CORNWALL & ISLES OF SCILLY ALCOHOL NEEDS ASSESSMENT 2016/17

Version 1.0 FINAL May 2017

Needs Assessment prepared by:

Cornwall Council, Amethyst Alex Arthur Strategic Analyst Community Safety Intelligence Team Cornwall Council, Amethyst James Butler Strategic Analyst Community Safety Intelligence Team Cornwall Council, Amethyst Strategic Intelligence and Erika Sorensen Community Safety Performance Manager Intelligence Team Cornwall & Isles of Scilly Primary Care Development Angela Andrews Drug and Alcohol Action Manager Team Cornwall & Isles of Scilly Marion Barton Social Inclusion Officer Drug and Alcohol Action Team Cornwall & Isles of Scilly Jez Bayes Alcohol Strategy Manager Drug and Alcohol Action Team Cornwall & Isles of Scilly Kim Hager Joint Commissioning Manager Drug and Alcohol Action Team Cornwall & Isles of Scilly Drug-related Deaths Co- Sid Willett Drug and Alcohol Action ordinator Team

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 2 OFFICIAL

Contents Introduction 5 Section 1: Key messages and priorities 8 Our 8 themes 8 Commissioning priorities 18 Overview of Recommendations for Commissioners 20 Section 2: Setting the scene 26 Section 3: Our services and what people say 40 What did we achieve in 2015/16? 40 What our people say 43 Section 4: Examining the impacts of alcohol 48 National trends and evidence 49 Measuring the impacts on health 60 Alcohol Consumption and Risk Levels 62 Hospital admissions 65 Frequent Attenders 70 Alcohol and Suicide in Cornwall 76 Early Intervention 83 Identification and Brief Advice 84 Messaging and Communication 92 Mapping the treatment system 96 Why invest in treatment? 98 ‘Map and gap’ of existing services 100 Getting people into treatment 102 Tier 4 110 Mental health 112 Families 121 The impacts of parental substance use 122 Together for Families Programme 124 Transitions and young adults in treatment 135 Social Impact 138 Homelessness and housing need 140 Gypsy, travelling and migrant worker communities 151 Worklessness 154 Alcohol, crime and disorder 162 Alcohol-related crime 164 Anti-Social Behaviour 169 Road Traffic Collisions and Drink Driving 171 Reoffending 178 The Police and Crime Plan 185 Licensing and Retail 193 Health as a Licensing Objective (HaLO) 194 Local Alcohol Action Area Phase 2 198 Appendices 202

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 3 OFFICIAL

Page intentionally left blank

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 4 OFFICIAL

Introduction Reducing the harms of alcohol has been a priority in Cornwall for many years. Our first Alcohol Harm Reduction Strategy was published in 2006. Our current alcohol strategy “Taking Responsibility for Alcohol1” draws on evidence compiled for the Alcohol Needs Assessment and has three overarching objectives:

1. Enable people to make informed choices about alcohol 2. Improve services to reduce the harm associated with alcohol 3. Partnerships to reduce alcohol’s negative impact on communities

Cornwall Council and Cornwall’s Community Safety Partnership, Safer Cornwall, are responsible for reducing the harm related to drugs and alcohol locally.

The statutory framework regulating Community Safety Partnerships (CSPs) requires partnerships to analyse and assess on an annual basis:

 Levels and patterns of crime, disorder, substance misuse and reoffending in both adults and young people;  Changes in these areas since the last strategic assessment and why;  The extent to which the previous year’s partnership plan was implemented.

It is important therefore to review local needs and evidence for drug and alcohol provision and assess the impacts upon individuals, families and local communities. This information is used to inform the commissioning of a range of services and system improvements that seek to make a positive impact.

The majority of the drug and alcohol services currently commissioned have contracts in place until March 2018. The Drug and Alcohol Action Team (DAAT) intends to undertake a procurement process to re-commission services for a revised system to be in place from April 2018 onwards. This needs assessment is a key part of that process.

Drawing on a wide range of data sources (including self-reports, research and service level data) the needs assessment provides a series of recommendations for consideration (Commissioning Priorities). How Cornwall chooses to respond to these recommendations will be detailed within the Commissioning Strategy.

Joint Strategic Needs Assessment support pack 2017/18: commissioning and good practice prompts Reducing the harms of alcohol is also a priority area of health and wellbeing improvement2 in the Sustainability and Transformation Plan. Alcohol consumption

1 Available to view and download from the alcohol pages of the Safer Cornwall website 2 The online resource library of assessments and focus papers for the Joint Strategic Needs Assessment includes the Alcohol Needs Assessment

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 5 OFFICIAL

is identified as one of five lifestyle behaviours (smoking, alcohol, physical inactivity, diet and social isolation) that contribute to the high prevalence of five diseases which cause 75% of premature death and disability.

The national guidance from Public Health England for the needs assessments to support 2017/18 commissioning for drugs, alcohol and young people’s services is comprehensive and challenging. The DAAT Needs Assessment Expert Group has stretched to incorporate these new areas into its needs assessment each year.

As before, we have rated ourselves against the national checklist, which has assisted us in mapping what is working well, what needs to improve and gaps for future development.

The recommendations are wide ranging and indicate where we require the assistance of partners as well as commissioned services.

Our self-assessment against the checklist for 2017/18 is available as part of the separate supporting documentation set for this needs assessment.

What is needs assessment? Needs assessment is the cornerstone of evidence-informed commissioning.

NICE (National Institute of Clinical Effectiveness) defines health needs assessment as a ‘systematic method for reviewing the health issues facing a population, leading to agreed priorities and resource allocation that will improve health and reduce inequalities’3.

It is based on:  Understanding the needs of the relevant population from reliable data sources, local intelligence and stakeholder feedback;  Systematic and comprehensive analysis of legislation, national policy and guidance;  Understanding what types of interventions work, based on analysis of impact of local services, research and best practice.

It is:  A way of estimating the nature and extent of the needs of a population so services can be planned accordingly;  A tool for decision making;  To help focus effort and resources where they are needed most.

A robust needs analysis provides commissioners with the range of information required to feed into and inform planning and prioritisation.

3 NICE guidance on Health Needs Assessment – www.nice.org.uk

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 6 OFFICIAL

Aims and objectives The purpose of 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.

Through undertaking a rigorous needs assessment, we aim to continue to ensure that systems and services are recovery focused, provide value for money and meet the needs of local communities.

An effective needs assessment for drug 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  Where there are gaps for clients in the wider reintegration and treatment system  Where the system is failing to engage and / or retain people  Who the hidden populations are and 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?

This provides a shared understanding of the local need for services, which then informs treatment planning and resource allocation, enabling residents to have their needs met more effectively, and ultimately benefiting the communities in which they live.

Such an assessment will need to take full account of the gender, ethnicity and other diverse needs of the target population and any unmet needs from this perspective. The assessment also needs to be undertaken in accordance with the requirements of national guidance on undertaking equality impact assessments.

Finding your way around  Section 1 Key Messages and Priorities contains a summary of the key findings across the 8 themes of the Alcohol Strategy, gaps and priorities for improvement identified through mapping services against the relevant NICE guidance and other recommendations for commissioners, drawn from the evidence presented within each section of the Needs Assessment;  Section 2 Setting the Scene describes the relevant national and local strategic contexts and provides a brief description of Cornwall in key statistics;  Section 3 Our services and what people say provides a summary of new initiatives and service development, and presents the results of our consultation with service users, providers and key stakeholders;  Section 4 Examining the impacts of alcohol provides detailed information and key findings of our analysis across a broad range of areas, spanning everything from health and the treatment system through to crime and the night time economy;  The document closes with some useful reference information in the Appendices, including case studies, evidence reviews for pharmacological and other interventions and the outputs of the NICE mapping exercise.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 7 OFFICIAL

Section 1: Key messages and priorities Our 8 themes The main delivery framework around alcohol issues in Cornwall is provided by our local Cornwall Alcohol Strategy 2016-19,’Taking responsibility for Alcohol’.

The Alcohol Strategy is structured into eight thematic areas:

1. Advice and Information Helpful preventative and early intervention activities, including Identification and Brief Advice, population level messaging and targeted social marketing.

2. Children, Young People, Parents and Families Education, youth, family and household interventions, including Together for Families.

3. Community Safety Schemes Reducing the harmful impacts of alcohol on Cornish streets, including Anti-Social Behaviour (ASB), and Fire and Rescue.

4. Criminal Justice Interventions Appropriate interventions to reduce alcohol related offences, including diversionary and sentencing pathways.

5. Domestic abuse and sexual violence Good pathways between alcohol, domestic abuse and sexual violence services, including MARAC referrals and sentencing pathways.

6. Employment, Deprivation and Inclusion Interventions to reduce alcohol related employment problems, including Social Care, Homelessness and Housing.

7. Health, Treatment, Aftercare and Recovery Easy access to treatment, and effective care throughout, including hospital admissions, mental health and the treatment system.

8. Licensing, alcohol retail and the Night Time Economy Promoting and supporting a safe, responsible, successful alcohol trade, including health input into licensing, best practice schemes and bar staff training.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 8 OFFICIAL

1: Advice and information National Guidelines and Messaging  In January 2017, the unit level was reduced from 21 to 14 units per week for men, in line with the previous weekly amount recommended for women, on the basis of the non-gender specific nature of the alcohol related cancer risk compared with all other health impacts;  This is calculated to reduce the risk of an alcohol related health issue to 1% across a lifetime. In addition, the advice is to drink the full amount over no less than 3 days, and to have ‘several’ alcohol free days each week.

Identification and brief advice  There is extensive and consistent evidence that brief advice in health care settings reduces alcohol-related harm and that brief interventions are cost– effective. Evidence of the extent to which brief advice works in non-health care settings, however, is less clear;  NICE guidance recommends that screening should target people who are at increased risk of harm from alcohol and those with an alcohol-related condition;  Local research into health burden of alcohol misuse in terms of hospital admissions reiterates the national guidance and has highlighted a number of other areas where we need to focus our efforts, including those living in deprived areas, people with financial problems or long term unemployment/ worklessness issues, victims and perpetrators of crime and anti-social behaviour, people with a drug problem or who are known to self-harm;  Cornwall uses More than 300 front line staff have been trained in the last year, including pharmacy services and GPs, domestic abuse and sexual violence services, housing providers and services working with offenders;  Pharmacy delivered IBA highlights males over the age of 40 as the dominant at-risk group, with females making up the majority of young drinkers within the data;  There is evidence within the pharmacy data that IBA provision could and should be increased in and around the Newquay, Truro and Liskeard areas;  Numbers signposted into specialist treatment services further to pharmacy delivered IBA are low, with less than half of those identified as being possibly dependant receiving this information;  Robust means of monitoring and evaluation of delivery of local delivery of IBA, to include the level and effectiveness of interventions delivered by trained individuals, continues to be a challenge but is a priority to resolve.

Messaging and Communication Plymouth University research into the ‘What Will Your Drink Cost’ campaign provided 10 Action Points for consideration in updated campaign material. The main lessons were:

 Positively framed posters produce a short term improvement in responsible drinking attitudes, which could reduce an amount of immediate harmful or binge drinking during a Pub or Club visit, although this is not universal as several participants had a greater willingness to consume alcohol after seeing the posters;  Effect on others was highlighted as the most effect deterrent of alcohol use;

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 9 OFFICIAL

 This campaign will potentially reduce violent tendencies in a just over a third of the participants who actually commit such acts;  Images should feature people of the same age as the target audience. As images in this campaign could cause distress, they need to be accompanied by information about how to change, or where to get support or advice.  Future campaigns should consider repetition and presentation of material over long periods of time using a combination of sources and methods, during different periods of exposure, as well as describing the motives of the appeal.

2: Children, young people, parents and families Parental drug and alcohol use  Witnessing alcohol and/or drug use is identified as one of the key Adverse Childhood Experiences (ACEs) which also include poor mental health of a parent, witnessing violence /abuse and experiencing a parent in prison;  Children and young people who have experienced four or more ACEs are significantly more likely to adopt unhealthy behaviours themselves and more likely to establish homes with similar harmful behaviours;  There are 700 people in drug and alcohol treatment (27% of the population total) that are living with children, which is in line with the national average. These households are recorded as having a total of 1,300 children;  Living with children has a positive impact on treatment outcomes for parents, for all drug groups, but the level of successful completions amongst drug users (opiates and non-opiates) living with children has declined.

Together for Families Programme  It is likely that the families of many of the people in treatment (where there are children in the household) would be eligible for the Together for Families programme due to the prevalence of other programme criteria within this cohort, but engagement in the programme is low at just under 10%;  The pathway between drug and alcohol services and the Together for Families programme has taken some time to establish and is not currently resulting in referrals in either direction or engagement of eligible families;  The Complex Families Index indicates that families in the locality areas of Penwith and Restormel, particularly in areas categorised as deprived, are most likely to present complex multiple needs and these areas are where we would expect to identify the greatest numbers of eligible families;  Overall the priority Community Network Areas identified are: Bodmin, Penzance, Marazion and St Just (West Penwith), St Austell and Mevagissey, St Blazey, Fowey and Lostwithiel, Camborne and Redruth.

Transitions and young adults in treatment  The established structured transition protocol and process ensures that young people are safely and successfully transferred into adult services;  Young people in the adult service who had previously engaged with the young people’s service showed higher levels of multiple need. Key themes include previous traumatic events, homelessness, having been in care and mental health conditions;  85% of young people in the adult drug and alcohol service were not previously known to the young people’s service, despite the majority starting using

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 10 OFFICIAL

before the age of 18. How we identify and engage these young people remains a challenge.

3. Community Safety schemes Crime and anti-social behaviour  15% of all reported crime in 2015/16 was recorded as linked to alcohol; this rises to 30% for violent crime. The number of crimes recorded as alcohol- related has dropped year on year;  There is health-related evidence including emergency presentations and hospital admissions, however, to suggest that police data may under-report alcohol- related assaults;  Street drinking incidents make up only 6% of the total number of anti-social behaviour incidents recorded, but it is very visible and this causes concern amongst local residents and affects their feelings of safety in their local area. The volume of reports has increased over the last couple of years;  There are also increasing reports of vulnerable adults with complex needs, homeless drug and alcohol users and associated problems with drug litter and anti-social behaviour.  Hotspots for alcohol-related crime and disorder violence are concentrated in larger town centres, with notable hotspots in Truro, Camborne, Newquay, St Austell and Penzance. Over three quarters of alcohol-related violence occurs between 9pm and 5am reinforcing the link to the Evening and Night Time Economy.

Road traffic collisions and drink driving  The Local Alcohol Profiles for England highlight that incidence of alcohol related road traffic collisions in Cornwall is exceptionally high, higher than the rates for both England and the South West (which is also above national rate);  Local evidence found that alcohol impairment was a major factor in incidents involving pedestrians, and young car drivers and passengers aged 17-24;  The trend in drink driving has seen a significant fall, however, both locally and nationally. This could be interpreted as suggesting that the message concerning the dangers of drink driving is having a positive impact on the behaviours of the public, although it is possible that reporting may have become inconsistent compared to previous years due to reductions in the number of enforcement staff.

4: Criminal Justice interventions  Whilst recorded alcohol-related crime continues to reduce year on year, problem drinking is consistently one of the most common complexity factors affecting the health, wellbeing and behaviour of both victims and offenders, and appears to be more problematic in Cornwall than the national average;

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 11 OFFICIAL

 Potential gaps have been identified in terms of staff in local criminal justice settings4 being able to screen, identify and refer drug and alcohol related needs appropriately, which could relate to skills and/or capacity;  The proportion of people in alcohol treatment that are in contact with the criminal justice system is above national average but offenders presenting with alcohol problems are less likely to complete treatment successfully with our local CJS Team than the national average;  The Police are due to launch a new diversion scheme (Pathfinder Scheme) which will have alcohol as one of its behaviour change areas, and the Police and Crime Commisisoner is commissioning a new regional Restorative Justice service from October 2017.

5: Domestic abuse and sexual violence  Domestic abuse and sexual violence (DASV) is identified as a treatment pathway need at all levels of intervention: Identification and Brief Advice, individuals and families with multiple needs, adverse childhood experiences, assault victims and schemes targeting the Night Time Economy – including male victims, and specialist rehab settings.

6: Inclusion, employment and deprivation  Housing outcomes are good locally. Positive housing outcomes on exit for alcohol clients are consistently very close to 100%; meaning that nearly every person completing alcohol treatment successfully leaves with no housing problems. The national rate in 2015/16 was 84%;  Housing problems are less prevalent amongst people starting alcohol treatment than amongst those starting any kind of drug treatment. Around 1 in 10 alcohol clients present to treatment with a housing problem compared with 1 in 5 for drug clients;  Rough sleeper numbers are rising. Problems with mental health, alcohol and drugs are the biggest issues faced by the homeless community;  Although we have complex needs housing provision, some very complex clients are banned from all provision due to previous behaviour. Budget pressures could further reduce housing options for the most vulnerable clients;  Huge changes in the welfare system have been and will continue to provide significant challenges for people with drug and alcohol problems. Public Health England recognises that client engagement with employment support often focuses on maintaining benefits and avoiding sanctions;  Levels of paid work being undertaken by alcohol clients in the month prior to leaving treatment successfully, are in line with the national average – with 7% in part-time work and 26% in full time work (compared with 5% and 25% respectively nationally);  Employment is one of the most strongly positive factors in successful completion and then sustaining recovery;

4 Identified in our local community Rehabilitation Company and the Liaison and Diversion service in courts and police custody

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 12 OFFICIAL

 Cornwall has a strong track record of effective partnership working between drug and alcohol services and employment service providers and many clients are making positive steps towards employment.  Cornwall’s Gypsy and Traveller Liaison Officer believes there to be around 1,100 men, women and children with a culture or way of life as a Roma Gypsy, Irish Traveller or New Traveller in Cornwall. There is very limited literature on the health needs of this population.  Based on those accessing treatment, drug and alcohol issues are three times more prevalent amongst Gypsies and Travellers. They are more likely to be heroin users; at around a third, the proportion of problem drinkers in this group is similar to the wider treatment population. Dual diagnosis is more common amongst this cohort.

7(a): Health Alcohol Consumption and Risk Levels  Alcohol intake among the local population, based on the most recent estimates available and using overall hospital admissions as a proxy indicator, appears to be similar overall to national and regional rates;  Just under a quarter of people are estimated to drink at above the recommended levels. 6% or 26,300 people are drinking at higher risk levels, double the recommended safe levels or above. In addition, an estimated 84,000 people (19%) are binge drinkers;  There are estimated to be 6,600 dependent drinkers in Cornwall and the Isles of Scilly, equating to 1.5% of the population. This is above the national average of 1.4% but not significantly higher;  Research indicates that the UK may be “on the cusp of an epidemic of alcohol related harm amongst older people.” An estimated 1.4 million people aged 65 and over currently exceed recommended drinking limits. Currently this age group makes up only 3% of those in alcohol treatment (both men and women);  Alcohol forms a strong factor in the local economy, with a large apparent influence of tourism, which both boosts Cornwall’s population and alcohol consumption. Cornwall welcomes tourists while they are ‘off duty’ and likely to drink at higher frequency and levels than when they are in their normal routine at home, and at higher levels than the local population;  Contrastingly, Cornwall is part of a region with low alcohol related mortality in the local population.

Hospital admissions  Hospital admissions for alcohol-related conditions (narrow)5 are higher than national and regional rates, and rising, whilst the national trajectories are comparatively level. Cornwall is below national rates for the broad measure;

5 Where an alcohol-related condition is the primary diagnosis, or any secondary diagnosis with an alcohol-attributable external cause

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 13 OFFICIAL

 Alcohol-specific admissions for under-18s are higher than national and regional rates, with the South West having high rates generally. Alcohol specific admissions for under-18s are falling, but slower than the national trajectory;  In the vast majority of the alcohol-related and alcohol-specific hospital admission conditions, the rate for men is at least double the rate for women, but the rate for women is rising at a worse rate than national trends and the gap between national and local rates is greater for women than men;  Rates for certain conditions – alcohol liver disease, alcohol-related unintentional injuries, mental and behavioural disorders and intentional self-poisoning – are above (worse than) national rates. With the exception of cancers and alcohol-related self-poisoning, rates for men are at least double that of women;  Our alcohol related road traffic collisions are also consistently significantly higher than the South West, which in turn performs worse than national rates. There were 186 such collisions in Cornwall in 2016;  Cornwall’s workforce, social cohesion, economy and welfare budget are detrimentally impacted by high benefit claimants due to alcohol dependence. The rate has consistently tracked above the national rate;  Target groups and issues identified from the Local Alcohol Profile for England: o Male drinking, especially the amount drunk by a proportion of men with excessively risky drinking patterns; o The male drinking pattern being damagingly assumed by women; o Alcohol-related road traffic collisions in Cornwall; o Under-18s, whose risky drinking appears to be reducing in Cornwall, but at a slower rate than nationally; o Alcohol related unintentional injuries, with excessively high rates among men; o Alcohol related mental and behavioural disorders, with especially high rates among men and rising trend amongst women; o Alcoholic liver disease, with especially high rates among men; o Rising rates of alcohol-related cardiovascular conditions, with especially high rates among men (noting that this is a national as well as a local trend); o Rates of alcohol-related intentional self-poisoning in women.  A review of case studies of frequent attenders at Royal Cornwall Hospital Trust Treliske reflect that these service users are often very vulnerable with multiple health and mental health needs. Many were found to have a chaotic lifestyle and demonstrate problems with engagement, often being resistant to treatment and change;  A joint initiative has been developed between commissioners and service providers to offer alternative approaches and care pathways for change resistant drinkers (what Alcohol Concern refer to as a “Blue Light Project”, because it seeks to reduce the burden upon emergency services). Initially highlighted by the review of hospital frequent attenders, this problem was further emphasised through localised issues around street drinking, anti- social behaviour and rough sleeper populations;  The introduction of the new Alcohol Liaison Team, and a more individualised approach to care for people admitted with complex alcohol-related health problems, has has resulted in improved outcomes and fewer hospital bed days.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 14 OFFICIAL

Alcohol and suicide  Cornwall has a higher suicide rate than the national average, reflecting a significantly higher male suicide rate. This rate has been increasing since 2007. The 2015 Suicide Audit concluded that “the increase in suicide rates since 2007 is likely to be a consequence of the recession.”  In 2013 there were 65 deaths by suicide in Cornwall and the Isles of Scilly, with the highest number amongst the 45-59 age group.  The most common methods are ‘hanging, strangulation and suffocation’ by men and ‘poisoning by drugs/alcohol’ by women;  24% of all suicide cases were reported to have taken alcohol at the time of death.

