crime and Disorder Reduction Partnerships (CDRPs) and Drug and Alcohol Action Teams (DAATs) offer opportunities to reduce alcohol related harm and co-ordinate local initiatives. However, it is important that these thematic groups are given a strong mandate from the principle partnership - usually the Local Strategic Partnership (LSP). It is important that Crime Reduction, Health and Regeneration (Transport and Planning) are all aware of the contribution that they can make to the alcohol harm reduction agenda.

Local Practice Examples

Amethyst data collation and analysis, a local authority and Police partnership, developing Strategic Assessments and Needs assessments, allowing stategy development and commissioning to be based on robust evidence. In addition, the CIOS DAAT internal arenas, such as the Joint Commissioning Group, the Needs Assessment Expert Group, the Criminal Justice Drug and Alcohol Task Group, etc are all examples of partnership working. The DAAT is also represented on the Cornwall CDRP, within the LAA process, where a large number of local authority agencies and public services work in partnership.

2: Develop activities to control the impact of alcohol misuse in the community:

Make use of all the existing laws, regulations and controls available to all the local partners to minimise alcohol related harm. Make use of the powers under the Licensing Act (2003) and the Violent Crime Reduction Act (2006). Use the Local Development Framework to 'design out' alcohol harm and enable planners to reject inappropriate proposals at an early stage.



Manage the night-time economy to reduce alcohol harm. This includes initiatives to help to reduce assaults, robbery and antisocial behaviour.


Newquay Safe, which is a partnership that was formed as a result of alcohol related incidents and accidents in Summer 2009. This partnership incorporates a few new approaches, and a number of Community Safety initiatives that were already in place and continue to cover other parts of the County as well.

New initiatives include the Newquay LOST campaign, marketed at safety awareness in the Club and Coastal environments; Budget Accomodation and Landlords Guidance around young people, which outlines the responsibility of landlords to make sure that staff are CRB checked, and that relevant parental consent has been obtained; the practice of PCSOs meeting and greeting visitors as they leave trains and arrive at campsites, and checking quantities of alcohol being brought in, especially by young people; patrols in town and residential streets by Night Marshalls, to address potential antisocial behaviour; the Exodus Youth Project which encourages and monitors safe alcohol free entertainment for post GCSE students visiting the town; and the Streetsafe cabin, a longstanding Community Safety project which provides a safe place, advice and help for people in a vulnerable condition around the NTE.

Many of these initiatives could form the basis of work to be duplicated in other towns and areas. As such, all the initiatives are to be outlined in a ‘Newquay Toolkit.’

Existing initiatives in the County which have also been used by Newquay Safe are the SMART worker, providing training on alcohol awareness and responsible alcohol sales for Pub, Club and Bar staff; Wireless CCTV, which adds value to the existing CCTV provision as it is more flexible, and can be targetted at areas suffering specific problems; Bluetooth messaging around responsible and safe behaviour; Metal Detector Wands to prevent knife crime, in a town that has succesfully kept violent crime at a very low level. In addition, Newquay will benefit from a Countywide Best Bar None scheme, which is planned for 2010-11.

Many of these approaches are not unique to Newquay, and are incorporated into Community Safety work throughout the County.

3: Influence change through advocacy:

The DAAT currently has a seconded Alcohol Strategy Co-ordinator, and is in the process of generating partnership funding for a 3 year post, expected to commence on 01/04/10. This role is key in acting as a catalyst within the partners in a number of fields, in order to develop the County’s response to alcohol related harm.

There are also key individuals within partner agencies committed to partnership work and developing projects and initiatives addressing alcohol issues. Some areas which will be highlighted as gaps (e.g. A&E) will need similar advocates.

4: Improve the Effectiveness and Capacity of Specialist Treatment:

Dependent drinkers represent a very high-risk group for alcohol-related hospital admissions. This Alcohol Needs Assessment, based on current evidence and such tools as the Alcohol Learning Centre Ready Reckoner, has enabled us to set priorities in how to refocus our alcohol services, especially to develop Tier 4 residential and in-patient pathways. As part of



the process, all alcohol treatment pathways are being reviewd, defined and mapped. This is based on the MoCAM 4 tiered approach.


This is work in progress, which is covered earlier in the Treatment Mapping section.

