Skills for the future – a look into the crystal ball

Dr Emily Finch, Clinical Director, Addictions, South London and

Maudsley NHS Trust

What did it use to look like?• Strong emphasis on opiates, focus on numbers in treatment • Alcohol services less prominent• Joint commissioning influenced by health and criminal justice• Financial growth in the sector, ring fenced budgets• Strong national control from the National Treatment Agency • Strong political interest

Workforce

• Long careers in one organisation• Professional groups assured of careers in addiction• DANOS, University MSc courses

The people we treat?• Opiate use declining• Ageing treatment population – prematurely aged• Increasing physical health needs• Increasing mental health needs• Increasingly socially disadvantaged• Polydrug use increasing

• Addiction to medicines – associated with other physical and psychiatric comorbidities

• NPS – range of problems some complex some not

Alcohol is different?• Vast amount of unmet need• Broader range of interventions and needs• Harmful and hazardous drinkers need evidence based brief

interventions• Treatment in non-treatment and non specialist situations• Patients in different environments e.g acute hospitals

• Dependent drinkers requiring evidence based psychological and pharmacological treatment interventions

• Most severe drinkers require a full range of harm reduction and social interventions

How are we organised?• Commissioning moved to local authorities with strong influence from

public health• NTA moved into Public Health England• Creation of PHE Tobacco, Alcohol and Drugs

• Escalation of competition in the sector, regular retendering of services• Strong emphasis on local political decision making • Many innovative models emerging e.g. integrated care, focus on well

being, “parity of esteem” – unsure of impact on substance misuse• Less political attention• Role of “Francis”. Drive to quality in health

• Fewer but larger non-statutory organisations, less role of the NHS

The Money

• Removal of ring fenced money• Part of public health grant• Competing with other public health priorities• Use of retendering to remodel services and to

reduce costs.

What is public health?• Focus on health of the whole population• Benefits for large groups not individuals• Reducing inequalities • Obesity, tobacco, exercise• Prevention and wellbeing

• Alcohol – but generally at a population level• Infectious diseases e.g. HCV

• Important benefits for our clients but little emphasis on more intensive treatments. This may disadvantage our treatment population

Gaining the skills• Most training internal – within large organisations. But risk of TUPE• Universities need to adapt and find ways to provide specialist

education• Broader range of skills needed e.g. smoking and brief interventions• Professional groups are responding e.g. SMMGP. • Role of Health Education England (HEE)? But…• Change expected – populations less predictable and systems less

predictable. Innovation necessary• Need a long term view – retaining managers and leaders through

uncertainty is difficult• Need system leaders • Maintaining a high quality motivated workforce a priority.

Focusing on outcomes and using the evidence

• Skills in evidence based interventions e.g RP, MI, 12 step facilitation, recovery skills

• Transferable skills• New pharmacologies e.g. for tobacco and alcohol• Health interventions e.g. for HCV• Mental health interventions e.g. CBT• New populations e.g. in the acute hospital and in

primary care• NICE and other evidenced based and

recommended interventions

Recovery and beyond

• Broader range of skills to support clients full recovery

• May not need all skills in one person • Embedding former service users into the

workforce and supporting them properly• Skills in working in partnership

Who is the workforce?

• Generalists e.g. in acute hospitals and primary care. Substance misuse skills may be one of many

• New specialities e.g. pain clinics, liver clinics• Those with careers in substance misuse need

to adapt with core skills embedded. • Ex-service users• Professionals who are specialists.

Doctors, nurses, psychologists• Specialist training still remains e.g. RCPsych and

RCGP• But rapidly decreasing placement and training

opportunities• Sector is less attractive due to uncertainly and

disruption• Psychology and nursing – fewer speciality

placements• But more interest in generalist training e.g. for

medical and nursing students

The role of addiction specialist doctors in recovery orientated treatment systems

A resource for commissioners, providers and clinicians

• Outlines contribution of doctors

• Set out standards for training and supervision for commissioners

• Expectations of contracts

• Outlines ways of providing training for doctors

Solutions• Specialists and generalists need different

solutions. Clarity of who does what and who needs which skills.

• Preserve standard of training for specialists and professionals

• Use all opportunities to set standards • Encourage universities and other training

organisations to provide sustainable specialist training.

• Opportunities for generalists to train in SM both undergraduate and post graduate.

It’s a bit fuzzy but……• Money is likely to be the biggest problem but..

• Keep supporting and motivating staff• Acquire new skills where needed• Building high standards in contracts at all opportunities• Allow opportunities for creativity and innovation. New

career paths in recovery

• Use every opportunity to create careers in the sector