7(b): Treatment, aftercare and recovery What is working well?  Numbers entering drug and alcohol treatment are on an upward trajectory (but are above contracted capacity for the service);  Local services are cost effective. At £4,441, Cornwall and the Isles of Scilly pays 9% less per successful outcome than the national benchmarks;  More people have accessed treatment. Compared with 2014/15, there were: o 4% more alcohol users in treatment: nationally numbers fell by 5% o 21% more non-opiate and alcohol users in treatment: nationally numbers were static  In line with the national picture, the main access route into treatment is self-referral accounting for just over half of all referrals in 2015/16. GP referral accounts for the next largest segments of referrals at 21%, which is above the national average of 17%;  At 11%, the proportion of criminal justice referrals for alcohol has dropped slightly compared with previous years, but remains above the national average of 8%;  Early unplanned exits are better than the national profile for alcohol, as they are for all of the drug groups. This indicates that the system is initially meeting the needs of service users, and successfully promoting engagement with services. Overall around 10% of people leave treatment in an unplanned way and before 12 weeks;  Although overall performance in successful completions has declined, some client groups have seen an increase in the proportion completing treatment successfully and these were: o Unemployed/NEET on presentation to treatment; o Presenting to treatment with lower consumption levels of alcohol (under 200 units in the preceding 28 days); o Clients NFA/rough sleeping on presentation to treatment; o Clients referred between treatment services; o Clients with a disability - particularly physical disability.

What needs to improve  Referrals through other health (hospitals/ED) and social care routes remain low at 3% and 1% respectively, compared with 6% and 2% nationally.  There was a numerically small but significant increase in the number of people presenting to treatment having consumed 1000+ units in the preceding 28 days (at least 250 per week). This very high risk group makes up 8% of the

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 15 OFFICIAL

people who started treatment episodes in the last 12 months and the rise is entirely in male clients;  We need to improve the proportion of people completing treatment successfully, which has declined for alcohol as it has for all other drug groups. In people terms, in 2016 we fell short of the national average by 106 successful completions;  Contributory factors include addressing concurrent mental health problems, couples impacting negatively upon each other’s treatment, unresolved early life trauma and the need to build recovery capital in employment, training and housing.

Tier 4  63 people accessed residential services in 2015/16, of whom 49 (78%) completed successfully. This is almost exactly the expected number to require residential rehabilitation, with a very high rate of completion;  Particular challenges include re-emergence and management of physical and psychological pain, particularly of early life trauma; families and/or partners where relationships are dysfunctional or there are dependence issues; additional complex needs such as learning disability or homelessness;  Other negative factors include being unable to manage lump sum PIP payments and lack of sufficient preparation.

Dual Diagnosis  Drug and alcohol problems are usual rather than exceptional amongst people with mental health conditions but the relationship between the two is complex. Health guidance stresses the importance of drug/alcohol and mental health services working together effectively, otherwise both will fail;  It is estimated that 12,000 people in Cornwall (2.6% of the adult population) has a mental health condition concurrent with alcohol dependency. There were 192 people in treatment for alcohol problems with a concurrent mental health condition (dual diagnosis), so only a small fraction of the estimated number are receiving specialist treatment;  Violence and abuse, particularly when experienced in childhood, is strongly associated with later onset and persistence of mental health conditions and problematic use of drugs and alcohol;  Although we have higher than average levels of concurrent contact with mental health and drug/alcohol services, local data indicates that there is significant unmet need, particularly in the offender population that commonly present with this combination of issues;  A survey with staff across a range of community safety services found that experiences of successfully referring into mental health services were mixed, with dual diagnosis, increasing theresholds, ease of contact and unclear pathways being described as the barriers;  The delivery of Mental Health First Aid training has been successful in raising staff confidence and knowledge when working with someone with a mental health condition.

8: Licensing, alcohol retail and the Night Time Economy  We have achieved national recognition for our innovative work as part of the national HaLO pilot (Health as a Licensing Objective), supporting greater involvement by health in licensing decisions. This project showcased effective

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 16 OFFICIAL

data gathering to demonstrate the impact of alcohol the health of residents, and the burden on NHS and Emergency services;  As a result of our contribution to and participation in the HaLO pilot, we have successfully bid to become a Local Alcohol Action Area (LAAA) in round 2 of the scheme, with the action plan fully embedded within our local Alcohol Strategy;  This programme is intended to tackle alcohol-related crime and health harms, and to support the evolution towards a more diverse night-time economy. The main aims for Cornwall as a LAAA2 are: o To continue to expand the Cornwall HaLO dataset and tool; o To embed it in operational use; o To improve Licensing practice use of health related evidence in forming conditions and objections, in order to improve Licensing practice and make customers and localities more safe; o To contribute to the drive to reduce alcohol related violence; o To contribute to the drive to reduce the harmful impact of alcohol on localities and communities; o To identify and support problematic drinkers through support and (where necessary) enforcement; and o To contribute to reducing alcohol related hospital admissions.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 17 OFFICIAL

Commissioning priorities Key themes from research show that effectively configured services:

 Are accessible  Are acceptable  Are as non-stigmatising as possible  Focus on early interventions  Address the whole person  Are based on evidence of what works  Build upon existing successful networks and are sustainable  Have effective assessment, planning and care co-ordination systems.  Prioritise those most in need.  Improve based upon real time feedback.  Are only as effective as the therapeutic relationship between the worker and the person seeking help.

Priority Outcomes

1. Freedom from dependence on drugs or alcohol

2. Improvement in mental and physical health and wellbeing

3. Reducing drug related deaths

4. Reduced hospital admissions

5. Prevention of the spread of blood borne viruses

6. A reduction in crime and re-offending

7. Sustained employment

8. The ability to access and sustain suitable accommodation

9. Improved relationships with family members, partners and friends

10. Improved capacity to be an effective, caring parent

11. Delivering value for money

Equality and human rights are key in all of these areas, with implications for equitable service delivery and access, encompassing gender, sexual orientation, disability, age, isolation, vulnerability, ethnicity, religion and beliefs.

Complex needs Working more effectively with people who have multiple complex needs is an overarching priority that cuts across a wide range of commissioning areas.

We have a large and apparently growing number of people are experiencing alcohol and drug dependence, homelessness, domestic abuse and sexual violence, offending and poor mental health.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 18 OFFICIAL

“Commissioners responsible for existing different service elements will work together to commission a joined up ‘whole system approach’ to support people with multiple needs. This will ensure services are integrated around the needs of the person, improving individual outcomes whilst also ensuring best use of resources.” Making Every Adult Matter http://meam.org.uk

Right Care6 identified 1,764 complex patients costing the health system in Cornwall £32 million per annum; this did not include social care, criminal justice, welfare and social costs.

 A growing number of people don’t ‘fit’ any one service;  Many are repeat attenders at hospital, sometimes getting multiple unplanned detox;  Some are ‘handed off’ by services and often end up in the least appropriate setting until they escalate to crisis care levels or death.

Whilst there are pockets of excellence, there is no systematic response, with duplication, an inefficient use of resources, limited joined up working and poor access to mental health services and appropriate accommodation.

There are challenges in relation to increases in complexity, secure information sharing, shared management of risks and missed opportunities for timely interventions.

Drug and alcohol treatment needs cannot be seen in isolation, but need to be addressed within the wider context of multiple problems, to deliver sustained recovery.

 Create a ‘whole system’ approach through an Adult Complex Needs Commissioning Plan providing an improved offer to people with multiple needs;  Develop a more efficient system through a model of support that reduces duplication and delivers an improved client experience with positive outcomes;  Oversight provided by a single multi-agency group which can problem solve and overcome barriers and obstacles and embed learning and change;  Create a contractual environment where outcomes are, at a minimum, mirrored across all contracts (e.g. DASH and alcohol and drug screening by all, mental health pathways for all) and, at best, where suppliers share responsibility for achieving outcomes and are mutually supportive, making decisions based on the best outcome for the service user.

Utilising Integrated Personalised Commissioning to provide flexible responses outside of the norm:

6 Right Care gives local health economies in England practical support in gathering intelligence, data, evidence and tools to help them improve the way care is delivered for their patients and populations.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 19 OFFICIAL

 Supported by a Workforce development programme to ‘up skill’ staff, enabling specialist services to be more targeted whilst improving service delivery and outcomes;  Increase capacity in the system through applications for grant funding and exploration of social capital investment programmes.

Overview of Recommendations for Commissioners The treatment system Services were mapped against the relevant NICE guidance7 and the following gaps and priorities for improvement were identified:

Families  Families and Carers - whilst services are available a ‘an assessment of needs’ is not provided as such;  ‘Affected other’ groups are provided and individual support. We do not have access in every locality yet.

Community services  Prevention through alcohol screening, using AUDIT-C; o More screening is needed of patients attending with relevant physical conditions in wider health services, and better data collection; o No routine screening takes place for patients with relevant mental health conditions in GP or mental health services; o No evidence of screening of victims/offenders of alcohol-related assaults taking place in Emegency Departments or by the police; o No evidence of screening of regular attenders for accidents and trauma, including 'falls' taking place in Emegency Departments; o No commissioned service in place that covers screening in regular GUM and emergency contraception service attenders.  Community Detoxification – updating skills of community staff is required to encourage take up

Identification and Brief Advice (IBA)  More delivery of IBA in primary healthcare – some practice nurses and GPs do this but it is not widespread practice;  Delivery of IBA in Emergency Departments – no evidence that this takes place;  Expand IBA delivery to other healthcare services listed by NICE.

7 NICE pathways – drug misuse

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 20 OFFICIAL

Wernicke-Korsakoffs syndrome (WKS)  Establish adequacy of specific care for WKS within Cornwall residential units and community provision, that enable: o Supported independent living for those with mild cognitive impairment; o Supported 24-hour care for those with moderate or severe cognitive impairment.

Co-Morbid Conditions  Pathways into secondary mental health services remain inadequate for depression and other mental health disorders;

Psychological interventions  Confirm whether the programmes delivering psychological interventions (CBT/Behavioural therapies/social therapies/couples therapy) are Cornwall- wide and quality assured.

Pharmacological Interventions  No specific pathway/ recommendations or monitoring of the use of Nalmefene locally. Specialist treatment does not use it, and Naltrexone may be preferable;  Naltrexone is not widely used locally. Prescribing in both specialist services and GP led services is monitored through prescribing data. Primary Care lead GP and Consultant Psychiatrist for Addictions offer regular supervision and training for other medical staff including GPs;  Disulfiram is not widely used locally.

In addition, service users identified the following as important:

 Help with transport and parking costs to get to treatment every day;  Help with childcare, especially in school holidays;  Drugs and alcohol and mental health services working together;  Getting counselling for early life trauma prior to detox.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 21 OFFICIAL

The following recommendations have been drawn from the evidence presented within each section of the Needs Assessment. Not all are within the remit of the DAAT or drug and alcohol services to address but have been included to inform the commissioning of services that work with people who usealcohol and other drugs.

Treatment system

Access to Healthy Relationships programmes and joint couples 1. interventions are a priority to improve outcomes; Use Session Rating Scales for all episodes or psychosocial 2. intervention in order to ensure treatment responsiveness and strong alliance factors are maintained;

Counselling resources and a trauma informed approach is 3. required to assist people striving to overcome early life trauma;

Redesign the treatment pathways to allow for a more intensive 4. approach in the first six months of treatment;

Provide longer-term employment and housing support, including 5. in-work support, to help people gain and maintain employment and appropriate housing.

Criminal Justice System

Sustain robust and integrated pathways between drug and alcohol 1. treatment and all points of the criminal justice system, including pathways between prison and community-based treatment; Establish whether and how rates of referral and engagement of people 2. identified by the Liaison and Diversion and offender management services could be improved.

Families

Support earlier identification and intervention through embedding routine screening for alcohol and other drugproblems in all 1. health, children and family services and Child and Adolescent Mental Health Services (CAMHS); Develop and deliver targeted interventions to build resilience and reduce harm for children and young people most at risk of 2. Adverse Childhood Experiences, including parental substance use and domestic abuse; Improve the effectiveness of the Together for Families 3. pathway and establish the impact that this is having on outcomes for families;

Undertake a robust evaluation of the new residential unit for 4. young people and families, and continue to develop interventions using a co-production model;

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 22 OFFICIAL

Support earlier identification and intervention through embedding routine screening for alcohol and other drugproblems in all 5. health, children and family services and Child and Adolescent Mental Health Services (CAMHS).

Physical Health

All drug and alcohol service staff to participate in ASIST training to 1. aid suicide prevention amongst this high risk group;

Further embedding the NHS England initiative Making Every Contact Count (MECC) approach which aims to support people in making positive changes to their physical and mental health and wellbeing. Specifically, within the treatment population, this should focus on: 2. o Smoking cessation o Alcohol consumption amongst dependent drug takers, and as a relapse risk o Physical activity o Sexual health

Mental Health Identify and agree the priority areas and outcomes to improve mental health across each community safety strategy, team and 1. service at a partnership level and report performance on a quarterly basis;

Improve skills and confidence in the workforce to identify, assess 2. and refer people with complex needs; Improve understanding of service demands of adults and young people with complex needs, including an agreed mental health assessment within each service’s assessment, recording processes 3. and case management systems (where applicable), alongside DASH risk assessments and alcohol and other drug screening and assessment; Understand and better capture the impact of Adverse Childhood Experiences (ACEs) both in early years and as an adult. Include 4. questions within assessments and ongoing work as to the number of ACEs experienced by the individual, what impact they have had, and what help has been received or is required;

Achieve system improvement in children’s, families and adult services through enabling citizens and services to navigate local 5. systems via an online pathway mapping tool and routinely reviewing system failures.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 23 OFFICIAL

Homelessness and housing need

Further analysis of the various cohorts of clients identified as having poor outcomes would help us to understand how to improve them. This could include additional analysis of the responses in the rough 1. sleeper survey for people who had previously been in private rented accommodation or supported housing to better understand the circumstances that led to their rough sleeping;

Enhanced funding to the complex needs sector providing security 2. of contracts and enabling the development of a model that will accommodate the most complex people;

Additional female only provision to accommodate complex and 3. vulnerable females;

4. Continuation of Homelessness Hospital Discharge protocol work; Provision of accommodation for clients in close proximity to 5. support services with access to good transport links;

Establish a co-ordinated partnership approach to complex needs clients by implementing the learning from the new rough 6. sleeper proposal, and provide a balance between enforcement and assistance in local areas, to prevent future occurences and meet the statutory requirement to protect vulnerable people;

Additional support within the treatment programme for 7. vulnerable service users to minimise the impact of welfare reforms and subsequent homelessness;

A pilot treatment service in close proximity to Boscarn to make 8. treatment more accessible to the Gypsy and Traveller population and could result in more people being engaged in treatment.

Worklessness

Service mapping and pathways for all new employment services 1. that are being implemented, with Single Points of Contact across employment and treatment organisations;

Continued delivery of cross-agency training workshops to build shared skills and knowledge amongst both treatment providers and 2. employment providers, to include Welfare Reforms, DEA employment support and identification of drug/alcohol problems and other needs;

Target client friendly employment sectors in order to maximise 3. the local employment opportunities for clients recovering from drug and alcohol issues and also those with a history of offending;

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 24 OFFICIAL

Create a network of peer mentors to act as advocates and visible symbols of recovery, tasked with encouraging safe 4. disclosure and engagement and providing appropriate support which would have the potential to increase the number of referrals between organisations;

Ask clients if they have a claimant commitment when they first 5. access treatment so early links can be made across organisations to provide support;

6. Introduce 3-way case conferencing;

Capturing case studies to highlight what is working well and the additional challenges that still need to be addressed. Videos could be 7. used to capture success stories and employment and recovery journeys that can be shared with other clients;

Trial a process of contact with DWP prior to client exit from treatment 8. so that more intensive support can be offered at this crucial time;

A number of data and performance management improvements have been identified, including: o Improve recording of employment related information within the case management system and DAAT reviews with servicesto include employment outcomes and progress being made; o Collection of outcomes for clients accessing the Big 9. Lotteries Building Better Opportunities Fund (BBO) services and Reed in Partnership Work Route’s programme and other employment providers in order to enhance understanding of longer term outcomes; o Develop and pilot a recovery measure to capture the range of progress being made by clients in advance of an expanded recovery model being implemented by government.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 25 OFFICIAL

Section 2: Setting the scene National strategic context NEW National Public Health England Alcohol Evidence Review The national Public Health Alcohol Evidence Review8 was published in December 2016 and looked at the impact of alcohol on the public health and the effectiveness of alcohol control policies. Key trends identified:

 Young people are drinking less;  Harmful drinking levels amongst middle aged/older people;  Liver disease is rising in the UK, against the trend in other parts of Europe;  Alcohol is now the leading risk factor for ill-health, early mortality and disability for those aged 15 to 49 years and the fifth leading risk factor for ill- health across all age groups;  Consumption has declined in recent years, but levels of abstinence have also increased. This means that those who drink may still be drinking at unchanged levels;  Over 1 million hospital admissions relating to alcohol each year, half of which occur in the lowest three socioeconomic deciles;  Average age at death from an alcohol-specific cause is 54.3 years, whereas the average age of death from all causes is 77.6 years;  More working years of life are lost in England as a result of alcohol-related deaths than from all of these cancers, combined - cancer of the lung, bronchus, trachea, colon, rectum, brain, pancreas, skin, ovary, kidney, stomach, bladder and prostate.

Conclusions about what works:

Affordability  Policies that reduce the affordability of alcohol are the most effective, and cost- effective, approaches

Availability  Reducing hours for alcohol sales – particularly late night on-trade sale – reduces alcohol-related harm in the night time economy;  There is a clear relationship between the density of alcohol outlets and social disorder.

Acceptability  Self-regulatory systems that govern alcohol marketing practices do not succeed in protecting vulnerable populations.

8 The public health burden of alcohol and the effectiveness and cost-effectiveness of alcohol control policies: an evidence review, Public Health England (December 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 26 OFFICIAL

Reducing drink-driving  Enforced legislative measures to prevent drink-driving are effective and cost- effective;  Lower alcohol limits for young drivers are economic and effective at reducing casualties and fatalities in this group.

Brief interventions and treatment  Large scale, well-resourced health interventions aimed at drinkers who are already at risk (e.g. Identification and Brief Advice) and specialist treatment for people with harmful drinking patterns and dependence, are effective approaches to reducing consumption and harm in these groups, and show favourable returns on investment.

The policy mix  Combining alcohol polices may create a ‘critical mass’ effect, changing social norms around drinking to increase the impact on alcohol-related harm, but alcohol policies should be coherent and consistent;  Warning labels highlighting the risks of alcohol consumption should not be undermined by a unit price that encourages heavy consumption.

NEW Modern Crime Prevention Strategy 2016 This legislation was enacted initially within the Policing and Crime Act 2017 (January 2017). The strategy9 is based on research into the drivers of crime, including alcohol, and includes such provisions as:

 Late Night Levy improvements to apply to defined areas, rather than whole Licensing Authority areas;  Cumulative Impact Policy improvements, with more statutory powers to control alcohol sales;  Consult on Licensing interventions for groups of premises in certain locations, in a group review intervention power (GRIP) which may require improved security or other area license conditions;  Civilian (police) staff powers of entry to enter and inspect licensed premises;  Sobriety tagging as a Court Order and improved GPS based electronic monitoring.

Preventing alcohol-related crime and disorder requires a three-pronged approach. All those with a stake in the evening and night time economy have a responsibility to securing the effectiveness of this approach:

1. Improving local intelligence 2. Establishing effective local partnerships 3. Equipping the police and local authorities with the right powers

9 Modern Crime Prevention Strategy, Home Office (March 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 27 OFFICIAL

NEW National NICE Guidance update NICE Quality standard 83: Preventing harmful alcohol use in the community (March 2015)10

This latest guidance compiles and summarises a range of approaches at a population level to prevent harmful alcohol use in the community by children, young people and adults.

It is expected to contribute to improvements in the following outcomes:  Quality of life  Admissions to hospital; alcohol-related, and for violence or accidents resulting from alcohol  Alcohol-related deaths  Anti-social behaviour and violent crime related to alcohol  Prevalence of harmful and hazardous drinking  Rates of under-age drinking

It is delivered through these 4 Quality Statements:

1: Using local crime and related trauma data  Local authorities use local crime and related trauma data to map the extent of alcohol-related problems, to inform the development or review of a statement of licensing policy.

2: Under-age sales  Trading standards and the police identify and take action against premises that sell alcohol to people under 18.

3: Alcohol education  Schools and colleges include alcohol education in the curriculum.

4: Schools and colleges  Schools and colleges involve parents, carers, children and young people in initiatives to reduce alcohol use.