5: Appoint an Alcohol Health Worker:

Since their report in 2001, The Royal College of Physicians have advocated the appointment of a dedicated Alcohol Health Worker or an Alcohol Liaison Nurse in each major acute hospital, to work with a named Consultant/Senior Nurse Alcohol Lead, to provide a focus for:

• Medical management of patients with alcohol problems within the hospital • Liaison with community alcohol and other specialist services • Education and support for other healthcare workers in the hospital • Implementation of case-fi nding strategy and delivery of brief advice within the

hospital.


Work is in progress to update an existing service, which is currently provided by the community NHS Alcohol Team within CDAT, geared around providing a contact point for treatment of CDAT clients in RCHT detox. This would develop that role, to embed it within Treliske, based from A&E, but monitoring alcohol cases in the wards, as well as providing a pathway back into community services on discharge.

There is also a developmental service for in A&E, for Young People, targeting all Substance Misuse cases. These roles need well configured definition and evaluation.

6: IBA - Provide more help to encourage people to drink less:

Identification and Brief Advice (IBA) coverage is being expanded within Primary Care settings for newly registered patients, for patients with uncontrolled hypertension, and within certain health checks. Probation staff are also being trained to make use of the AUDIT screening tool, and they will offer this service to all Probation clients. There is a need for IBA within A&E, and within more community settings, beyond Primary Care.

Delivered effectively, IBA will reduce the load on the specialist treatment services in Tiers 3 and 4, and will reduce the incidence of repeat visits to A&E, and Hospital readmissions. Evidence suggests that for every eight people who receive simple alcohol advice, one will reduce their drinking to within lower-risk levels (Moyer et al., 2002) which is a greater level of impact than for similar smoking interventions.


In Cornwall, IBA is being delivered in Primary Care for new registrants in selected surgeries, as well as in treatment for issues around uncontrolled hypertension. It has also been introduced into the Health Check service delivered by Pharmacists and Surgery Nurses.

There is some IBA within Police Custody, delivered by the CJIT Arrest referral staff, although this service needs updating to make use of the same toolkit used for the Primary Care IBA pathway, based on the Alcohol Learning Centre e-learning module. Probation staff have also been given training around the use of AUDIT, but this needs to be launched as a coherent



service. In future, IBA could be extended beyond Orimary Care into other community access points, such as Job Centre and Citizens Advice Bureaus, and local support groups.

The toolkit, based on the e-learning resources, and in the pathway order, can be found here:

http://www.cornwall.gov.uk/alcoholawareness

Cornwall Health Promotion’s Brief Interventions Training is already listed as an example of good practice on HubCAPP ( www.hubcapp.org.uk/TL73 ) encompassing the co-ordination of training materials and the delivery and evaluation of training sessions to a range of organisations across Cornwall.

7: Amplify national social marketing priorities

Social marketing is the systematic application of marketing, alongside other concepts and techniques, to achieve specific behavioural goals for a social good. For alcohol, the goal is to reduce alcohol related hospital admissions by influencing those drinking at higher risk to reduce their use of alcohol to within lower risk levels.

PCTs and partners are advised to commission local social marketing activity which builds on the evidence, strategic framework and tools emerging from the national alcohol social marketing programme, such as direct marketing materials, wall charts and fact sheets for GPs, and the Your Drinking & You booklet.


In Cornwall, the Alcohol awareness Week campaign was based on the national ‘Know Your Limits’ message. In addition Newquay LOST was an entirely local initiative marketed at safety awareness in the Club and Coastal environments.

Funding has been requested from the LAA Reward process to create a coherent Alcohol Social Marketing approach for the County. This work could be taken forward by the CIOS DAAT Alcohol Strategy Lead, Cornwall Public Health Alcohol Lead, Cornwall Public Health Social Marketing Lead, Cornwall Health Promotion, Cornwall PCT Media Manager, and the Cornwall Council Publicity, Marketing and Media Department.

Produced by Cornwall and Isles of Scilly Drug and Alcohol Action Team (DAAT)

Mail: Fistral House 8a Truro Business Park Threemilestone TR4 9NH Tel: 01872 354471 Web: http://www.cornwall.gov.uk/default.aspx?page=21534 Online: www.amethyst.gov.uk/strataudit

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