National Alcohol Strategy 2012 Our local alcohol strategy is set within the context of the national response to alcohol issues, as outlined in the Government’s 2012 Alcohol Strategy which seeks to reduce drinking above health guidelines or to excess. It intends to reduce alcohol-fuelled violent crime, binge drinking, alcohol-related deaths and underage drinking.

10 Alcohol: preventing harmful use in the community, Quality standard [QS83], National Institute for Health and Care Excellence (March 2015)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 28 OFFICIAL

Measures introduced included a consultation on minimum alcohol unit pricing, and greater control on alcohol retail offers and advertising. However, minimum Unit Pricing (‘MUP’) was ‘postponed’ as Government policy for a decision until after the election. It was communicated that “We do not yet have enough concrete evidence that its introduction would be effective in reducing harms associated with problem drinking — this is a crucial point —without penalising people who drink responsibly.”

This statement contradicts academic peer reviewed research evidence (e.g. British Columbia and Sheffield University) and was critiqued by the BMJ as bowing to disproportionate industry influence and undue pressure.11

Anti-Social Behaviour, Crime and Policing Act 2014: Reform of anti-social behaviour powers New measures have been introduced to increase the range of responses to anti-social behaviour, including positive requirements addressing the root causes of offending behaviours, and to enable hospital emergency departments to better address on-site alcohol related offences. Various new sentencing options for alcohol-related offences have been piloted, and family and youth policies have been trialled in places.

Offender Rehabilitation Act Coming into effect on 1 February 2015, the Offender Rehabilitation Act introduces a number of further measures intended to support the drive to reduce reoffending, including:

 A new drug appointment requirement for offenders who are supervised in the community after release;  An expansion of the existing drug testing requirement after release to include Class B as well as Class A drugs;  A more flexible Rehabilitation Activity Requirement for adult sentences served in the community which will give providers greater freedom to develop innovative ways to turn an offender’s life around.

Drugs Strategy 2010 “Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life” The national drug strategy has two overarching aims:

 Reduce illicit and other harmful drug use, and  Increase the numbers recovering from dependence.

11 ’Consultation on minimum price for alcohol was a sham, BMJ investigation shows’, BMJ (Gornall, J January 2014)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 29 OFFICIAL

The Government aims to offer ‘every support’ for people to choose recovery as an achievable way out of dependence and recognises that the causes and drivers of drug and alcohol dependence are complex and personal and that their solutions need to be holistic and centred around each individual.

Advisory Council on the Misuse of Drugs Report on Recovery from Drug and Alcohol Misuse 2012 The 2012 ACMD Report on Recovery from Drug and Alcohol Misuse highlighted three overarching principles – “wellbeing, citizenship, and freedom from dependence’ and describes recovery as an individual, person-centred journey, as opposed to an end state, and one that will mean different things to different people”.

One of the best predictors of recovery being sustained is an individual’s ‘recovery capital’ – the resources necessary to start, and sustain recovery from drug and alcohol dependence. These are:

 Social capital - the resource a person has from their relationships (e.g. family, partners, children, friends and peers). This includes both support received, and commitment and obligations resulting from relationships;  Physical capital - such as money and a safe place to live;  Human capital – skills, mental and physical health, and a job; and  Cultural capital –values, beliefs and attitudes held by the individual.

In order to deliver recovery-oriented services, there is an acknowledgment that links with housing, employment and family services are essential and must be firmly established and integrated into overall treatment services and that supportive relationships with families, carers and social networks must be promoted.

The 2013 review of the National Strategy, ‘Delivering within a New Landscape’ moves the recovery focus very much towards the housing and employment initiatives that are required to deliver sustainable recovery being priorities for 2014/15 and beyond.

Healthy Lives, Healthy People: our strategy for public health in England (2010) Previous funding made available nationally is brought into the Public Health Grant, along with the local NHS contributions. The local Health and Wellbeing Boards and the Director of Public Health become jointly accountable for ‘strong leadership’ of alcohol and drug treatment.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 30 OFFICIAL

Local Strategic Context Sustainability and Transformation Plan Health and care organisations in Cornwall and the Isles of Scilly have published their proposals for service transformation over the next five years, putting the prevention of ill health and more care at home at the heart of their plans.

The local Sustainability and Transformation Plan (STP)12 is a response to the NHS England Five Year Forward View and Devolution Deal for Cornwall, and it seeks to achieve three aims:

1. Improve the health and wellbeing of the local population. 2. Improve the quality of local health and care services. 3. Deliver financial stability in the local health and care system.

At the consultation stage (January 2017) the Transformation Board, which is made up of all the leaders from the major public sector health and care organisations, engaged with clinicians, practitioners, stakeholders and local residents to input to the shaping of future services.

The plan is based on the fact that we now know that 5 lifestyle behaviours contribute to 5 diseases which cause 75% of premature death and disability.

 Smoking – Higher rate of smoking attributable admissions than national rate  Diet – Over a quarter of children are overweight or obese  Alcohol – Estimated 25,000 people drink at harmful levels costing £75m a year to the health and social care system  Physical inactivity – People in the most deprived areas are twice as likely to be physically inactive than the least deprived.  Social isolation – 15% of all households in Cornwall have a person over 65 living alone.

Measures of success will be:

 Healthy life expectancy at birth.  Fewer pregnant women smoking.  Fewer households in fuel poverty.  Fewer overweight children aged 10 or 11.  Fewer people admitted to hospital for smoking or alcohol related conditions.

The Plan recognises that major social factors are a big influence on demand – 20% of NHS costs are associated with avoidable risk factors to do with diet, physical

12 The Draft Outline Business Case and engagement document - Taking Control, Shaping our Future – are available from Cornwall Council’s website

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 31 OFFICIAL

activity, smoking and alcohol consumption with alcohol related harm accounts for 4,060 hospital stays per year.

The plan outlines different areas of interventions. Under ‘Health and wellbeing improvement’, it lists four high impact changes, one of which is identification and brief advice (IBA) targeting harmful lifestyle behaviours including smoking and alcohol consumption. This will include co-ordinated smoking prevention programmes, alcohol identification (AUDIT-C) and brief advice in primary, community and secondary care.

Key health outcomes and benefits are expected to be achieved from changes that include “alcohol consumption is reduced and related hospital admissions are lowered.”

Under a different intervention, ‘Prevention and self-care’ and seeking to achieve “admission avoidance for high risk groups”, it states that:

“In order to reduce harm from alcohol, we could also implement an Alcohol Assertive Outreach Team as an extension to our drug and alcohol services (DAAT) to offer more intensive support.”

Police and Crime Plan 2017-2020: The new Police and Crime Plan 2017-202013 “Safe, Resilient and Connected Communities” was published in January 2017.

Key points in the Plan:  Connecting our communities and the police – through a new Local Policing Promise to ensure policing in the local area is ‘Accessible, Responsive, Informative and Supportive’;  Preventing and deterring crime – so we can stop people becoming victims of crime and help them move on with their lives;  Protecting people at risk of abuse and those who are vulnerable – safeguarding the vulnerable and keeping them safe from harm;  Providing high quality and timely support to victims of crime to help them recover and to get justice by improving the criminal justice system;  Getting the best out of the police – making best use of resources, supporting and developing our workforce and working well in partnership with others.

This work will include commissioning a behaviour change diversion scheme focussed on pathways into crime, as well as a new regional Restorative Justice service, and expansion of the victim focus.

A detailed analysis of the PCC’s Plan in relation to our response to alcohol is provided in the section on Alcohol and Crime.

13 Safe, Resilient and Connected Communities, The Police and Crime Plan 2017-2020 for Devon, Cornwall and the Isles of Scilly (OPCC, 2017)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 32 OFFICIAL

The Public Health Outcomes Framework

Vision: To improve and protect the nation’s health and wellbeing, and improve the health of the poorest fastest.

The Public Health Outcomes Framework14 focuses on the two high-level outcomes to achieve across the public health system and beyond. These two outcomes are:

Outcome 1: Increased healthy life expectancy. Taking account of the health quality as well as the length of life (Note: This measure uses a self-reported health assessment, applied to life expectancy.)

Outcome 2: Reduced differences in life expectancy and healthy life expectancy between communities. Through greater improvements in more disadvantaged communities.

Alcohol and other drugs form part of the set of supporting public health indicators that help focus our understanding of how well we are doing year by year nationally and locally on those things that matter most to public health, which we know will help improve the outcomes stated above.

The 2 overarching indicators that the Drug and Alcohol Action Team are responsible for delivering against are:

2.15 Drug and alcohol treatment completion and drug misuse deaths

2.18 Alcohol-related admissions to hospital

Alcohol Related Hospital Admissions is the key indicator for the overall impact of all aspects of alcohol interventions in any given area. As such it is a definition of how much the system fails to prevent people arriving in a hospital bed with a condition for which alcohol is a direct cause or contributory factor.

When analysed, it can also provide guidance for preventative interventions in key community health treatment settings, in order to identify alcohol issues before they become severe enough to contribute to hospital admissions. Similar analysis also provides guidance for treatment pathways for patients leaving hospital after episodes addressing conditions where alcohol is a direct cause or contributory factor.

We will continue to incorporate any new national policies and initiatives alongside our commitment to addressing local needs, and the continued development of our own good practice and strategy.

14 Public Health Outcomes Framework 2016-2019, Department of Health (August 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 33 OFFICIAL

Two new sub-indicators have been added from 2016:

 2.15iii – Successful completion of alcohol treatment  2.15iv – Deaths from drug misuse

Successful completion of alcohol treatment has been added as an additional sub indicator to reflect the fact that drug and alcohol services are increasingly commissioned together and the data that is used to report on access and provision all comes from the same monitoring system.

Substance misuse has serious health implications and treatment is proven to reduce the strain on local health services. The impact of substance misuse is far reaching and contributes to 28 of the 66 indicators reported through the Public Health Outcomes Framework.15

0.1 Healthy life expectancy Differences in life expectancy and healthy life expectancy between 0.2 communities Domain 1: Improving the wider determinants of health

1.01 Children in low income families

1.03 Pupil absence

1.04 First time entrants to the youth justice system

1.05 16-18 year olds not in education, employment or training

1.09 Sickness absence rate

1.12 Violent crime (including sexual violence)

1.13 Levels of offending and re-offending

1.15 Statutory homelessness

1.18 Social isolation

Domain 2: Health improvement

2.01 Low birth weight of term babies

2.03 Smoking status at time of delivery Hospital admissions caused by unintentional and deliberate injuries in 2.07 under 25s

15 Public Health Outcomes Framework (2016 to 2019), Department of Health (August 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 34 OFFICIAL

2.08 Emotional well-being of looked after children

2.10 Self-harm

2.15 Drug and alcohol treatment completion and drug misuse deaths Adults with substance misuse treatment need who successfully 2.16 engage in community-based structured treatment following release from prison 2.18 Alcohol-related admissions to hospital

2.23 Self-reported well-being

2.24 Injuries due to falls in people aged 65 and over

Domain 3: Health protection

3.04 People presenting with HIV at a late stage of infection

Domain 4: Healthcare public health & preventing premature mortality

4.03 Mortality rate from causes considered preventable

4.06 Under 75 mortality rate from liver disease Mortality rate from a range of specified communicable diseases, 4.08 including influenza 4.10 Suicide rate

4.11 Emergency readmissions within 30 days of discharge from hospital

4.14 Hip fractures in people aged 65 and over

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 35 OFFICIAL

A changing delivery landscape

Changing national priorities, driven by a change in government, fast evolving legislation and the impacts of the economic downturn and austerity measures have had a significant impact on our communities and our service delivery environment.

Further substantial cuts are expected in public sector funding. The cumulative impact of reduced resources across all partner agencies is creating gaps in service provision, increasing risk and limiting our options for putting mitigating action in place. The following factors have been identified as particularly crucial in influencing partnership responses over the next 3 years.

Cornwall Devolution Deal and Every health and care system in

the delivery of the Case for England is required to produce a five

Cornwall: £5 billion of devolved year Sustainability and

government funding, with key Transformation Plan (STP),

development areas including the showing how local services will

integration of health and social evolve and become sustainable over

care and co-location and sharing of the next five years. Our local STP

resources by blue light services. provides limited focus on the key community safety issues identified Conversely, many public sector as wider determinants of health, agencies (such as Police and in particular domestic abuse and Probation Services) are working sexual violence. This limits the STP’s across wider geographical areas, scope to engage wider partners in to achieve efficiencies and addressing the underlying causes of harmonise working practices. poor health and deliver radical transformation.

New Housing legislation – including Housing and Planning Public sector plans to increase use Act, Welfare Reform and Work Bill, of Voluntary, Community and reforms to Local Housing Social Enterprise (VCSE) sector Allowance, Universal Credit and capacity to make savings and build the Immigration Bill – expected to community resilience - VCSE sector increase demand for housing reports, however, that existing support, alongside a decline in supporters are “getting older” with housing stock, reduced difficulties in recruiting young operating budgets for services people. Plus, reduced grant and potential for adverse income due to budget cuts responses in the rental market, compromises their ability to recruit particularly for our key client and retain quality (paid) staff. groups who are particularly vulnerable but perceived as more Increasing threat presented by challenging to house. on-line environments as

Predicted to impact on rough locations for criminality and the

sleeping and use of temporary challenges that this presents for

accommodation (particularly for safeguarding people, detecting and

young people) with knock on investigating crime. Potential for

effects on crime and reoffending massive rise in recorded crime

and increased demands on health as we improve identification,

and social care services. recording and response.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 36 OFFICIAL

All agencies are reporting that people presenting to services have increasingly complex, multiple needs. Responding effectively requires partners to work together to address those needs holistically and provides opportunities for joint commissioning, co-design and delivery of services. But “silo” working due to pressures on budgets and resources is a major barrier to achieving this.

Additional demands are being The UK’s decision to leave the placed on local partnerships to European Union has created contribute intelligence and uncertainty over the future of EU expertise to the development of funded projects. Although the the new Serious and Organised Treasury will honour agreements Crime Profiles and to co-ordinate signed before the 2016 Autumn local responses, with no Statement, this still leaves £300 additional resources or funding. million of investment at risk This creates five new strands of that has been earmarked for work that are complex and growing businesses, creating jobs overlapping and include Modern and boosting skills, including work Slavery, Child Sexual Exploitation programmes for those furthest and the Trafficking of Drugs, People from the workplace. and Weapons. The predicted drop in income for supported housing providers, due The transition of the majority of to Government plans announced adult offender management last year to cap housing benefit services to the private sector, in the social sector at the same alongside a much smaller public levels paid to private landlords, sector Probation Service, has puts future service provision at resulted in reduced budget and risk. Implementation has been resources to deliver offender deferred until 2018 whilst a review management in Cornwall, requiring is conducted into funding for the partners to rethink how we work supported housing sector. together to reduce reoffending. There is national uncertainty over the future of the Youth Justice The number of hate crimes Board and local partnerships, reported in the UK rose by 57% pending the delayed results of the in the week following the EU departmental review and plans to Referendum result, with higher transform the youth justice system. increases in areas that were A White Paper and consultation strongly pro-leave. Although the process is likely and we anticipate impact locally has been less clear, that the concept of ‘secure there is an increased risk of schools’ replacing the current victimisation for our minority Youth Offending Institutions will communities, requiring agencies to continue to be explored. work together proactively to safeguard those who are most vulnerable, build confidence to The local partnership is well placed report and promote unity and to address these challenges, tolerance. This will be particularly drawing on the combined resources important as we start the and strong leadership of the six resettlement of refugees in responsible authorities to deliver Cornish communities. effective joint responses.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 37 OFFICIAL

Section 3: Our services and what people say This section provides a summary of new initiatives and service development, based upon priorities identified in last year’s needs assessment, and the results of our consultation on what works with service users, providers and key stakeholders.

What did we achieve in 2015/16? Increased early intervention opportunities through community and specialist health settings  Identification and Brief Advice (IBA) training in community and specialist health settings is one of the measures which has been identified as making the highest impact upon prevention, reducing hospital admissions. The IBA training scheme seeks to identify and intervene alcohol issues and increased risk of alcohol conditions, as early as possible in a someone’s problematic use, rather than allow Alcohol Use Disorders to become established and complex before treatment is sought or needed;  In the last 4 years we have trained around 3,000 front line staff in the community and the NHS. Knowledge and learning-based feedback forms show that 97% of staff who attended IBA training showed increased knowledge of alcohol units, the AUDIT screening tool and the ability to interpret and address scores, increased confidence and intention to increase the frequency of addressing alcohol issues in their client group.

Increased treatment accessibility and availability  The availability of outreach provision has increased in localities and improved success in attracting and engaging the more hard to reach. This has included embedded workers in supported housing provision (including wet hostel, bail hostel and Prolific Offenders Provision). There has also been an outreach service to prisons where assessment and residential referrals have been completed. The Outreach Model piloted in Truro has gained recognition as a model of good multi-disciplinary practice;  Mutual aid meetings are available in 12 sites across Cornwall where people who have successfully completed treatment can meet and support each other to sustain their recovery;  Chy Colom have secured funding for a kennel and, alongside kennelling arrangements at Bosence and Boswyns, this has removed the barrier to accessing residential rehabilitation for people who have dogs and no one to care for them;  We are also working with Royal Cornwall Hospitals Trust to start to improve identification of alcohol problems in hospital and identify onward referral needs.

Reduced the impact of alcohol on communities  We developed a scheme to respond to any local intelligence about local drug and alcohol related problems by targeting an intelligence-led outreach service from Addaction to visit sites and engage service users, who were often homeless, in conjunction with homeless services;

 ARID, the Assault Related Injuries Database is a scheme delivered in the Emergency Department (ED) and Minor Injury Units (MIU) in Cornwall and supports health engagement in violence prevention. It captures data about assault and alcohol related incidents, through trained reception staff. This data makes a significant contribution to the evidence around alcohol-related violence, particularly for those crimes that are not reported to the police, and is used to target licensing operations. We have a Peninsula-wide model in place with ARID in all 5 Devon and Cornwall EDs, plus 5 MIUs in Cornwall.

Improved targeted support into housing and employment  The specialist community service has worked alongside housing providers and Cornwall Council to provide a range of supported housing packages for individuals in housing need including supporting people in their own accommodation and taking services into hostel provision;  Addaction provided a direct daily service into the Cold Weather Provison and there is a homelessness lead in both Camborne and Truro. The service is part of the Task Force in St Austell;  Addaction staff are based in stage 1 supported housing projects to to offer support and advice to supported housing teams and engage as many clients as possible;  The tier 4 protocol has been expanded to include St Petroc’s, Stonham Homegroup, Cornwall Housing Limited, Bosence Farm and Addaction Chy. This supports clients to access supported accommodation on discharge from rehabilitation, with the aim of increasing their recovery rates;  In 2015/16 employment pathways continued to support clients into treatment from employment and into employment from treatment;  The first Active Plus course was delivered within the residential rehabilitation service, run by veterans;  Housing and Job Centre Plus staff participated in DAAT multi-agency training sessions.

Improved responses to individuals and families with complex needs  A joint DAAT/DASV protocol has been developed to improve outcomes for people affected by both issues. This is now in the process of implementation. All drug and alcohol service staff have attended the DASH Training. Drug and alcohol services work closely with the IDVA Service and police in order to provide a rapid response to individuals who are at high risk as a result of domestic abuse and continue to participate in the MARAC process;  A Dual Diagnosis Strategy is in place for drug and alcohol treatment and mental health services to work together to better support people affected by both of these issues. The pathway and implementation plan now need to be progressed. Outcome reports for people in treatment show significant improvement in mental and physical wellbeing;  Partnership working with Community Mental Health Teams continues to remain challenging. The Multi-Agency Safeguarding Meeting at Bolitho, however, is piloting ways of joint working in relation to vulnerable adults with dual diagnosis who are being exploited in their own homes;  The Criminal Justice Team has extended its coverage of custody to include five days a week with rapid assessments being offered the following day. Addaction is now providing a service directly to Crown Court as well as its

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 41 OFFICIAL

regular service to the Magistrates’ Court. Restorative Justice is being incorporated into drug and alcohol treatment;  A multi-agency response was pilotted in Truro, involving the Council’s Anti-Social Behaviour team, Addaction and police, which demonstrated the benefits that could be achieved by a joint approach to tackling with alcohol and drug- related anti-social behaviour and homelessness and which can be built upon and rolled out to other localities;  The Community Safety training programme, co-ordinated by the DAAT, has built upon the success of the DASV multi-agency DASH training, and provided multi-agency training in Mental Health First Aid, Motivational Interviewing, Drug and Alcohol Awareness and Young People’s Substance Use Screening Tool (SUST), to facilitate interagency working with people with combined problems.

Developed the criminal justice pathway within the new arrangements for offender management  Prison releases and court orders along with MAPPA referrals and arrest referrals continue to come directly to the drug and alcohol service. Prolific and Priority Offenders continue to be worked with via the Turnaround Model;  A specialist presence in the Crown Court has led to improved communication and engagement as has an Enhanced Custody liaison role;  Addaction has been working with HMP Eastwood Park to ensure safe escort of women back into Cornwall from prison on discharge, as means of reducing risk and increasing their engagement in treatment.

Delivered universal and targeted social marketing  In conjunction with the Cornwall Council’s Public Health and Communications Department, we have delivered both universal and targeted campaigns, with some of the messaging being Community Safety focussed (‘What Will Your Drink Cost?’), and some contributing to the Public Health Campaign ‘One You’. This includes a 43 second video animation of the recently updated national alcohol responsibility message;  We have also been developing more of an online presence, especially on social media, in order to underline responsibility messages, especially at key periods like the festive season. These activities support the overall goal of early intervention and prevention;  We have worked in partnership with Plymouth University to evaluate the effectiveness of our messaging, so that we can improve the impact of future campaigns.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 42 OFFICIAL

What our people say Every year, we undertake a survey of service users, staff, stakeholders and affected others to see how well or not we have responded to the feedback we have received in previous years and to identify the priorities for improvement in the future.

Key messages from 2016:  Outreach is highly valued;  The quality of support from staff is high;  Services are flexible and accessible and there is a wide range of support offered, but communication about what is available could improve;  The services cited by service users as being most helpful to recovery were the Mutual Aid Programme (MAP) groups, volunteering, training and extra activities;  Stakeholders said that stronger joint working between agencies is helping to support people more effectively, particularly vulnerable people;  The DAAT training is enabling staff in a range of other agencies to identify substance misuse and can offer an intensive support package working closely together to promote recovery and community integration;  Better access to and joint working with mental health services was universally identified as a priority for improvement;  Other areas to improve include more childcare/child friendly services, help with transport costs and developing a better service offer to vulnerable women with multiple needs;  Stakeholders want to see an expansion of assertive outreach and better range, co-ordination and supervision of supported accommodation options.

Service users can respond through a survey (as provided in Appendix B) or through their local Community Service User Forum meeting. Alternatively, they can contact the DAAT team directly by telephone or email. A total of 118 surveys were returned by service users this year and five focus groups were held across the area, attended by 43 people.

Service users What is good and most helpful about drug This is a safe Everyone’s friendly and alcohol services in Cornwall? place; anyone Being

can come here accepted  Quality of support from staff – safe and non-judgemental; I didn’t realise how  Having offices across the county and many other services easy access; were available  Volunteering, training and extra activities to give constructive things to I feel I can trust do with time outside of treatment, people in the particularly Lifeskills and Cookery Club; group  MAP (Mutual Aid Programme) groups. Seeing my Recovery Co- ordinator at the GP’s

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 43 OFFICIAL

What is not helping or is a barrier to your School holidays are a recovery? barrier for me as I just can’t

come because of the  Recovery café needed, especially at the children. If there were some weekends to support people to maintain kind of group here they abstinence; could go to whilst I  Childcare needed in holiday time in attended mine it would help order to attend;

Travel costs can be high to attend  The cost of travelling Communication with and understanding  to and from the office of Mental Health services could be for groups – I would improved; come more often if I  Breathalyser needed in each office; could afford Difficulties when transferring from one  Addaction service to another; When you’re in Availability of detox and rehab places;  hospital after an OD  Waiting times for counselling; you need something  Having workers who have experienced in place and support and recovered from addiction. when you leave

People are scared MH, drugs about getting help and and alcohol You can’t see mental health coming off. They need have a stigma and services while you’re drinking help not to be scared need extra focus or on prescription and vice

versa, it’s a catch 22

Service providers What are the strongest aspects of drug and alcohol services in Cornwall?

 Locally based services to make treatment more We’ve done some accessible in localities; good work together  Stronger links between drug and alcohol and with other agencies Domestic Abuse and Sexual Violence services to this year jointly support people affected by both;  Stronger joint working with supported accommodation, the Anti-Social Behaviour Team and other services to support people, particularly The outreach work vulnerable women with multiple needs; has meant that we  Partnership working with the Alcohol Liaison Team; have been able to do creation of treatment loops from hospital to Boswyns; more for people with  Intelligence-led outreach and engagement activity; multiple problems  Criminal justice pathways;  Preparation for Treatment groups;  Mutual Aid and recovery support has increased;  Volunteer provision;  Women only groups;  Naloxone delivery to service users;  Hepatitis C screening and treatment;  Lifeskills programme to support recovery;

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 44 OFFICIAL

What are the weakest aspects of drug and alcohol services in Cornwall?

 Dual Diagnosis – joint working with people with combined mental health and substance misuse issues is still widely inconsistent and challenging to manage;  The burden of recording and reporting is too great;  Internet access to enable record keeping in remote areas with poor access places a high demand upon recovery workers;  Lack of creative use of digital technology particularly in remote areas.

Stakeholders The Stakeholder Survey was circulated twice and 10 responses were received, spanning Police, Supported Accommodation, domestic abuse and sexual violence services services, Town Council and Hospital Liaison. Consultation of wider stakeholders is also delivered through the Safer Cornwall Partnership Groups.

What is working well/has been most helpful in helping reduce risks and promote recovery from drug and alcohol related harms in Cornwall and Isles of Scilly to date?

 The range of support services offered in groups and 1:1;  There has been increasing inter-agency cooperation, founded on confidence that a Dedicated outreach workers service user will be supported promptly – have been putting in the essential when issues have been identified time with some of the most but service users are vulnerable and anxious problematic adults and this is about approaching another agency; having a huge impact upon  Flexibility and accessibility of services; the Police’s workload and the  Following the DAAT training, staff are able associated problems that are to identify substance misuse and can offer prevented by targeted an intensive support package working outreach/support work closely together to promote recovery and community integration;  Better understanding of services and information about what help is We are now able to available; identify women entering  Improved information, communication refuge who are previously and relationships between different not known to drug and agencies to support joint working to protect alcohol services and can vulnerable people; encourage them to  Homelessness and begging appear to engage in treatment have reduced in St Austell Town centre;  Supported housing have been able to accommodate a higher number of more Addaction are a very valuable challenging drug users than before because resource for Penzance with the of a combination of naloxone provision amount of issues we have with and a drug and alcohol use policy; drugs and alcohol. We find that  Regular visits from Addaction worker to staff are always willing to help see clients on site in supported

accommodation.

What has not been working so well or needs to improve?

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 45 OFFICIAL

 Community support for those with a dual diagnosis of both mental health difficulties and drug/alcohol problems, where it is unclear of which the primary issue is;  Better links between domestic abuse services, drug and alcohol service and the mental health team to support women in refuge with a combined package of support (hospital);  Support safeguarding children of substance misusers. An increase of treatment services and domestic abuse services working jointly to deliver family interventions for families and children affected by substance misuse and DASV, including aftercare so that people leaving refuges can maintain recovery;  Consideration of more women-only provision to attract, engage and promote recovery for women specifically. Mixed provision is tending to deter in some circumstances. This includes support for women seeking supported housing to ensure they can secure and sustain the accommodation suitable to their needs and promote recovery;  Access to evening and weekend drug and alcohol services to encourage women to engage with the help that is available;  A general need for specific and practical training on managing drug use at a refuge;  Limited alternative for those who feel that Addaction and AA does not meet their personal needs;  The Town Council has recently taken responsibility for a number of parks and open spaces and have reported needles and drug paraphernalia finds but would like feedback as to any actions taken as a result of these reports;  Crime linked to drugs and drug sales has been a problem in St Austell in recent years with an increasing amount of violence associated with it;  Lack of expansion of the services that are needed to address the increase in rough sleepers: many of them already have substance misuse issues and those that do not will soon turn to drugs and / or alcohol as an escape mechanism from their desperation;  Public perception of people with substance misuse issues and the effects on the community of the services that help them;  Better co-ordination provision for people leaving prison, many of whom return with drug dependency issues;  Better co-ordination and supervision of supported accommodation with the full range of ‘wet’ and ‘dry’ houses being utilised alongside the pathways to recovery. An increase in ‘dry’ houses or tougher control of drug use within supervised accommodation would assist during transitional phase;  More dedicated outreach provision.

If we could improve only 3 things in 2017-20, what would your top priorities be?

 Better access to mental health services for people with active addictions and a recognition that drug and alcohol misuse often results from, or leads to, mental health problems so that the two cannot be separated;  More supported accommodation for people with drug and alcohol issues in order to get them off the streets and into a safe and non-judgemental environment where they can be encouraged to address those issues;  Greater public awareness about the causes of substance misuse and the benefits to the community of helping people with substance misuse issues to address their problems;  Better promotion of the work carried out by DAAT, providing I cannot think of anything apart from advertising more apart from advertising Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 yourselves a lot more so that 46 OFFICIAL more people know you exist

frontline staff with information on services available, and contact details for the locally responsible representative. Addaction are known by everyone, having a strong operational presence on the street, however DAAT are not so readily known, being more strategic, so need to push their public image to ensure everyone is aware of the work they do, and how their efforts can practically benefit us in our day to day work.  Greater availability of acute/out of hours services;  Training in managing drug and alcohol misuse in a residential setting where there are other vulnerable residents living with their children;  Better links between housing and drug and alcohol teams that provide psychosocial intervention, groups and structured day programmes;  Better communication between all healthcare settings i.e GP surgeries, Paramedics, Social Services, Hospital, Substance Misuse support and Mental Health Services;  More police resource and a greater police presence in and around the town centre in St Austell;  Planning and/or commissioning restrictions to restrict the number of hostels and rehabilitation centres that may be located in any one area;  Improved supervision levels for recovering addicts /alcoholics trying to reintegrate themselves into society;  Funded places on Recovery Programmes outside of Cornwall to break the cycle and provide specialist support. Each placement should be awarded on merit, based on the commitment to change of the subject, and likelihood of success of the programme with them;

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 47 OFFICIAL

Section 4: Examining the impacts of alcohol

National trends and evidence Measuring the impacts on health Early Intervention Mapping the treatment system Families Social Impact Alcohol, crime and disorder Licensing and Retail

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 48 OFFICIAL

National trends and evidence Public Health England alcohol evidence base review

“Following a declining trend between 2005 and 2012, the proportion of men and women drinking in the past week in Great Britain has remained stable over the past three years of available data.

Men continue to be more likely to drink than women and young adults drink less frequently than older age groups. However, young adults are more likely to exceed daily benchmarks regarding alcohol consumption.

In 2014, 8% of children aged 11-15 in England drank alcohol in the last week; this was the lowest level recorded since a peak of 27% in 1996. Most pupils who drank in the last week had done so on one or two days (63% and 25% respectively). On the days they did drink, 45% drank more than four units of alcohol on average.

Alcohol-related conditions were responsible for 104,030 hospital admissions in England in 2014/15. In 2014/15 there were 35,059 alcohol-related stays for patients resident in Scotland.

There were 8,680 alcohol related deaths in the UK in 2014. Alcoholic liver disease was the most common cause of death.”

House of Commons Library Briefing16 ‘Statistics on Alcohol’

Health Survey for England 2015 The latest consumption17 figures show that:

Drinking amongst children aged 8-15 is at its lowest since this survey began, with 16% of boys and 15% of girls reporting having experience of drinking alcohol.

For adults, mixed trends in consumption were found, generally supporting concerns over middle to older adults being at risk of rising consumption and harms.

16 Statistics on Alcohol, House of Commons Research Library (CBP-7626, Harker R., January 2017) 17 Health Survey for England 2015: Health, social care and lifestyles (Copyright © 2016 Health and Social Care Information Centre)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 49 OFFICIAL

 Mean consumption for men by age group shows consumption reducing in the under 45s, but increasing for 65-74 year olds.

Consistent differences are found with men typically drinking more, particularly in the North East, North West and South East, and amongst the higher socio- economic groups across both sexes (though less likely to experience harm).

Despite the positive trends, PHE warned that by the age of 17 half of all girls and almost two-thirds of boys drink alcohol every week and consumption is higher than the European average. Furthermore the decline in drinking among 11 to 15 year olds may be starting to level off with girls.

Consumption Overall, alcohol consumption nationally has been falling since 2004, but may now have levelled and started to rise again18

This piece concludes that “falls in consumption over the last decade may in part be linked to public health activity and growing consumer awareness of health risks. A swing back to rising consumption could indicate the limitations of this activity in the face of stronger economic influences.”

Longer term, current national alcohol consumption levels put us back where the UK was before World War 1, with the biggest reductions coming during the World Wars and post-war economic hardship.

18 An end to falling UK consumption (news article, Alcohol Policy UK, August 2015)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 50 OFFICIAL

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 51 OFFICIAL

Alcohol-related Hospital Admissions Despite falling consumption levels, alcohol related hospital admissions have continued to rise. The two main reasons for this are:

 A sector of the population continuing to drink at increasingly higher risk levels, despite reductions in consumption levels in the wider population;  A time lag for the onset of some health harms and conditions, as a population drinking at increasing and high risk levels over a number of years reaches late middle age.

Liver Disease There have been noticeable impacts on health, as seen in the local LAPE figures for different health conditions in this report. These graphs demonstrate the national changes in mortality rates for various conditions since 1970.

 While medical advances, standard of living, and diet have all helped to reduce mortality for various conditions, liver disease has escalated disproportionately.

What is worth noting is that this increasing liver death trend is not inevitable. Many (but not all) European countries are seeing reducing rates:

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 52 OFFICIAL

Current national Alcohol Related Hospital Admission data Under the latest national figures, the new 'narrow' measure of alcohol-related admissions, based on just alcohol-related primary diagnoses, alcohol- related/specific admissions fell by 0.7%

The longstanding 'broad' measure of admissions, which includes all alcohol related admissions, still increased overall - up by 1.3% in 2014/15.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 53 OFFICIAL

As can be seen throughout the local data below (LAPE), male and female trends tend to be similar, but men are suffering alcohol related episodes in hospital in higher quantities than women.

Other specific conclusions “A stronger downward trend in alcohol-specific admissions in under 18s continued with an 8.6% fall in 2014/15, likely to reflect the more acute nature of younger people's admissions and falls in drinking amongst younger people. Admissions are also falling in the under 40s, but rising in the over 65s. An IAS blog post by Dr Tony Rao, a Consultant Old Age Psychiatrist, attributed this to the 'baby boomer' effect, with at least one-in-four alcohol-related admissions aged 65 and over.

Whilst overall rates of alcohol hospital admissions may be plateauing out, admissions specifically for alcoholic liver disease continue to rise - up 3.4% on last year and 33% up on 2008/09. This may reflect a longer lag effect than general alcohol-related admission rates, with advanced liver cirrhosis typically taking many years to develop.

A new measure of alcohol-related cancers has also been introduced, showing a gradual upward trend in the rate of alcohol-related tumours over the past decade, also likely to have a longer lag period than majority of alcohol-related conditions.”19

19 'Alcohol-related hospital admissions in 2015 - is the tide turning?', Alcohol Policy UK (Morris, J, May 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 54 OFFICIAL

The Public Health Burden of Alcohol and the Effectiveness and Cost-Effectiveness of Alcohol Control Policies: An evidence review The health data sections of the review provide a useful data bank for business cases and needs assessments, the kind of data that is available all the time, but can take some digging to find, e.g. in the annual alcohol statistics bulletin20 which means that this is useful now as a snapshot, and will remain so as a landmark Government official document.

The health section thus forms a good overview of the weight of different health impacts.

The later sections of the document contain succinct panels of different interventions and approaches, and their effect and economic value.

This is a summary of the key findings and effective interventions and approaches21:  Over 10 million people are drinking at levels which increase their risk of health harm;  Among those aged 15 to 49 in England, alcohol is now the leading risk factor for ill-health, early mortality and disability and the fifth leading risk factor for ill-health across all age groups;  Since 1980, sales of alcohol in England and Wales have increased by 42%, from roughly 400 million litres in the early 1980s, with a peak at 567 million litres in 2008, followed by a subsequent slight decline;  Growth areas: increased consumption among women, a shift to higher strength products, and increasing affordability of alcohol;  In 2016 there were 210,000 licensed premises in England and Wales, a 4% increase on 2010, and in addition most alcohol is now bought from shops and drunk at home;  Consumption has declined in recent years, but levels of abstinence have also increased. This means that those who drink may still be drinking at unchanged levels;  Now over 1 million hospital admissions relating to alcohol each year, half of which occur in the lowest three socioeconomic deciles;  Alcohol-related mortality has also increased, particularly for liver disease which has seen a 400% increase since 1970, in contrast to much of Western Europe;  Average age at death from an alcohol-specific cause is 54.3 years, whereas the average age of death from all causes is 77.6 years.  More working years of life are lost in England as a result of alcohol- related deaths than from cancer of the lung, bronchus, trachea, colon, rectum, brain, pancreas, skin, ovary, kidney, stomach, bladder and prostate, combined;

20 'Statistics on Alcohol, England, 2015', NHS Digital (June 2015) 21 'The public health burden of alcohol: evidence review', Public Health England (December 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 55 OFFICIAL

 Positive trends include reduced alcohol consumption amongst under young people under the age of 18 and steady reductions in alcohol-related road traffic collisions;  The economic burden of alcohol is substantial, estimated between 1.3% and 2.7% of annual GDP;  Taxpayers contribute a larger amount of the overall cost of responses to alcohol related harm than individual drinkers;  Governments should implement effective policies to reduce the public health impact of alcohol, because it is an important aspect of economic growth and competitiveness;

This review evaluates the effectiveness and cost-effectiveness of the array of policy approaches in 3 areas: price (affordability), ease of purchase (availability) and the social norms around its consumption (acceptability).

Affordability Taxation and price regulation  Policies that reduce the affordability of alcohol are the most effective, and cost- effective, approaches;  Increase in taxation leads to increase in government revenue, and substantial health and social returns;  Cuts in alcohol duty since 2013 reduced income to the Exchequer by £5 billion over five years, reducing to £3.45 billion if consequential consumption increases are considered;  Minimum unit price (MUP) is a highly targeted measure: tax increases are passed on to the consumer and most improves the health of the heaviest drinkers. These people are experiencing the greatest amount of harm;  MUP measure has a negligible impact on moderate drinkers and the on-trade.  Index linked increased taxation and MUP would further reduce harm and increase government revenue, whereas current price and promotions legislation is ineffective.

Availability Regulating availability  Reducing hours during for alcohol sales – particularly late night on-trade sale – reduces alcohol-related harm in the night time economy;  There is a clear relationship between the density of alcohol outlets and social disorder;  The voluntary pledge to reduce the number of units in the market seemed ineffective, as it related to the launch of new products, potentially increasing the size of the market.

Managing the drinking environment  Interventions in and around the drinking environment are expensive and only lead to small reductions in acute alcohol-related harm;  Multi-component community reviews are effective, cost-effective and are amenable to local implementation;  Safety principles support the use of safe glass alternatives, or voluntary removal of cheap and high strength alcohol, even though these can be undermined by outlets in neighbouring areas.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 56 OFFICIAL

Acceptability Regulating marketing  Exposure to alcohol marketing increases the risk that children will start to drink alcohol, or consume greater quantities;  Self-regulatory systems that govern alcohol marketing practices do not succeed in protecting vulnerable populations.

Providing information and education  There is little evidence to suggest that providing information, education and labels is sufficient to lead to reductions in alcohol-related harm, and education programmes are not cost-effective;  These policies do increase support for more effective policies and labels fulfil a consumer right to be better informed;  The delivery of education messages by the alcohol industry has no significant public health effects.

Reducing drink-driving  Enforced legislative measures to prevent drink-driving are effective and cost- effective;  Lower alcohol limits for young drivers are economic and effective at reducing casualties and fatalities in this group.

Brief interventions and treatment  Large scale, well-resourced health interventions aimed at drinkers who are already at risk (eg IBA/’Identification and Brief Advice’) and specialist treatment for people with harmful drinking patterns and dependence, are effective approaches to reducing consumption and harm in these groups, and show favourable returns on investment.

The policy mix  Combining alcohol polices may create a ‘critical mass’ effect, changing social norms around drinking to increase the impact on alcohol-related harm, but alcohol policies should be coherent and consistent. Warning labels highlighting the risks of alcohol consumption should not be undermined by a unit price that encourages heavy consumption.

National Guidelines and Messaging

In January 2017, the unit level was reduced from 21 to 14 units per week for men, in line with the previous weekly amount recommended for women.

This is calculated to reduce the risk of an alcohol related health issue to 1% across a lifetime. In addition, the advice is to drink the full amount over no less than 3 days, and to have ‘several’ alcohol free days each week.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 57 OFFICIAL

This was on the basis of the non-gender specific nature of the alcohol related cancer risk compared to all other health impacts.

A summary of the new advice:

In real terms, this means no more than 2 normal servings in a normal drinking day, with each week split evenly between dry and drinking days.

14 units equates roughly to:

 5 Pints of normal Beer/Lager/Cider, or  6 glasses of Wine, or  1 and a ½ bottles of Wine, or  7 doubles of Spirits.

In summary, the message is this:

 2 drinks is a normal amount for a day when you’re drinking;  3 days (at least) to drink the full amount each week, if you do want to drink the full amount (14 units);  3 days (at least) without drinking each week, to remain in control and to give your body a rest.

There was plenty of academic support for the new guidance22 but there were some reservations expressed as well.

These are now the universally accepted guidelines, even though this has made a lot of existing publicity and training material obsolete.

All Identification and Brief Advice (IBA) training in Cornwall now uses these guidelines, whilst highlighting the evidence from Cancer Research that neither the guidelines nor the cancer risks are yet widely known.

22 'Expert reaction to new Alcohol Guidelines Review from the Chief Medical Officers', Science Media Centre (January 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 58 OFFICIAL

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 59 OFFICIAL

Measuring the impacts on health Key findings Alcohol Consumption and Risk Levels  Alcohol intake among the local population, based on the most recent estimates available and using overall hospital admissions as a proxy indicator, appears to be similar overall to national and regional rates;  Just under a quarter of people are estimated to drink at above the recommended levels. 6% or 26,300 people are drinking at higher risk levels, double the recommended safe levels or above. In addition, an estimated 84,000 people (19%) are binge drinkers;  There are estimated to be 6,600 dependent drinkers in Cornwall and the Isles of Scilly, equating to 1.5% of the population. This is above the national average of 1.4% but not significantly higher;  Research indicates that the UK may be “on the cusp of an epidemic of alcohol related harm amongst older people.” An estimated 1.4 million people aged 65 and over currently exceed recommended drinking limits. Currently this age group makes up only 3% of those in alcohol treatment (both men and women);  Alcohol forms a strong factor in the local economy, with a large apparent influence of tourism, which both boosts Cornwall’s population and alcohol consumption. Cornwall welcomes tourists while they are ‘off duty’ and likely to drink at higher frequency and levels than when they are in their normal routine at home, and at higher levels than the local population;  Contrastingly, Cornwall is part of a region with low alcohol related mortality in the local population.

Hospital admissions  Hospital admissions for alcohol-related conditions (narrow)23 are higher than national and regional rates, and rising, whilst the national trajectories are comparatively level. Cornwall is below national rates for the broad measure;  Alcohol-specific admissions for under-18s are higher than national and regional rates, with the South West having high rates generally. Alcohol specific admissions for under-18s are falling, but slower than the national trajectory;  In the vast majority of the alcohol-related and alcohol-specific hospital admission conditions, the rate for men is at least double the rate for women, but the rate for women is rising at a worse rate than national trends and the gap between national and local rates is greater for women than men;  Rates for certain conditions – alcohol liver disease, alcohol-related unintentional injuries, mental and behavioural disorders and intentional self-poisoning – are above (worse than) national rates. With the exception of

23 Where an alcohol-related condition is the primary diagnosis, or any secondary diagnosis with an alcohol-attributable external cause

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 60 OFFICIAL

cancers and alcohol-related self-poisoning, rates for men are at least double that of women;  Our alcohol related road traffic collisions are also consistently significantly higher than the South West, which in turn performs worse than national rates. There were 186 such collisions in Cornwall in 2016;  Cornwall’s workforce, social cohesion, economy and welfare budget are detrimentally impacted by high benefit claimants due to alcohol dependence. The rate has consistently tracked above the national rate;  Target groups and issues identified from the Local Alcohol Profile for England: o Male drinking, especially the amount drunk by a proportion of men with excessively risky drinking patterns; o The male drinking pattern being damagingly assumed by women; o Alcohol-related road traffic collisions in Cornwall; o Under-18s, whose risky drinking appears to be reducing in Cornwall, but at a slower rate than nationally; o Alcohol related unintentional injuries, with excessively high rates among men; o Alcohol related mental and behavioural disorders, with especially high rates among men and rising trend amongst women; o Alcoholic liver disease, with especially high rates among men; o Rising rates of alcohol-related cardiovascular conditions, with especially high rates among men (noting that this is a national as well as a local trend); o Rates of alcohol-related intentional self-poisoning in women.  A review of case studies of frequent attenders at Royal Cornwall Hospital Trust Treliske reflect that these service users are often very vulnerable with multiple health and mental health needs. Many were found to have a chaotic lifestyle and demonstrate problems with engagement, often being resistant to treatment and change; A joint initiative has been developed between commissioners and service providers to offer alternative approaches and care pathways for change resistant drinkers (what Alcohol Concern refer to as a “Blue Light Project”, because it seeks to reduce the burden upon emergency services). Initially highlighted by the review of hospital frequent attenders, this problem was further emphasised through localised issues around street drinking, anti-social behaviour and rough sleeper populations.  The introduction of the new Alcohol Liaison Team, and a more individualised approach to care for people admitted with complex alcohol-related health problems, has has resulted in improved outcomes and fewer hospital bed days.

Alcohol and suicide  Cornwall has a higher suicide rate than the national average, reflecting a significantly higher male suicide rate. This rate has been increasing since 2007. The 2015 Suicide Audit concluded that “the increase in suicide rates since 2007 is likely to be a consequence of the recession.”  In 2013 there were 65 deaths by suicide in Cornwall and the Isles of Scilly, with the highest number amongst the 45-59 age group.  The most common methods are ‘hanging, strangulation and suffocation’ by men and ‘poisoning by drugs/alcohol’ by women;  24% of all suicide cases were reported to have taken alcohol at the time of death.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 61 OFFICIAL

Alcohol Consumption and Risk Levels Alcohol Related Hospital Admissions Public Health England monitor alcohol related impacts on health, the NHS and local communities through the Local Alcohol Profiles for England (LAPE). 24 This dataset allows you to see local factors alongside national and regional comparisons.

Cornwall is below national rates for the broad25 measure of alcohol related hospital admissions, and above national rates for the narrow measure.

In the vast majority of the alcohol related and specific hospital admission conditions, the rate for men is at least double the rate for women, even when the rate for women is rising at a worse rate than national trends.

Rates for women and under-18s and certain conditions (alcohol liver disease, alcohol-related unintentional injuries, mental and behavioural disorders and intentional self-poisoning) are above (worse than) national rates.

More detailed findings from the LAPE are included later in this section under Measuring the Impacts on Health.

Estimated Risk Levels – drinking behaviour New estimates from Public Health England26 indicate that there are around 6,600 dependent drinkers in Cornwall and the Isles of Scilly, equating to 1.5% of the population. This compares with a national rate of 1.4% and, although this places

24 Local Alcohol Profiles for England – profile for Cornwall, Public Health England 25 The broad measure includes all episodes containing alcohol-related diagnoses, whereas the narrow measure includes only admissions where the primary diagnosis is an alcohol-related condition or where the primary diagnosis is not an alcohol-related condition but one of the secondary diagnoses is an external cause with an alcohol-attributable fraction. 26 Estimates of Alcohol Dependence in England based on the Adult Psychiatric Morbidity Survey (APMS) 2014, Pryce et al, Public Health England (2017).

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 62 OFFICIAL

us in the “above average” quartile of upper tier local authority areas, our local rate is not significantly higher.

26,300 Estimates of levels of Drinking risk levels, drinking risk in the local 67,300 % of population aged 16+ population were previously 78,100 based on the outputs of a synthetic model developed by Abstain 15% the North West Public Health Lower 63% Observatory. Increasing 17%

Estimates were included Higher 6% within the LAPE and featured 286,800 in previous alcohol needs assessments in Cornwall.

They were based on self-reported surveys, e.g. The Lifestyle Survey, and have not been updated more recently to fit the new reduced 14 unit CMO guidelines for men.

They put Cornwall and the South West in line with national estimates.

Research based on HMRC tax returns for alcohol sales demonstrate that these are probably underestimates of actual consumption, but they do provide a comparison with national rates.

Drinking risk CIOS % CIOS n Regional National Abstain 14.7% 67,300 14.3% 16.5% Lower risk (% of drinkers) 62.5% 286,800 72.7% 73.8% Increasing risk (% of drinkers) 17.0% 78,100 20.4% 20.0% Higher risk (% of drinkers) 5.7% 26,300 6.9% 6.8% Binge (% of adults) 18.8% 83,800 20.7% 20.1%

Just under a quarter of people, however, are estimated to drink at above the recommended levels. 6% or 26,300 people are drinking at higher risk levels, double the recommended safe levels or above. In addition, an estimated 84,000 people (19%) are binge drinkers.

Other Research Cornwall has high consumption rates, with tourism and second home ownership likely to be influencing factors.

Outcomes as reported put the South West in the highest consumption bracket, based on retail and HMRC returns, but with low alcohol related mortality in the resident population.27

27 ‘Regional alcohol consumption and alcohol-related mortality in Great Britain: novel insights using retail sales data’, Robinson, M. et al, BMC Public Health (2015)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 63 OFFICIAL

“Per adult consumption in northern England was above the GB average and characterised by high beer sales.

A high level of consumption in South West England was driven by on-trade sales of cider and spirits and off-trade wine sales. Scottish regions had substantially higher spirits sales than elsewhere in GB, particularly through the off-trade.”

Overall, this research was in line with the findings of Boniface et al,28 that conventional estimates of alcohol intake are based on self/under reporting, and that the amount consumed by drinkers must logically be much higher than our normal estimates.

28 ‘Finding the missing units: identifying under-reporting of alcohol consumption in England’, Boniface, S, UCL (2013)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 64 OFFICIAL

Two factors could not be distinguished from the overall data:

1. Regional pricing variations – the findings were based on volume sales by on and off trade retailers, and didn’t have access to average price per unit below national level. Alcohol prices in London tend to be much higher than in the South West; 2. Tourism – the high volume of alcohol sold per adult in South West is probably affected by tourism and by the region having the highest rate of second homes used for holidays per usual resident, than any other region. It also has the highest number of incoming overseas tourists per resident (except London).

The Older Population The Older Persons’ Substance Misuse Working Group of the Royal College of Psychiatrists report “Our Invisible Addicts”29 identified that both alcohol and illicit drugs are among the top ten risk factors for mortality and morbidity in Europe and substance misuse by older people is now a growing public health problem.

Between 2001 and 2031, there is projected to be an increase of 50% in the number of older people in the UK. The proportion of older people in the population is increasing rapidly, as is the number of older people with substance use problems. Mortality rates linked to drug and alcohol use are higher in older people compared with younger people.

According to Wadd et al30 “evidence suggests that the UK may be on the cusp of an epidemic of alcohol related harm amongst older people.”

Those aged 65 and over form a small proportion of those in alcohol treatment – 3% of both men and women. However, an estimated 1.4 million people in this age group currently exceed recommended drinking limits.

Hospital admissions From this year’s LAPE, we drew the following conclusions about the impacts of alcohol on the health of the people of Cornwall.

Key indicators  On most indicators (overall alcohol-related/specific mortality, broad alcohol related hospital admissions, alcohol-specific hospital admissions) Cornwall’s rates are similar to or lower than national and regional rates;

29 ‘Our invisible addicts’, Royal College of Psychiatrists, College Report CR165 (June 2011) 30 ‘Working with Older Drinkers’, Wadd et al (August 2011)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 65 OFFICIAL

 Hospital admissions for alcohol-related conditions (narrow) are higher than national and regional rates, and rising, whilst the national trajectories are comparatively level;  The broad measures – overall, and for men and women – are rising but in line with the national trajectory;  Alcohol-specific admissions for under-18s are higher than national and regional rates, with the South West having high rates generally. Alcohol specific admissions for under-18s are falling, but slower than the national trajectory.

Overall, narrow admission episodes for alcohol-related conditions are all slightly worse than national rates and rising, while the national trajectory is comparatively level.31

There were 4,194 admissions in 2015/16, equating to a rate of 735 per 100,000 residents, compared with a rate of 650 for the South West and 647 for England.

31 The black line is the national rate.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 66 OFFICIAL

Age and gender In the vast majority of the alcohol-related and alcohol-specific hospital admission conditions, the rate for men is at least double the rate for women, but the rate for women is rising at a worse rate than national trends.

 The gap between national and local rates is greater for women than men;

Female Male

This suggests gradually increasing impact from a slow change in female drinking patterns, but it also suggests than men are twice as likely to drink in such a way that it will cause health problems that require hospital treatment.

The number of people under 18 admitted to hospital for alcohol specific conditions is higher than national and regional rates. In 2015/16, there were 155 admissions, equating to 49.1 per 100,000 residents aged under 18, compared with a rate of 46.8 for the South West and 37.4 for England.

 The rate is falling but slower than the national trajectory.

Overall alcohol-related hospital admissions for under-40s have consistently tracked above the national trend but both trends are currently fairly level. The gap between national and local rates is greater for men than women and men account for more admissions overall.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 67 OFFICIAL

 Alcohol-related hospital admissions for 40-64 year olds overall, and for both men and women, are rising above the national rate (which is on a level trajectory). The rate for women is rising more sharply but men account for nearly two thirds of the admissions;

 Alcohol-related hospital admissions for over 65s overall, and for men and for women, are in line with the national trend but rising more quickly, particularly for females. The male rate is more than double that of females.

Conditions Rates for certain conditions – alcohol liver disease, alcohol-related unintentional injuries, mental and behavioural disorders and intentional self-poisoning – are above (worse than) national rates.

With the exception of cancers and alcohol-related self-poisoning, rates for men are at least double that of women.

 Cardiovascular disease is by far the greatest contributor to alcohol-related hospital admissions – 6,022 admissions, equating to a rate of 951 per 100,000 residents. Hospital admission rates for alcohol-related cardiovascular disease are lower than national rates, but local and national rates on a rising trajectory. At The male rate is more than double that of women;

 The broad rate for alcohol- related episodes for mental and behavioural disorders amongst women has risen above the national rate, which is on a level trajectory. The rate for men is in line with national rates, but is roughly double that of women.

 Alcoholic liver disease episodes overall, and for men and women have risen to significantly above the national rate, which is on a slower rising trajectory.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 68 OFFICIAL

The rate for men is roughly double that of women and both rates have seen some recent improvement.

Female Male

 Alcohol related unintentional injury episodes overall, and for men and women have consistently tracked at a rate signficantly higher than the national rate. The rate for men is roughly three times that of women, probably caused by risky drinking, vulnerable disinhibited behaviour and disorder;  Overall admissions and those for both men and women episodes for intentional self-poisoning are all significantly above national rates.

 Rates overall and for men and women are rising locally, particularly for women, whereas the national rate is fairly level. Rates of alcohol intentional self-poisoning are higher for women than men.

 Trends for alcohol related cancers bear out the risk factors assessed in changing the CMO guidelines, in that the gender comparison rates are

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 69 OFFICIAL

similar, whereas for all other conditions the male rate is at least double the female rate. The numbers are however much lower than for some other conditions, such as cardiovascular, but may be more significant due to a higher mortality rate. Cornwall is in line with national rates.

Other impacts  Cornwall’s workforce, social cohesion, economy and welfare budget are detrimentally impacted by high benefit claimants due to alcohol dependence. The rate has consistently tracked above the national rate. In 2016, there were 510 claimants, equating to a rate of 163 per 100,000 residents; it was 16% above the South West rate and 23% above the national;  Our alcohol related road traffic collisions are also consistently significantly higher than the South West, which in turn performs worse than national rates. There were 186 such collisions in Cornwall in 2016.

Target groups and issues identified from the LAPE  Male drinking, especially the amount drunk by a proportion of men with excessively risky drinking patterns;  The male drinking pattern being damagingly assumed by women;  Alcohol-related road traffic collisions in Cornwall;  Under-18s, whose risky drinking appears to be reducing in Cornwall, but at a slower rate than nationally;  Alcohol related unintentional injuries, with excessively high rates among men;  Alcohol related mental and behavioural disorders, with especially high rates among men and rising trend amongst women;  Alcoholic liver disease, with especially high rates among men;  Rising rates of alcohol-related cardiovascular conditions, with especially high rates among men (noting that this is a national as well as a local trend);  Rates of alcohol-related intentional self-poisoning in women.

Frequent Attenders Royal Cornwall Hospital provided the DAAT with a list of the 50 most frequent attenders with alcohol-related conditions at Treliske hospital during 2015/16.

41 of those individuals were known to community specialist services, who have provided a brief overview of each of their treatment journeys.32 Brief details of the 41 case studies are included at Appendix H.

32 See Appendix F

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 70 OFFICIAL

The diagram below indicates some of the recurring themes, based on the information provided in the case studies.

The case studies reflect that these service users are often very vulnerable with multiple health and mental health needs. Many were found to have a chaotic lifestyle and demonstrate problems with engagement, often being resistant to treatment and change.

Many are involved or have been involved previously with multiple services including those along the Criminal Justice Pathway.

An individual care plan approach was taken, reviewing each person’s care and treatment experience. The majority were found to have multiple problems, needs and vulnerabilities, requiring more intensive, multi-agency packages of care.

A number of initiatives have been developed out of this review:

1. A pathway between RCHT and Boswyns residential detox centre to facilitate immediate transfer for those willing to do so (further pathways to be developed to Community Hospital Alcohol Detox and Home and Dry for those who are eligible); 2. Assertive outreach is needed to engage those who are discharged from hospital but not engaging with community treatment services. This is a priority for any future new funding opportunities; 3. Awareness of initiatives elsewhere have led us to secure funding and to commence implementation of a project to engage treatment resistant drinkers (what Alcohol Concern refer to as a “Blue Light Project”, because it seeks to reduce the burden upon emergency services).

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 71 OFFICIAL

4. Regular, monthly review of frequent attenders between the Alcohol Liaison Team in RCHT and community specialist services, to identfiy those who are a priority for assertive engagement.

Treatment Resistant Drinkers The traditional approach to treatment resistant drinkers has been the pessimistic belief that nothing can be done for people who do not want to change.

Over the course of the year, a joint initiative has been developed between commissioners and service providers, to offer alternative approaches and care pathways for change resistant drinkers, who place a huge burden on public services. Initially highlighted by the review of hospital frequent attenders, this problem was further emphasised through localised issues around street drinking, anit-social behaviour and rough sleeper populations.

The Blue Light approach is not an additional level of resource in itself or an additional service to existing provision but the sum of partners coming together and sharing information to cooperate in a joint approach.

The Department of Health’s 2005 Alcohol Needs Assessment33 suggested that an engagement level of 15% of problem drinkers in treatment was about average. This begs the question: what happens to the 85% who are not changing their drinking?

More recently Public Health England has refined this figure and suggests that 94% of dependent drinkers are not engaged with services. More importantly this is a group of people which contains some of the most risky and vulnerable members of the community.

They will include people with criminal justice histories, personality disorders and/or mental health conditions.

Many of these difficult to engage clients will be the focus of concern in other parts of the health, social care and criminal justice system. They will be the frequent attender in the hospital system, the perpetrator of anti-social behaviour, the nuisance 999 caller and the repeated arrestee.

Since 2011, local authorities have been required to undertake a Domestic Homicide Review after local homicides related to domestic abuse. Since their inception, over 100 of these reviews have been undertaken nationally.

Alcohol Concern examined 24 of these reports.34 In this randomly chosen sample, alcohol played a significant contributory role in 75% and in most of these cases perpetrators and, sometimes victims, were treatment resistant drinkers.

33 Alcohol Needs Assessment Research Project (ANARP): The 2004 national alcohol needs assessment for England (Department of Health, 2005)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 72 OFFICIAL

In tackling alcohol’s impact on chronic health conditions, violence or anti-social behaviour, many of the people society most needs to target are drinkers who appear not to be ready to change.

This approach impacts most acutely on the pathway between frontline generic services and specialist alcohol agencies. It is a specific and often voiced concern of non-specialist services that alcohol services do not work well with difficult to engage problem drinkers.

A series of training needs analyses with non-specialist workers in Birmingham has highlighted that the issue that they most want training on is not identification or one to one interventions but “how to work with difficult to engage drinkers”.

The same message has come out in consultations with housing workers in Surrey and probation officers in Wandsworth. This is not a criticism of alcohol services. They have a limited capacity and have been targeted towards recovery.

Such an approach has always been open to challenge but it is now particularly hard to justify because:

 Public services are very focused on specific outcomes such as preventing emergency hospital admissions, domestic abuse or crime and anti-social behaviour, all of which are highly associated with non-changing drinkers;  An approach which focuses on clients who are motivated will effectively perpetuate the exclusion of those who are already most socially excluded. As such, it is a priority in 2017/18 to cascade the approach across services most likely to come into contact with this group, with the aim of developing and multi-disciplinary, multi-agency approach to help them to achieve positive outcomes.

RCHT Alcohol Liaison Team National evidence of effectiveness Hospital Alcohol Care teams are a recommended element of NICE guidance ‘Alcohol-use disorders: preventing harmful drinking’ (NICE public health guideline 24). Different elements of an alcohol team approach have been introduced in different places with significant results.

Implementation of an Alcohol Specialist Nurse Service in Nottingham improved the health outcomes and quality of care of patients admitted to hospital for detoxification, and also of those admitted for the complications of alcohol-related cirrhosis.35

34 Domestic abuse and change resistant drinkers: preventing and reducing the harm, part of Alcohol Concern’s Blue Light Project in partnership with AVA’s Stella Project (Alcohol Concern, 2016) 35 Effectiveness of a nurse-led alcohol liaison service in a secondary care medical unit, Ryder et al. (2010) Clinical Medicine, Journal of the Royal College of Physicians 10: 435-440.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 73 OFFICIAL

 Hospital admissions were reduced by two-thirds, resulting in a saving of 36.4 bed days per month in patients admitted for detoxification;  Clinical incidents were reduced by 75%;  Liver enzyme abnormalities were halved;  There was also a reduction in bed days used in the cirrhotic group from 6.3 to 3.2 days per month

The Royal Liverpool Hospital has introduced an extension of the role of alcohol specialist nurses from ED to inpatient care, preventing 150 admissions per year. The roles of alcohol specialist nurses in Liverpool have since been further developed into a Nurse-led Alcohol Services Lifestyle Team, with daily clinics in different locations in the city. They provide access for GPs to refer patients to the service.

Between 2007 and 2013 the number of hospitals providing specialist care for alcohol using patients increased significantly. From the PHE survey of hospitals and subsequent research into non-responding hospitals, information was gathered about the existence or non-existence of alcohol services. 144 of the 191 district general hospitals estimated to be an appropriate size to merit an alcohol service responded.

From this information, at least 139 (73%) offered a specialist alcohol service. Only five hospitals were positively identified as having no alcohol service at all, of which RCHT was one.

At that time RCHT provided:

 A Psychiatric Liaison Nurse who specialised in alcohol work (<1WTE), whose main focus on assisting complex detoxification  An alcohol Multi-Disciplinary Team (MDT) from 2013, which was poorly attended  No alcohol liaison team, and  No alcohol screening.

The new Alcohol Liaison Team was commissioned through an NHS QIPP Plan36 by the Kernow Clinical Commissioning Group and has been in place since December 2015.

This provides a 7 day alcohol liaison service between the hours of 8am and 4pm, which delivers:

 Brief intervention / motivational  Weekly nurse-led alcohol clinic interviewing  Detoxification pathways  Working closely with community specialist services

36 The QIPP Programme (Quality, Innovation, Productivity and Prevention), is a large-scale programme developed by the Department of Health to drive forward quality improvements in NHS care, at the same time as making up to £20 billion of efficiency savings

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 74 OFFICIAL

 Fibroscan  Monthly alcohol complex MDT (all partners)  Liver pathology/ pancreatic disease  Individual care plans for frequent treatment attenders  Daily attendance Gastroenterology  Across hospital education programme ward round  Daily attendance MAU rapid round  Rapid access transfer bed Boswyns  Daily base in ED  Facility for outpatient detoxification

326 patients were referred to the Alcohol Liaison Team between December 2015 and October 2016.

The following Before and After case studies illustrate the shift in approach and impact this has had on patient outcomes.

Before Alcohol Liaison Team and routine screening established

59 year old male:

 Admitted with hematemesis, abdominal pain

 Alcohol screening not undertaken  Patient attended endoscopy  Immediately following procedure: o Hallucinations o Ataxia o Confusion o Aggression o Fall with head injury  Slow recovery, with an inpatient stay of 13 days  Acute alcohol withdrawal  Simple duodenal ulcer treated with PPI

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 75 OFFICIAL

After Alcohol Liaison Team and routine screening established

56 year old male:  Bi monthly admissions May 2015 – May 2016  Intoxication/ suicidal ideation +/- overdose  12 unsuccessful detoxification attempts over 5 year period  Engaged with ALT May 2016 (previously seen psychiatric liaison)  Engaged with support from community specialist services  Appointment discharge day for alcohol specific counselling  Remains abstinent and discharged from community alcohol services  No further hospital admissions

34 year old female  10 admissions pre ALT, abdominal pain, requesting benzodiazepines  Alcohol screening identified as higher risk (previous had underreported)  “Teachable moment”  Alcohol withdrawal managed appropriately  ALT liaised with Addaction who visited on ward  Continuation of pharmacological detoxification at home  In same period 3 admissions post intervention (abdominal pain)  Care plan in place- for direct contact to ALT/ not requiring pharmacological detoxification and for early discharge

As the team is in the early stages of development, a more in depth review will be available in subsequent years. The priority for 2017/18 is to establish an assertive outreach service in the community to engage those identified within the hospital setting who are not currently in treatment services.

Alcohol and Suicide in Cornwall Cornwall has a higher suicide rate than the national average. There is a known correlation between suicide, Criminal Justice involvement, Alcohol and Drugs.

Excessive use of alcohol and drugs may increase impulsivity and reduce inhibitions, resulting in an increased likelihood of suicidal or offending behaviour during a time of crisis.

This is especially true of men, who have a propensity to use alcohol and drugs in response to distress, especially in the context of relationship breakdown and loneliness.37 The Suicide Surveillance Group operates to improve practice and identify service improvement areas, so that suicide preventative approaches are

37 Conner and Ilgen, (2011)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 76 OFFICIAL

implemented as we work together to reduce our suicide rate towards zero. This group is in the process of improving our access to data and analysis.

The Confidential enquiry into self-inflicted deaths in custody highlights the overwhelming statistic that 97% of these deaths are male.38

In Cornwall, Public Health undertake a Suicide Audit. There is one being prepared for publication in 2017. These are some key points from the Suicide Audit 2015:39

 Males: higher rate than the national average;  This rate has been increasing since 2007;  2013: 65 deaths by suicide, 49 male and 16 females (a ratio of 3:1). o 13.99 per 100,000 population for Cornwall and the Isles of Scilly o 10.98 per 100,000 nationally. o Other regions: North East 13.2 deaths per 100,000 population, London 7.8 per 100,00040  Nationally, the risk is reported to be highest among males aged 35-64. Locally, the highest rates are seen among males aged 35-64 and 75+;  Highest numbers in the 45-59 age group;  Most common methods: o ‘hanging, strangulation and suffocation’ by males; o ‘poisoning by drugs/alcohol’ by females.  The largest proportion are not in mental health services.

The next graph shows trends in mortality from suicide and death by injury of undetermined intent in Cornwall and Isles of Scilly, and England & Wales: 1993- 201341

38 ‘National Study of Self-Inflicted Death by Prisoners 2008-2010’, Shaw et al, University of Manchester (January 2013) 39 ‘Suicide audit in Cornwall and Isles of Scilly’ Public Health Cornwall & Isles of Scilly (April 2015) 40 ONS (2014) 41 HSCIC Indicators

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 77 OFFICIAL

The Cornwall Suicide Audit noted this summary of the high risk groups identified at a national level, and concluded that these are likely to be relevant at a local level:

15 High Risk Groups  Males  Older people  People with a family history of suicide  Women during pregnancy and after childbirth  People from ethnic groups – women born in Sri Lanka and the East African Commonwealth are approximately 50% more likely to die by suicide than the general population as a whole  Certain occupational groups – unskilled occupations, doctors, nurses, vets, farmers  Sentenced and remand prisoners and ex-prisoners recently released into the community  People who have been discharged from inpatient psychiatric services within 4 weeks  People with a history of self harm  People with alcohol and/or drug problems  People with mental health problems, especially depression, schizophrenia and personality disorders (many may not be in contact with secondary mental health services, especially people with depression)  People with serious physical illnesses  Divorced people  People recently bereaved (sudden isolation)  Lesbian, gay and bisexual people

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 78 OFFICIAL

Key quotes from the Cornwall Suicide Audit, highlighting the correlated issues of criminal justice issues, masculinity, drug and alcohol use, mental health and suicide risk:

Consequences of criminal activity/disciplinary proceedings “The group has looked at several cases where the person was subject to criminal investigation or awaiting trial. Fear of the consequences (public knowledge/ condemnation and sentencing) could be a significant risk factor for suicide. The courts are aware of this and ‘harm to self’ is a reason to refuse bail.

The criminal justice/mental health liaison team has a role to play in signposting to available support services. The Samaritans might be a useful service in this situation, as people can speak to them anonymously without fear of judgement. Disciplinary proceedings at work can also cause great stress. Workplaces can help to mitigate this by providing support.”

Males “Males are at greater risk of suicide for a number of reasons. Depression is less likely to be diagnosed and treated because men are more likely to be reluctant to admit to problems or to seek help. Cultural expectations for men to be decisive and strong can cause men to suffer low self-esteem and lead them to hide their perceived ‘weaknesses’ or to feel humiliated when they are exposed. Men often find their emotional support from a female partner and feel the loss very strongly when a relationship breaks down, whereas females tend to get additional emotional support from friendship groups.

The risk among men can only be completely overcome by achieving cultural change. However, steps can be taken to reduce stigma and make services more accessible. CALM (Campaign Against Living Miserably) is a programme that is designed to meet the needs of men, particularly young men. Although based outside Cornwall, it is now a national charity and the help line service is available to all.”

Alcohol and drugs “One of the factors that increase the likelihood a person will take his or her own life is the abuse of substances such as alcohol and drugs. Alcohol and some drugs can result in a loss of inhibition, may increase impulsive behaviour, can lead to changes in the brain that result in depression over time, and can be disruptive to relationships—resulting in alienation and a loss of social connection. Furthermore, excessive acute drug and/or alcohol ingestion could result in death. Local data collected from the Coroner, GPs and Mental Health services can provide an indication of the role of alcohol and drugs. Unfortunately in many cases the relevant questions about history of alcohol or drug misuse on the audit forms have not been answered. With regard to whether alcohol or drugs were taken at the time of death, the proportion of unknown or blank answers is lower, as this is less likely to be a hidden factor.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 79 OFFICIAL

The results are shown below.

Was alcohol taken at the time of Were other non-prescribed drugs death? taken at the time of death? Yes: 25 Yes: 71 No: 154 No: 118 Not known or left blank: 115 Not known or left blank: 105 8.5% of all cases were reported to 24% of all suicide cases were have taken non-prescribed drugs at reported to have taken alcohol at the time of death. the time of death. However, this was equivalent to However, this was equivalent to 14% of those for whom the 38% of those for whom the information was provided. information was provided.

The incidence of alcohol and drug use at the time of death is fairly high. The intention behind their use is not known, but the act would be likely to reduce inhibitions and increase impulsive behaviour.

The 2015 Suicide Audit concluded that “the increase in suicide rates since 2007 is likely to be a consequence of the recession.”

Both long and short term misuse of alcohol increases the risk of suicide. Over time, alcohol misuse can disrupt relationships, and lead to alienation and depression. The immediate effects of alcohol can be to increase impulsive behaviour, with a loss of regard for the consequences.

 It is known that almost a quarter of people who died by suicide in recent years in Cornwall and the Isles of Scilly had taken alcohol at the time of death, but where more detailed specific information was available this rose to over a third.

Cornwall has significantly a lower proportion of the population accessing mental health services than the England average. Patients with mental health services are significantly less likely to be in settled accommodation or be in employment.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 80 OFFICIAL

Cornwall also has higher emergency admissions for self-harm, higher suicide rates and higher hospital admissions for unintentional and deliberate injuries.

Poor mental health also underlies risk behaviours, including smoking, alcohol and drug misuse. Problem drinking is heavily associated with mental illness (from anxiety and depression through to schizophrenia) and personality difficulties.

Heavy drinkers are more than twice as likely to die from suicide as non- drinkers. Between 16% and 45% of suicides are thought to be linked to alcohol and 50% of those 'presenting with self-harm' are regular excessive drinkers.

Older research into Suicide and Alcohol in Cornwall Suicide prevention and alcohol Mukamel identified a strong suicidal correlation with the quantity of alcohol consumed per drinking day, compared to simply overall volume – suggesting that targeted initiatives to ‘binge-pattern drinkers’ may be of particular benefit. Changes addressing this are most effective if backed up with large initiatives such as national alcohol policies.42

In 2011, Dr Andy Liu identified 3 main ‘interactions’ between alcohol use and suicide:  The relationship of acute alcohol inebriation and the act of suicide completion;  The relationship of chronic alcohol abuse and the increased lifetime risk of suicide;  The relationship of total alcohol consumption on a population scale correlated with overall suicide rates over time.

Recommendations:  Measures shown to be most effective are restricting alcohol use or access.  Specific initiatives aimed at controlling bingeing43  Screening of alcohol dependence for other psychiatric symptoms and suicidality44

Contact data for ‘Liaison and Diversion’ Mental Health Team Suicide and self-harm needs of people accessing the Liaison and Diversion (L&D) services based in Police custody suites, in 2015/16:

 940 presentations between 1st April 2015 and 31st March 2016;  147 (16%) instances presented with Current Suicide/Self Harm Risk;  28 cases (3%) presented as risk of harm through personal neglect;  Of the 147 cases identified 14 (1%) refused contact with L&D services.

42 Bilban & Skibin (2005); Pimpili et al (2010) quoting Mukamal et al (2007) 43 Mukamal et al (2007) 44 Pompili et al (2010)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 81 OFFICIAL

In the remaining group of 133 cases:  The most prevalent primary mental health need identified was depressive illness (35%). followed by Personality disorder (26%);  Nearly half of people seen were previously known to mental health services (not currently open) and 31% were currently open to mental health services;  21% were open to substance misuse services with a further 21% known to these services in in the past;  The most common interventions to address mental health needs was advice (15%) and referral to secondary care service (15%), in 24% of cases the mental health needs were already being met.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 82 OFFICIAL

Early Intervention Key findings Identification and brief advice  There is extensive and consistent evidence that brief advice in health care settings reduces alcohol-related harm and that brief interventions are cost– effective. Evidence of the extent to which brief advice works in non-health care settings, however, is less clear;  NICE guidance recommends that screening should target people who are at increased risk of harm from alcohol and those with an alcohol-related condition;  Local research into health burden of alcohol misuse in terms of hospital admissions reiterates the national guidance and has highlighted a number of other areas where we need to focus our efforts, including those living in deprived areas, people with financial problems or long term unemployment/ worklessness issues, victims and perpetrators of crime and anti-social behaviour, people with a drug problem or who are known to self-harm;  More than 300 front line staff have been trained in the last year, including pharmacy services and GPs, domestic abuse and sexual violence services, housing providers and services working with offenders;  Pharmacy delivered IBA highlights males over the age of 40 as the dominant at-risk group, with females making up the majority of young drinkers within the data;  There is evidence within the pharmacy data that IBA provision could and should be increased in and around the Newquay, Truro and Liskeard areas;  Numbers signposted into specialist treatment services further to pharmacy delivered IBA are low, with less than half of those identified as being possibly dependant receiving this information;  Robust means of monitoring and evaluation of delivery of local delivery of IBA, to include the level and effectiveness of interventions delivered by trained individuals, continues to be a challenge but is a priority to resolve.

Messaging and Communication Plymouth University research into the ‘What Will Your Drink Cost’ campaign provided 10 Action Points for consideration in updated campaign material. The main lessons were:  Positively framed posters produce a short term improvement in responsible drinking attitudes, which could reduce an amount of immediate harmful or binge drinking during a Pub or Club visit, although this is not universal as several participants had a greater willingness to consume alcohol after seeing the posters;  Effect on others was highlighted as the most effect deterrent of alcohol use;  This campaign will potentially reduce violent tendencies in a just over a third of the participants who actually commit such acts;  Images should feature people of the same age as the target audience. As images in this campaign could cause distress, they need to be accompanied by information about how to change, or where to get support or advice.  Future campaigns should consider repetition and presentation of material over long periods of time using a combination of sources and methods, during different periods of exposure, as well as describing the motives of the appeal.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 83 OFFICIAL

Identification and Brief Advice Identification and Brief Advice (IBA) is a simple intervention aimed at individuals who are at risk through drinking above the guidelines, but not typically seeking help for an alcohol problem. It includes screening for problem drinking using an accredited tool, identification of the level of problem and brief advice to reduce alcohol-related harm (or onward referral for more intensive intervention if required).

In Cornwall we have chosen to use the World Health Organisation AUDIT tool – the Alcohol Use Disorders Identification Test. This involves a 3 question evaluation of consumption levels (AUDIT-C) and if necessary the remainder of the full 10 question set, in order to produce a score that identifies the risk level of someone’s drinking.

This then leads to an appropriate brief intervention or referral for more intensive support.

Brief interventions mean open access, non-care planned interventions. These include open access facilities and outreach that provide alcohol-specific advice, information, support (referred to as Tier 1) and extended brief interventions to help people with alcohol problems to reduce harm and to provide assessment and referral into care-planned treatment for those with more serious problems (Tier 2).

Identification and brief advice (Tier 1)  These include screening for problem drinking, identification of the level of problem and brief advice to reduce alcohol-related harm (or onward referral for more intensive intervention if required);  Identification and Brief Advice can be accessed in Cornwall in a range of settings, including GP surgeries, A&E at Royal Cornwall Hospital, Treliske and pharmacies, and it is a routine part of assessment for anyone coming into contact with the Criminal Justice System.

Open access, non-care planned interventions (Tier 2)  These include provision of open access facilities and outreach that provide alcohol specific advice, information, support and extended brief interventions to help people with alcohol problems to reduce harm and to provide assessment and referral into care-planned treatment for those with more serious problems.  The commisioned treatment service provider, Addaction provide a GP based service in almost every GP surgery across Cornwall, as well as a telephone helpline, and support is also available through Alcoholics Anonymous. A&E at Treliske have also provided some extended interventions and the homeless can access services through outreach at St Petroc’s and Health for Homeless.

Evidence of effectiveness It is known that excessive drinking is a major cause of disease and injury, both short term due to alcohol poisoning and the consequences of risk taking behaviour, and longer term due to the effects of regular alcohol misuse on mental and physical health.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 84 OFFICIAL

Alcohol-related death rates are 45% higher in areas of high deprivation. Identifying problems with alcohol at an early stage and providing information and advice to help reduce drinking risk is proven to have the greatest long term impact on reducing alcohol-related harm.45

The UK Alcohol Treatment Trial46 found that evaluated alcohol therapies saved about five times what they cost to public sector resources including health, social care and criminal justice, so for every £1 spent on evidence based alcohol treatment, there is a net saving of £5 to the public sector.47

There is extensive and consistent evidence that brief advice in health care settings reduces alcohol-related harm and that brief interventions are cost– effective.48 A more detailed examination of the evidence is in Appendix A.

Around 98% of England’s population are registered with a general practice, so general practice can make a significant contribution to reducing alcohol- related harm. Studies have indicated that brief advice with a GP or practice nurse leads to one in eight people reducing their drinking to within low- risk levels, leading to improved health and reduced demand on hospital services.49

It is worth noting that more than 1 in 8 will reduce their drinking, but a researched 1 in 8 will reduce into the defined responsible drinking levels of ‘low risk drinking.'

Although this is the ultimate goal, all reductions in alcohol intake and risk levels should also be seen as successes.

 NICE guidance recommends that screening should target people who are at increased risk of harm from alcohol and those with an alcohol-related condition50;  Local research into health burden of alcohol misuse in terms of hospital admissions reiterates the national guidance and has highlighted a number of other areas where we need to focus our efforts;  Both local and national evidence also make clear links between alcohol use and social problems, such as deprivation, crime and anti-social behaviour, financial worries and debt. Deprivation is strongly associated with poor health in a wide range of areas, including higher levels of obesity, physical inactivity, unhealthy diet, smoking and poor blood pressure control.

45 Roberts S., Report to Health and Adult Social Care Overview and Scrutiny Committee on Alcohol Related Hospital Admissions, January 2013 46 UKATT Research Team 2005: British Medical Journal, 331:544 47 Review of the effectiveness of treatment for alcohol problems – 2006: NTA 48 Changing Health Choices: A review of the cost-effectiveness of individual-level behaviour change interventions (NWPHO, 2011); Evidence for the effectiveness and cost-effectiveness of interventions to reduce alcohol-related harm: WHO, 2009 49 The Government’s Alcohol Strategy, Home Office 2012, taken from (Moyer et al, 2002) Brief Interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment- seeking and non-treatment seeking populations, Addiction, 97, 279-292 50 Alcohol-use disorders: preventing the development of hazardous and harmful drinking - NICE, 2010

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 85 OFFICIAL

IBA target groups in in Health and Primary Care settings:

 With relevant physical conditions, such as hypertension and gastrointestinal or liver disorders  With relevant mental health problems, such as anxiety, depression or other mood  disorders  Have been assaulted  At risk of or known to be self-harming  Regularly experience falls, other accidents or minor traumas  Have been injured as a result of a road traffic collision  Present to Emergency Departments with acute alcohol intoxication/poisoning  Regularly attend GUM clinics or repeatedly seek emergency contraception

IBA target groups in wider community settings:

 At risk of or known to be self-harming  Involved in crime or other antisocial behaviour  Have been assaulted  At risk of or known to be a victim of domestic abuse or sexual violence  Whose children are involved with child safeguarding agencies  With drug problems  Living in areas of social deprivation  With debt and / or financial problems, such as housing or rent arrears  Long term unemployed or unable to sustain employment

A focus on people in deprived areas particularly offers wider benefits for tackling health inequalities.

Although we have strong evidence of IBA effectiveness in health care settings, we do not know the extent to which brief advice works in non-health care settings.51

Research into broadening the base of IBA delivery,52 undertaken by the Drug and Alcohol Research Centre at Middlesex University for Alcohol Research UK, found that training in IBA needs to be “related more directly to organisational cultures, behaviour, and development needs as well as retaining its focus on professional attitudes and behaviour.”

Planning and commissioning have an important role in supporting delivery of interventions after the training has taken place, ensuring that factors such as type

51 Evidence for the effectiveness and cost-effectiveness of interventions to reduce alcohol-related harm (2009) 52 The role of training in delivering alcohol IBA in non-medical settings: Broadening the base of IBA delivery, Thom et al, Drug and Alcohol Research Centre, Middlesex University (Alcohol Research UK, June 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 86 OFFICIAL

of training best suited to the target group/work context, the extent of organisational support and what ongoing support may be needed.

Robust means of monitoring and evaluation of delivery of local delivery of IBA, to include the level and effectiveness of interventions delivered by trained individuals, continues to be a challenge but is a priority to resolve.

Workforce development in 2016 More than 300 front line staff have been trained in the last year, including from:

 Addaction/YZUP  SUSIE Project  Bosence & Boswyns  WAVES  Re:Source  Clear Support  Twelves Company  Stonham Home Group  Cornwall Women’s Refuge  Devon & Cornwall Housing  Cornwall Refuge Trust Association  WRSAC  Cornwall Housing  Konnect Cornwall  FreshStart Chapter 1  Restorative Cornwall  Coastline Housing  Fire, Rescue and Community Safety  Devon & Cornwall Police Service  Pharmacists, GPs and Pharmacy staff

IBA delivered in Pharmacies Recent research53 into the effectiveness of IBA delivered in community pharmacies found no evidence of a positive impact on hazardous or harmful drinking, but noted the limited training provided and that enhanced training may improve this.

“Brief interventions delivered by community pharmacists appeared to have no effect on hazardous or harmful drinking. It was difficult to work out why the brief intervention might have failed because few studies have unpicked which elements make a brief intervention successful or unsuccessful. However, the limited training offered the pharmacists may have been a reason here and also in other settings where trials have not found brief interventions effective.

On the basis of these findings, the authors suggest that it would be inadvisable to extend services for tackling problem drinking to community pharmacies with little or no additional training.

However, the successful engagement with pharmacies and implementation of the intervention does suggest that this setting could be conducive to the delivery of brief interventions.”

53 The effectiveness of brief alcohol interventions delivered by community pharmacists: randomized controlled trial, Addiction (2015, 110(10), p. 1586–1594) by Dhital, Norman, and Whittlesea

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 87 OFFICIAL

Key lessons:

 Ensure that training is delivered and monitored at a high quality;  Give good training ‘aftercare’ and support;  Train Pharmacists to deliver IBA using AUDIT-C/AUDIT, but where relevant allow for onward referral to Addaction for Brief Interventions for people scoring above an agreed level, such as 12. This should avoid inappropriate referrals, but remove the need for ongoing case work by Pharmacists/Pharmacy staff.

Local delivery There are currently 45 pharmacies across Cornwall offering Identification and Brief Advice (IBA) as a simple intervention designed to identify individuals who are drinking alcohol above the recommended guidelines.

Using the Alcohol Use Disorders Identification Test (AUDIT-C), pharmacies are able to screen customers that demonstrate signs of drinking at increasing or higher risk levels and offer a brief intervention or signposting for those affected. Data is recorded on the national Pharmoutcomes system provided by Pinnacle Health Partnership LLP.

This is the first time we have had access to the data recorded and we aim to investigate how well this data can inform us of the effectiveness and appropriate placement of the provision, the level of data that we can gather and if there are any improvements that can be made to the data collection process.

 During the calendar year 2016, 36 of these pharmacies recorded at least one IBA intervention and a total between them of 1,780. The majority of the pharmacies recording provision are the national chains such as Boots or Day Lewis;  44% (777 people) of the those screened received brief advice in 2016. Based on the statistic that 1 in 8 'at risk' drinkers reduce their consumption to low risk levels after having received IBA, we can estimate that 98 individuals (6%) reduced their level of drinking to within the lower risk category.

Of the 1,780 people screened using the AUDIT-C tool in 2016, just over half (53%) of the group is made up of male drinkers, with the difference between the sexes being made up largely of those aged 61 or above, with the most common age between 66 and 70.

However, females appear more frequently than males at the younger end of the group, between the ages of 18 and 40. This can be considered alongside PHE’s LAPE data for alcohol-related hospital admissions for females under 40 and females admitted for alcohol-specific conditions, which are much higher than the national average.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 88 OFFICIAL

Of those screened, over half were presenting with Hypertension and linked conditions such as Heart Disease as an ‘at risk’ category. More than one in three of those that were screened went on to receive brief advice at the time. Over half of this group, given brief advice, was made up of male drinkers; however we again see a female prevalence over males amongst the younger drinkers.

 One in five (357 individuals) scored 5 or more on stage 1 (the initial evaluation phase) of the tool, indicating that they may fall into the increasing or higher risk categories of drinkers. Of these, a third went on to complete stage 2 of the AUDIT-C tool. At this point we begin to see an increasing prevalence of men within the cohort as two thirds of this group is made up of males;  A third of the group scored 7 or below which placed them in the lower risk category. Over half fell into the Increasing Risk category with the remaining 10% being split between Higher Risk or Possible Dependence categories;  Of those demonstrating Higher Risk or Possible Dependence, 70% were male, two thirds had presented with high blood pressure as a medical issue and all were over the age of 45. It is worth noting that a quarter (less than 5) of these individuals received signposting into specialist services, while the rest of the group all received brief advice.

Three quarters of Stage 2 participants report their general health as either good or excellent at the outset of the intervention, suggesting that introducing IBA at this stage is wholly relevant and appropriate as a preventative measure to combat the harmful effects of excessive alcohol consumption.

Delivery of interventions vs relative risk of harm Relative risk for a geographical area was estimated utilising the HaLO Tool, which is discussed in detail later in this assessment. In summary, the tool uses a range of impact measures of alcohol-related harm to determine the potential risk that the availability of alcohol currently poses in any given location in Cornwall.

Pharmacies in Wadebridge have provided the most interventions in 2016, 401, which is almost one in four of all IBA interventions in Cornwall. In terms of measurable risks of alcohol in this area, only one LSOA54 in and around Wadebridge, ‘Egloshayle and St Breock’, breaks into the top 40 riskiest areas from the HaLO tool55. Further investigation has identified that this area has been providing interventions over and above the recommended levels.

Falmouth contains three pharmacies providing IBA, with 181 interventions reported between them. Falmouth contains two very high risk areas and therefore it appears that IBA provision is set to an appropriate level in this area.

54 Lower Super Output Area – a statistical geography that typically contains 1,500 people 55 See chapter on ‘Health as a Licensing Objective (HaLO)’

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 89 OFFICIAL

St Austell contains four of the 50 ‘most risky’ areas as calculated by the HaLO tool. ‘St Austell Poltair Ward South West’ and ‘St Austell Gover Ward South East’ placed 11 and 12 on the overall list. These two areas sit side by side and are also bordered by two further very high risk areas. The immediate vicinity is served by three IBA participating pharmacies, these stores have contributed 100 interventions between them in 2016. In addition to these outlets, nearby Holmbush contains a participating pharmacy which has contributed a further 108 interventions.

The next section is dedicated to looking at the provision of IBA in the five areas and their immediate surroundings in Cornwall deemed to be most ‘at risk’ in terms of highest level of risk to health posed by availability of alcohol based upon the data held within the HaLO tool.

# Area Detail 1 Newquay Gannel  Top of the list in Cornwall with a level of risk nearly eight Ward North East times higher than the Cornwall average;  It is neighboured by two further ‘high risk’ areas, ‘Newquay Edgcumbe North Ward West’ and ‘Newquay Edgcumbe North Ward North’. This is further surrounded by areas demonstrating ‘above average’ risk;  Just one pharmacy provides IBA in this area, delivering 7 interventions in 2016, the last of which was in April 2016. The next nearest provider is over 6 miles away in St Dennis;  It would appear that pharmacy based provision of IBA in this area is not set at a level relative to the current need.

2 Truro Boscawen  This area contains two providers. Between them, less than Ward City Centre 5 IBA interventions have been recorded during 2016. There are no other pharmacy based providers in the surrounding area;  This would suggest that there is work to do in terms of encouraging engagement and promoting the service in this area and/or improving recording.

3 Penzance Town  This area is bordered by two other areas inside the top 25 Centre Central highest risk areas and is served by two IBA participating pharmacies, one of which is the second busiest store in our list, with 167 (10% of the Cornwall total) interventions recorded in 2016, however the other store has not recorded any since October 2015;  It would appear that this area is better engaged in terms of Pharmacy based IBA than the Newquay and Truro examples above.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 90 OFFICIAL

# Area Detail 4 Liskeard South  This area is the fourth highest in terms of risk level from Ward East the HaLO tool, almost four times higher than the Cornwall average;  It is bordered by one other very high risk area and two at high risk;  There are two pharmacies within this vicinity providing IBA, however less than five interventions were recorded in 2016, all of those by one store;  This would suggest that there is work to do in terms of encouraging engagement and promoting the service in this area and/or improving recording. 5 Camborne West  This area is in close proximity to several other high and Ward East very high risk areas making up the Camborne/Redruth Central conurbation;  There are three pharmacies in this area providing IBA. One of the stores has no recorded interventions, however both the remaining stores recorded 66 interventions each, making them joint tenth highest provider. Neigbouring Redruth contains the fourth highest performing pharmacy in terms of numbers of interventions provided, with 118;  It would appear that this area is relatively well engaged in terms of Pharmacy based IBA.

Summary of findings and aims for the future  Males make up the majority of those identified as potentially benefitting from IBA, and an even higher proportional majority of those screened that are deemed to be at increasing risk;  The number of participants screened increases rapidly from the approximate age of 40 with the mode age being 66-70. This would appear to be consistent with the onset of various alcohol related conditions becoming more apparent as an individual reaches middle age;  Females make up the majority of young drinkers within the data, which along with the LAPE would suggest a need in Cornwall to target this group;  There is evidence within the data, when compared with information provided by the HaLO tool, that pharmacy IBA provision could and should be increased in and around the Newquay, Truro and Liskeard areas;  St Austell, Penzance and Camborne/Redruth show a higher number of interventions being undertaken which is more closely proportional with the risk posed by the availability of alcohol in these areas;  The data sets do not hold information relating to the clients name or date of birth and therefore it is difficult to establish the existence of repeat attenders or to track how many, if any, individuals that are signposted into Addaction actually make it into the treatment cohort;  Numbers signposted into specialist treatment services in general are low, with less than half of those identified as being possibly dependant receiving this information;  Provision in major towns such as Newquay, Truro and Liskeard is low in comparison with other areas in Cornwall and more individuals drinking at increasing risk levels could potentially receive an intervention if levels were increased.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 91 OFFICIAL

Messaging and Communication What Will Your Drink Cost? This is a summary of the findings from research by Beth Wrightson (Plymouth University), who evaluated the effectiveness of the campaign material of Safer Cornwall’s campaign What Will Your Drink Cost?, assessing whether positively or negatively framed messages are more effective at propmtingg behaviour change.

Local context provided ARID from Cornwall’s Emergency Department at Treliske Hospital in Truro, 2013:

 66% of assaults recorded were alcohol related and 80% of assault victims were male.  Young males aged eighteen to twenty-four years are the most significant victim group affected by violence against the person (VAP) in the night time economy (NTE), making up 34% of VAP injury and 26% of VAP without injury.  40% of offenders for detected crimes, for with or without injury, were males aged eighteen to twenty-four, a cohort that makes up 27% of all recorded crime.

We wanted to learn how to combat some of the associated problems, which put a strain on emergency services.

 Community safety alcohol campaigns have usually used negative or fear tactics to alter attitudes and behaviours of an audience; research has indicated that such methods can actually backfire, and produce short term adverse effects on some members of the target audience;  This study examined the effectiveness of comparative positive and negatyive framing effects on alcohol related attitudes and behaviours, using updated variant versions of the Safer Cornwall Partnership’s ‘What Will Your Drink Cost?’ campaign material;  The posters were based on effective deterrent consequences (breakdown of a relationship and death of a victim) of being involved in alcohol related violence, in a pilot study using the target audience of males aged eighteen to twenty four years old.

Theory Previous research from Jones, Sinclair and Courneya (2006) and Revlin and Russel (2012) suggest that the student participants will prefer the positively framed material rather than the negatively framed posters.

Methodology  Seventy-eight male participants invited to be surveyed in two sessions each.  M age twenty-one, range eighteen to twenty-four years old.  Mixed subjects design with four conditions: o relationship breakdown negatively framed o relationship breakdown positively framed o death of a victim negatively framed o death of a victim positively framed

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 92 OFFICIAL

Posters  Top Left: Breakdown of a relationship, negatively framed  Top Right: Breakdown of a relationship, positively framed  Bottom Left: Death of a victim, negatively framed  Bottom Right: Death of a victim, positively framed

Analysis Reducing Drinking:

 Positive framed posters produce a short term attitude change on responsible drinking, along with a reduction in the belief that their own drinking is influenced by others. This could reduce immediate harmful or binge drinking during a Pub or Club visit.

Reducing Violence:

 35.1% of participants had been involved in violence (involved in three violent altercations) which on average was with a stranger. Responses indicated that this campaign will reduce violent tendencies in a just over a third of the participants who actually commit such acts.

Visual Impact on Consequential Thinking:

 Thematic analysis of the questionnaire on the poster highlighted that participants liked the visual separation of the tear, as well as other visual aspects (such as the font) as they were straight to the point, and made them think about the consequences of alcohol related violence.

Suitability of Images:

 There was significant dislike for the photos used, being seen as too staged and unrealistic, undermining the message of the poster and making it comical;

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 93 OFFICIAL

 Aspects of the models were also raised as an issue, especially where they were not the same age as the target audience, which made the scenarios more difficult to relate to.

Relevance of Consequences:

 In some cases (e.g. nightclub images) there was confusion over the transition or connection of the positive top image to the negative image consequence;  There was also considerable confusion over the nature of the deterrent consequence of a breakdown of a relationship. Many thought that the message was about infidelity, which could cause feelings of anger, and a few viewers felt it looked sexist.

Sources of Information:

 Even though this was a mock-up campaign, only analysing the positive/negative imagery without an actual customer or service delivery context, people questioned the fact that it could cause distress but then lacked accompanying of information about how to change, or where to get support or advice;  This is echoed in research by Foxcroft, Ireland, Lister-Sharp, Lowe & Breen (2003) on campaigns which solely present information about health problems and alcohol units, finding them to be ineffective without guidance on how to live a healthy lifestyle, rather than just a warning to do so.

Negative Impact of Distress:

 Several participants had a greater willingness to consume alcohol after seeing the posters;  Similar short term effects were found by Jessop and Wade (2008) when using graphic images, as it induced anxiety, thus implying participants used defence mechanisms to combat the anxiety induced by the ambiguous message of alcohol related harm.

Direct Impacts:

 The death of a victim was highlighted as the most effective deterrent of being involved in alcohol related violence with 95.83% agreeing this would deter them;  The financial cost on emergency services (when they have to deal with a violent altercation) had the lowest proportion of people agreeing this would affect their levels of drinking;  Overall, the effects on others was highlighted as being the most effect deterrent of alcohol use, compared to personal and societal effects of alcohol related violence, followed by personal effects, with the breakdown of a relationship being the most deterring as a consequence.

Longevity and Continuity:

 Flay, DiTecco and Schlegel (1980) found that attitude and behaviour change effectively occurred when there was repetition and presentation of material over long periods of time using a combination of sources and methods, during different periods of exposure, as well as describing the motives of the

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 94 OFFICIAL

appeal and reinforcement of the methods required to achieve the desired behaviour;  If future campaigns by Cornwall Council for the Safer Cornwall Partnership use a combination of these factors, taking into account the findings from this study an effective body of campaign material should be produced for this target group.

10 Action Points for consideration in updated campaign material:

1. Positive framed posters produce a short term improvement in responsible drinking attitudes, which could reduce an amount of immediate harmful or binge drinking during a Pub or Club visit, although this is not universal as several participants had a greater willingness to consume alcohol after seeing the posters; 2. This campaign will reduce violent tendencies in a just over a third of the participants who actually commit such acts; 3. Participants liked the visual separation of the tear, which made them think about the consequences of alcohol related violence, but some disliked the photos used, which seemed staged and unrealistic; 4. Images should feature people of the same age as the target audience; 5. Images need to avoid confusion over the transition or connection of the positive top image to the negative image consequence, and conveying unintended sexist implications about relationships; 6. Images in this campaign theme could cause distress, and so they need to be accompanied by information about how to change, or where to get support or advice. The campaign will be relatively ineffective without any guidance on how to live a healthy lifestyle, rather than just a warning to do so; 7. The death of a victim was highlighted as the most effective deterrent of being involved in alcohol related violence; 8. The financial cost on emergency services was the least effective, with the lowest proportion of people agreeing that this would affect their levels of drinking; 9. Effects on others was highlighted as being the most effect deterrent of alcohol use, followed by impact on self with the breakdown of a relationship being the most deterring as a consequence; 10. Future campaigns should consider repetition and presentation of material over long periods of time using a combination of sources and methods, during different periods of exposure, as well as describing the motives of the appeal.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 95 OFFICIAL

Mapping the treatment system What is working well?  Local services are cost effective. At £4,441, Cornwall and the Isles of Scilly pays 9% less per successful outcome than the national benchmarks;  More people have accessed treatment. Compared with 2014/15, there were: o 4% more alcohol users in treatment: nationally numbers fell by 5% o 21% more non-opiate and alcohol users in treatment: nationally numbers were static  In line with the national picture, the main access route into treatment is self-referral accounting for just over half of all referrals in 2015/16. GP referral accounts for the next largest segments of referrals at 21%, which is above the national average of 17%;  At 11%, the proportion of criminal justice referrals for alcohol has dropped slightly compared with previous years, but remains above the national average of 8%;  Early unplanned exits are better than the national profile for alcohol, as they are for all of the drug groups. This indicates that the system is initially meeting the needs of service users, and successfully promoting engagement with services. Overall around 10% of people leave treatment in an unplanned way and before 12 weeks;  Although overall performance in successful completions has declined, some client groups have seen an increase in the proportion completing treatment successfully and these were: o Unemployed/NEET on presentation to treatment; o Presenting to treatment with lower consumption levels of alcohol (under 200 units in the preceding 28 days); o Clients NFA/rough sleeping on presentation to treatment; o Clients referred between treatment services; o Clients with a disability - particularly physical disability.

What needs to improve?  Referrals through other health (hospitals/ED) and social care routes remain low at 3% and 1% respectively, compared with 6% and 2% nationally.  There was a numerically small but significant increase in the number of people presenting to treatment having consumed 1000+ units in the preceding 28 days (at least 250 per week). This very high risk group makes up 8% of the people who started treatment episodes in the last 12 months and the rise is entirely in male clients;  The proportion of people completing treatment successfully, as a proportion of everyone in treatment, has declined for alcohol, as it has for other drug groups. In people terms, in 2016 we fell short of the national average by 106 successful completions;  Contributory factors include addressing concurrent mental health problems, couples impacting negatively upon each other’s treatment, unresolved early life trauma and the need to build recovery capital in employment, training and housing.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 96 OFFICIAL

Tier 4  63 people accessed residential services in 2015/16, of whom 49 (78%) completed successfully. This is almost exactly the expected number to require residential rehabilitation, with a very high rate of completion;  Particular challenges include re-emergence and management of physical and psychological pain, particularly of early life trauma; families and/or partners where relationships are dysfunctional or there are dependence issues; additional complex needs such as learning disability or homelessness;  Retrospective payment of Personal Independence Payments, providing a lump sum of £1,000 or more, has created too much temptation for people newly in recovery;  Some service users are still not adequately psychologically prepared, or have enough of their life in order to be able to make the best use of the experience.

Dual Diagnosis  Drug and alcohol problems are usual rather than exceptional amongst people with mental health conditions but the relationship between the two is complex. Health guidance stresses the importance of drug/alcohol and mental health services working together effectively, otherwise both will fail;  It is estimated that 12,000 people in Cornwall (2.6% of the adult population) has a mental health condition concurrent with alcohol dependency. There were 192 people in treatment for alcohol problems with a concurrent mental health condition (dual diagnosis), so only a small fraction of the estimated number are receiving specialist treatment;  Violence and abuse, particularly when experienced in childhood, is strongly associated with later onset and persistence of mental health conditions and problematic use of drugs and alcohol;  Although we have higher than average levels of concurrent contact with mental health and drug/alcohol services, local data indicates that there is significant unmet need, particularly in the offender population that commonly present with this combination of issues;  A survey with staff across a range of community safety services found that experiences of successfully referring into mental health services were mixed, with dual diagnosis, increasing theresholds, ease of contact and unclear pathways being described as the barriers;  The delivery of Mental Health First Aid training has been successful in raising staff confidence and knowledge when working with someone with a mental health condition.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 97 OFFICIAL

Why invest in treatment? Use is widespread, but addiction is concentrated There are strong links between poverty, deprivation, widening inequalities and problem drug use but the picture is complex. It may involve fragile family bonds, psychological discomfort, low job opportunities and few community resources. Not all marginalised people will develop a drug problem, but those at the margins of society, such as the homeless and those in care, are most at risk.

Alcohol misuse damages health  Alcohol misuse has serious health implications and treatment is proven to reduce the strain on local health services o Every 100 people treated can prevent 18 ED visits and 22 hospital admissions (Costs £40k, saves £60k)  Every 5,000 people screened for alcohol can prevent 67 ED visits and 61 hospital admissions (Costs £25k, saves £90K)

Alcohol misuse impacts upon families and communities  Treatment saves an estimated £960 million costs to the public, businesses, criminal justice and the NHS;  Cornwall has higher than average number of benefits claimants with alcohol and drug problems and higher than average positive outcomes for employment from those in treatment;  Early intervention saves costs downstream in, the health and wellbeing of children, housing and homelessness, reoffending, crime, employment, benefits and hospital admissions;

How cost effective are our local services when benchmarked nationally? Are we getting value for money? Putting our local data into the Public Health England Commissioning Tool, the outputs – using the latest available cost effectiveness data – are favourable.

This shows that at a system and intervention level – Cornwall and Isles of Scilly pays less per successful outcome than the national benchmarks for opiates, non-opiates and alcohol.

Alcohol The next graph shows the most common intervention pathways for the different severity/complexity groups of alcohol clients and the estimated spend per successful completion for each group. A national average for the group is presented to the right (in grey) as a comparator for each pathway.

For alcohol users across the whole system in Cornwall and Isles of Scilly cost per successful completion is £4,411 vs the national benchmark of £4,837 showing that local services cost 9% less per successful outcome.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 98 OFFICIAL

Drug and alcohol treatment represents just over a quarter (26%) of the Public Health Grant, from the period when drug and alcohol services were transferred into public health and into Local Authorities in 2013.

Costs were reduced by 1.6% in 2015/16 and a further 8.6% in 2016/17, due to the national cut to the Public Health Grant.

As a result, we discontinued the following:  Intuitive Recovery Thinking Skills (requiring Addaction to sub-contract from within their existing contract price);  Dry Blood Spot testing (requiring Addaction to sub-contract from within their existing contract price);  Family Interventions were discontinued initially, but subsequently funded at a reduced amount by the Together for Families programme;  Further efficiencies were delivered through the Addaction contract.

It was identified at this time that any further reductions would necessitate a reduction in treatment places available and significant changes to the drug and alcohol treatment system locally. Further incremental cuts to the Public Health Grant are anticipated over the next three years.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 99 OFFICIAL

‘Map and gap’ of existing services NICE guidance The alcohol-use disorders overview guidance from NICE56 covers prevention, diagnosis and management of alcohol-related disorders.

The following section is dedicated to the gaps in treatment provision identified following an audit of the guidance.57

Prevention – AUDIT Screening  Patients attending with relevant physical conditions – there is little evidence of adequate screening across health services;  Patients with relevant mental health conditions – no routine screening takes place in GP or mental health services;  Those who have been assaulted – no evidence of screening being undertaken in the Emergency Department or by police following an assault;  Regular attenders for accidents and trauma, including 'falls' – no evidence of screening being undertaken in the Emergency Department;  Regular GUM and emergency contraception service attenders - no commissioned service provides screening.

Identification and Brief Advice  Primary healthcare – some practice nurses and GPs do this but it is not widespread practice;  Emergency departments – no evidence that this takes place;  Other healthcare services – other listed services do not currently provide IBA.

Wernicke-Korsakoffs syndrome (WKS)  Supported independent living for those with mild cognitive impairment – need to establish adequacy of specific care for WKS within Cornwall residential units and community provision;  Supported 24-hour care for those with moderate or severe cognitive impairment. – need to establish adequacy of specific care for WKS within Cornwall residential units and community provision.

Co-Morbid Conditions  Depression – pathways into community mental health services provided by Corbnwall Partnership NHS Foundation Trust remain inadequate  Other mental health disorders – pathways into community mental health services provided by Corbnwall Partnership NHS Foundation Trust remain inadequate

56 ‘Alcohol-use disorders overview’, NICE (March 2016) 57 Full details can be found in Appendix E

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 100 OFFICIAL

Psychological interventions  Cognitive Behavioural Therapy/behavioural therapies/social therapies/couples therapy – it is not clear whether the programmes delivering these psychological interventions are available Cornwall-wide.

Pharmacological Interventions  Nalmefene – No specific pathway/ recommendations or monitoring of the use of this drug locally. Specialist services do not use it, and Naltrexone may be preferable. Evidence of GPs prescribing, but not alongside psychosocial interventions as indicated;  Disulfuram – Not widely used locally;  Naltrexone – Not widely used. Prescribing in both specialist services and GP led services is monitored through prescribing data. Primary Care lead GP and Specialist Consultant Psychiatrist for Addictions offer regular supervision and training for other medical staff including GPs

Assisted Alcohol Withdrawal  All unplanned and planned detox options use NICE recommended pharmacological interventions: diazepam and chlordiazepoxide, with validated symptom monitoring tool (CIWA-AR) and at least minimum level of supervision during the detoxification in place.

Alcohol related disease  Conditions for referral, diagnosis (including biopsy) and treatment are met within GP pathways and service offered through RCHT/Derriford care pathways for hepatology, including access to liver transplant.

Focus on Nalmefene A full review of the research into the effectiveness of Nalmefene can be found in Appendix C, with the key points highlighted here.

Nalmefene (also known as Selincro) is an opioid antagonist and NICE Guidance58 recommends it as a possible treatment for people with alcohol dependence who:

 Are still drinking more than 7.5 units per day (for men) and more than 5 units per day (for women) 2 weeks after an initial assessment, and  Do not have physical withdrawal symptoms, and  Do not need to either stop drinking straight away or stop drinking completely.

58 ‘Nalmefene for reducing alcohol consumption in people with alcohol dependence’, NICE (2014)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 101 OFFICIAL

Nalmefene should only be taken if the person is also having ongoing support to change their behaviour and to continue to take their treatment, to help them reduce their alcohol intake. This should take the form of continuous psychosocial support focused on treatment adherence and reducing alcohol consumption.

It was picked up fairly rapidly that this defined level of psychosocial support within the Nalmefene guidance contained some problematic issues. It was found that most psychosocial interventions currently provided are below the standard outlined in the NICE Guidance.

Rather than being tested against international or national psychosocial best practice guidance, Nalmefene was tested against what appeared to be on offer within treatment models that did not achieve those best practice standards.

Since its UK registration in November 2014, independent academic researchers have continued to find weaknesses in Nalmefene’s effectiveness, the psychosocial support, and the research process behind its accreditation. There is also evidence that the parent drug, Naltrexone, has been found to be just as effective and much cheaper.

A review of this research indicates that a new expensive drug has been licensed and promoted when a more universally available cheaper medication, Naltrexone,59 appears to be as effective, and when the missing ingredient in trials and treatment is NICE standard psychosocial support.60

Getting people into treatment Despite clear guidance that briefer interventions (under 12 weeks) are indicated for large numbers of dependent drinkers, recording of activity related to ‘non- structured’, i.e. under 12 weeks, treatment is not mandated for the National Drug Treatment Monitoring System and Public Health England measures treatment system effectiveness based on structured treatment activity (12 weeks plus) only. Performance and other diagnostic reports provided by PHE for the purposes of needs assessment thus include these figures only.

In April 2013, non-structured treatment was added to our case management system (Halo). Introducing a range of briefer treatment interventions has allowed us to

59 ‘Cornwall joint formulary recommended choices’, NHS (2017) 60 ‘Cornwall joint formulary recommended choices’, NHS (2017)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 102 OFFICIAL

measure the total number of clients accessing alcohol treatment with greater accuracy and ensure that clients are better placed, depending on their need.

Including individuals in briefer interventions (under 12 weeks), there are 1,546 people engaged in alcohol treatment. Within this number, 65% are in structured treatment, with the remainder placed in unstructured treatment or receiving brief interventions.

In 2015/16, our local treatment system engaged 2,323 adults in structured drug and alcohol treatment – 28% were in treatment for problem use Alcohol only of alcohol only and a further 12% for 28% non-opiate use alongside an alcohol Opiate 54% problem. Non-opiate & alcohol Compared with 2014/15, there were: 12% Non-  4% more alcohol users (n=+26) opiate – nationally numbers fell by 5% 6%  21% more non-opiate and alcohol users (n=+47) – nationally numbers were static  2% more opiate users (n=+26) – nationally numbers fell by 2%  26% more non-opiate users (n=+29) - nationally numbers increased by 3%

Provisional mid-year performance figures indicate, however, that these increasing trends may be starting to plateau.

A prompt response for help plays an important part in supporting the best chances for recovery. Until recently, waiting times for treatment had remained exceptionally low, despite the increases in demand across the system over the last 12 months.

In 2015/16, every client was able to start treatment within three weeks. In line with the national picture, the main access route into treatment is self- referral accounting for just over half of all referrals in 2015/16. GP referral accounts for the next largest segments of referrals at 21%, which is above the national average of 17%.

The proportion of criminal justice referrals for alcohol has dropped slightly compared with 2014/15 (from 13% to 11%) but remains above the national average of 8%; Referrals through other health (hospitals/ED) and social care routes remain low at 3% and 1% respectively, compared with 6% and 2% nationally.

Most people who require treatment for alcohol dependence will be drinking at higher risk levels when they start treatment. There is no direct correlation between regular consumption levels and dependence but this may give some indication of the severity of dependency and potential harm amongst the treatment population.

As the chart below shows, most of the growth in numbers coming into treatment has been in the middle to lower bands of higher risk consumption (under 400 units in the 28 days prior to commencing treatment, average of 100 units per week) and this is the case for both men and women.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 103 OFFICIAL

200 180 160 140 120 100 80 60 40 20 0 0 units 1-199 200-399 400-599 600-799 800-999 1000+

12m to Sep-16 2015/16 2014/15

The 2016 Chief Medical Officer’s consumption guidelines advise a single low risk consumption level for men and women of 14 units per week. In general terms however, as consumption increases women are more likely to become dependent and will experience health and social harms at a lower consumption level than men.

We have seen a numerically small but significant increase in the number of people presenting to treatment having consumed 1000+ units in the preceding 28 days (at least 250 per week), however. This very high risk group makes up 8% of the people who started treatment episodes in the last 12 months and the rise is entirely in male clients.

As well as the increased risk of serious harm to the individual, we also know that this group do less well in treatment, with a lower proportion completing treatment successfully.

That being said, our 30% consumption profile for clients % in treatment % in treatment (National) starting treatment is similar to 25% the national average. 20%

The consumption band with the 15% highest representation of women is 400-599 units, 10% where their number almost 5% equals the number of men. Above this consumption level, 0% the proportion of women drops 0 units 1-199 200-399 400-599 600-799 800-999 1000+ to around half that of men.

What is working well? Alcohol abstinence, positive Housing and Employment outcomes Treatment outcomes are monitored through the internationally validated assessment tool called the Treatment Outcomes Profile or TOP. The TOP is conducted at the start of treatment, in care plan reviews at approximately three month intervals throughout the client’s treatment journey and on treatment exit.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 104 OFFICIAL

Designed originally to measure outcomes for drug users, the TOP has been adapted to provide information on abstinence rates from alcohol and changes in average days drinking, and housing and employment outcomes on exit from treatment.

 Abstinence rates from alcohol at planned exit are above the national average for both men and All women. Women are more likely to be abstinent than men (60% vs 54%); Female  Abstinence rates have dropped slightly in the year to date, however, and this will require monitoring. Male

0% 20% 40% 60% 80% National Local

Positive housing outcomes on exit for alcohol clients are consistently very close to 100%; meaning that nearly every person completing alcohol treatment successfully leaves with no housing problems. The national rate in 2015/16 was 84%.

Housing problems are less prevalent amongst people starting alcohol treatment than amongst those starting any kind of drug treatment.

Around 1 in 10 alcohol clients present to treatment with a housing problem (3% NFA/homeless and 6% with a less acute housing problem, such as being in temporary accommodation), compared with 1 in 5 for drug clients. Although the majority see an improvement in their housing situation by the time they exit treatment, they are less likely to complete successfully and 10% will still be in housing need when they leave.

Employment outcomes indicate that levels of paid work being undertaken by alcohol clients in the month prior to leaving treatment successfully, are in line with the national average – with 7% in part-time work and 26% in full time work (compared with 5% and 25% respectively nationally).

Employment is one of the most strongly positive factors in successful completion and then sustaining recovery – with both being employed on presentation to treatment and undertaking paid work at last TOP review increasing the likelihood of leaving treatment successfully. Progress into work is a significant challenge, however - of those who commence treatment out of work, only 14% have progressed to undertaking 10+ days paid work when they complete treatment.

Housing and homelessness and worklessness are discussed in more detail later in this assessment.

Early Unplanned Exits An early unplanned exit relates to a client who, within the first 12 weeks of treatment, left in an unplanned way (dropped out, moved away, died) or were transferred but did not continue their treatment journey.

Overall around 10% of people leave treatment in an unplanned way and before 12 weeks.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 105 OFFICIAL

Early unplanned exits are better than the national profile for alcohol, as they are for all other drug groups. This indicates that the system is initially meeting the needs of service users, and successfully promoting engagement with services.

Outcome at exit People % National Opiates 43 11% 16% Non opiates 6 7% 17% Non opiates and alcohol 25 12% 17% Alcohol 37 8% 14% Source: DOMES Q2 2016/17

Successful completions, however, is an area of underperformance for us locally. This means that where clients are leaving treatment in an unplanned way, it is after a longer period in treatment rather than in the early phase of engagement.

What needs to improve? Successful completions People completing treatment successfully (and not subsequently returning to treatment) is used as an indicator of how effective our treatment system is and is measured in a number of different ways:

 The number of people that successfully complete treatment;  The proportion that successful completions accounts for in the total number of people in treatment;  We also take into account re-presentations – the number of people who come back to treatment again after only a short period of time (indicating that their recovery has not been successful).

The quarterly Diagnostic Outcomes Monitoring Executive Summary (or DOMES) report presents our performance information in the context of other Local Authorities with similar characteristics in terms of the complexity of their service user cohort and geographical areas. The latest figures are for Quarter 2 2016/17 (12 month period ending 30th September 2016).

 Information from NDTMS shows that 25% of alcohol clients in the latest 12 month period completed treatment successfully (194 people out of a total of 764 in treatment) and this is substantially below the national average of 39%;  There has been a decline in performance for alcohol, both from the previous quarter and baseline and figures are low compared with our outcome comparator group.

Although performance has declined, in terms of a lower proportion of people completing successfully, a further key factor impacting on this performance measure is that whilst numbers in treatment have been increasing (the denominator

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 106 OFFICIAL

of this performance measure), the rate of exits from treatment has not kept the same pace.

This is illustrated by the chart below, which shows a rolling 12 month total of people entering and exiting treatment and successful completions.61

The trend for Starts Exits Successful completions successful completions 800 has increased but at a much lower rate than 700 treatment starts. 600

500 In people terms, we are falling short of 400 the national average 300 by 106 successful 200 completions. 100

0

Contributory factors include addressing concurrent mental health problems and the need to build recovery capital in employment, training and housing.

Treatment discharge outcomes were reviewed across a wide range of factors to examine what has contributed to the decline and the degree of impact each may have had on the outcome. The analysis looked at clients with problem alcohol use only (no drugs) compared the last 18 months covered by this assessment (April 2015 to October 2016) with 2014/15.

 For alcohol users, just over a half of all exits are successful completions (52%) and this shows a small decline from 54% in 2014/15.

Although the drop in successful completions across all alcohol users is small, there is a lot of variance by individual characteristics; the most significant contributors are:  Self and GP referrals  Employment - employed on presentation to treatment and 10+ days paid work reported at last TOP  North and East Cornwall service area  Presenting to treatment with higher consumption levels of alcohol (800 units or more in the preceding 28 days)

61 Note that this chart counts every start and exit so clients that have engaged with the treatment system more than once in any given 12 month period will be counted as many times as they appear

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 107 OFFICIAL

Some client groups, however, have seen an increase in the proportion completing treatment successfully and these were:

 Unemployed/NEET on presentation to treatment  Presenting to treatment with lower consumption levels of alcohol (under 200 units in the preceding 28 days)  Clients NFA/rough sleeping on presentation to treatment62  Clients referred between treatment services  Clients with a disability - particularly physical disability

The next chart shows the positive and negative factors in successful completion for problem alcohol users.

 Key themes include housing, employment, family and relationships, offending behaviour and very high levels of alcohol consumption prior to treatment;  Consistent with last year, there was a positive skew towards older clients (aged 55+). Gender and ethnicity did not notably impact in either a positive or negative way;  Dual Diagnosis was another factor that did not impact on the likelihood of successful completion with an average of 53% of exits being successful for people with Dual Diagnosis and 54% for those without. Poor self-ratings of psychological health at last TOP, however, was strongly associated with leaving treatment unsuccessfully;  A further factor that is known to reduce the chances of successful completion is the number of previous treatment journeys63, with the best chances of success being for people on their first journey through treatment.

62 Base number of exits: NFA n=49 exits 63 Recovery Diagnostic Toolkit, Public Health England (release: November 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 108 OFFICIAL

Strongly positive  10+ days paid work at last TOP  Presenting to treatment in stable accommodation - homeowner, tenant  Presenting to treatment in employment  Aged 55+

Moderately positive  In a relationship  Parent living with child  Clients referred between treatment services

Alcohol only clients Successful completions 52% of all exits

Moderately negative  Aged 25 to 34

Strongly negative  Housing problems – presenting to treatment NFA; housing problem reported at last TOP  Presenting to treatment drinking 800+ units  Daily drinking - on presentation to treatment ; reported at last TOP  Criminal Justice referral  North and East Cornwall locality service

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 109 OFFICIAL

Tier 4 Tier 4 treatment covers in-patient assessment, stabilisation and detoxification and residential rehabilitation interventions.

The estimated need for in-patient interventions (assessment, stabilisation, and detoxification) is 10% of those in treatment, so approximately 100- 120 places per annum. This was exceeded by 28 places in 2015/16 and indicates a need to review numbers accessing this level of intervention.

Approximately 5% of the treatment population will require residential rehabilitation services (approximately 130 people per annum). Placements are for an average of 12 weeks. The average cost of a placement is £7,500.

These are structured residential programmes with rehabilitative goals and typically expect residents to be drug and alcohol free before they start. Beyond these common factors, programmes may differ according to their philosophy, intensity, inclusion criteria, programme content, and duration. As residential care is a social service, it is means tested and clients must make a contribution to the costs.

63 people accessed residential services in 2015/16, of whom 49 (78%) completed successfully. This is almost exactly the expected number to require residential rehabilitation, with a very high rate of completion.

Of the 14 people who did not complete successfully:  7 engaged back into community treatment  1 died  1 went into custody  5 returned to their partners and families

Whilst the majority leave in a planned and successful way, a review of all early leavers and unplanned discharges revealed a number of problems in the system that still require some attention to make more effective use of this provision:

 Being adequately prepared for the experience. Some service users are still not adequately psychologically prepared, or have enough of their life in order to be able to make the best use of the experience;  Psychological pain, particularly of early life trauma, can become uncovered and prove to distressing for the individual to cope with. A trauma informed approach is required, which helps people to recover from the underlying issues;  The emergence and management of mental health problems during withdrawal. As heroin and methadone can have anti-psychotic properties a range of psychiatric disorders may present during this period;  Negative aspects of external relationships start to impact – families and partners requiring attention or trying to undermine the success of treatment. There is evidence that families or partners may hinder recovery outcomes (if they are dysfunctional or have dependence issues themselves) or aid recovery outcomes (if they are supportive). Many are in coercive or co-dependent relationships which impact upon their ability to achieve recovery, often leading to leaving treatment early. Healthy Relationships programmes and joint couples interventions can improve outcomes for couples in treatment;

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 110 OFFICIAL

 Lack of clear discharge and aftercare plans which can be communicated to people confused during their withdrawal. There is a need to review and update plans during withdrawal or once the worst of withdrawal has been achieved, in the light of sobriety;  The lack of self-esteem and self-care, particularly of the street homeless, once they no longer have the dependence on the substance to mask their life experience;  The challenges for people with learning difficulties, many of whom have become very distressed and/or violent during and after withdrawal and may have been ‘self-medicating’ to self manage a range of issues;  In several instances, the person was suddenly in receipt of a retrospective Personal Independence Payment64, ranging from £1,400 - £4,000, which was created too much temptation. Relapse prevention needs to prepare people for this and for what steps they can take to minimise this derailing their recovery. Greater awareness of the debt people are in may also assist;  Problem alcohol users can find themselves too unwell to participate or manage, due to the long term effects of dependent drinking. These patients often require palliative care and an end of life plan.

64 Personal Independence Payment (PIP) is a benefit that helps with some of the extra costs caused by long-term ill-health or a disability if you’re aged 16 to 64.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 111 OFFICIAL

Mental health National guidance on Dual Diagnosis Public health guidance65 tells us that approximately 40% of people with psychosis misuse drugs and/or alcohol at some point in their lifetime, at least double the rate seen in the general population.

People with psychosis commonly take various non-prescribed substances as a way of coping with their symptoms, and in a third of people with psychosis, this amounts to harmful or dependent use.

In responding effectively to dual diagnosis, pathways into care66 state that:

 Adults and young people with psychosis and coexisting substance misuse should not be excluded from age-appropriate mental healthcare because of their substance misuse. Nor should they be excluded from age-appropriate substance misuse services because of a diagnosis of psychosis;  Treatment for both conditions should be provided by healthcare professionals in secondary care mental health services such as community-based mental health teams.

While it is by no means essential for the provision of services to be by the same provider, a closer relationship between commissioners may help to provide a more joined up service for those with a dual diagnosis. While the system in general works well, there are some issues of bouncing from one provider to the other and not taking responsibility for treatment.

Improved management of mental illness and substance misuse comorbidity has been a National Health Service priority for well over a decade, supported by studies such as the Co-morbidity of Substance Misuse and Mental Illness Collaborative study67which found that:

 75% of users of drug services and 85% of users of alcohol services were experiencing mental health problems;  30% of the drug treatment population and over 50% of those in treatment for alcohol problems had ‘multiple morbidity’;  38% of drug users with a psychiatric disorder were receiving no treatment for their mental health problem;  44% of mental health service users either reported drug use or were assessed to have used alcohol at hazardous or harmful levels in the past year.

65 Psychosis with coexisting substance misuse: Assessment and management in adults and young people - Clinical guideline 120 (NICE 2011) 66 Pathways into care, ref. 1.4.3, 1.4.4 and 1.4.5 67 Comorbidity of substance misuse and mental illness in community mental health and substance misuse services, Comorbidity of Substance Misuse and Mental Illness collaborative (COSMIC) study team (British Journal of Psychiatry, 2003, 183:304-313)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 112 OFFICIAL

In their Dual Diagnosis Good Practice Guide68, the Department of Health states that substance misuse is usual rather than exceptional amongst people with severe mental health problems and the relationship between the two is complex.

 Services are advised to generate focused definitions which reflect the target group for whom their service is intended;  Defining target client groups and agreements on provision must be achieved through inter-agency collaboration across mental health and substance misuse services, both statutory and voluntary, and the criminal justice system;  Alcohol is the most commonly misused substance by people with mental illness. Misuse of illicit substances will reflect local availability, of which mental health services should develop an awareness;  Significantly poorer clinical outcomes are expected among psychiatric clients who also misuse substances: nonetheless an optimistic approach to treatment is both warranted and appropriate.

Individuals with these dual problems deserve high quality, patient focused and integrated care. This should be delivered within mental health services. This policy is referred to as “mainstreaming”.

Patients should not be shunted between different sets of services or put at risk of dropping out of care completely. “Mainstreaming” will not reduce the role of drug and alcohol services which will continue to treat the majority of people with substance misuse problems and to advise on substance misuse issues.

Unless people with a dual diagnosis are dealt with effectively by mental health and substance misuse services these services as a whole will fail to work effectively. In addition, all mental health provider agencies should designate a lead clinician for dual diagnosis issues and all health and social care economies should designate a lead commissioner.

The guidance states that it is not acceptable for services to automatically exclude people with personality disorder. Personality disorder is seen as a separate dimension – which can coexist with a mental health problem or a substance misuse problem, or both. A diagnosis of personality disorder does not necessarily predict poor treatment outcome.

People with borderline personality disorder can often present to services in a crisis; indeed this is characteristic of many people with the disorder.69 They present with a range of symptoms and behaviours, including behavioural disturbance, self-harm, impulsive aggression, and short-lived psychotic symptoms, as

68 Mental Health Policy Implementation Guide - Dual Diagnosis Good Practice Guide: aimed at all those who commission and provide mental health and substance misuse services, Department of Health (2002) 69 Borderline Personality Disorder: Treatment & Management. National Clinical Practice Guideline Number 78 (NICE 2009)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 113 OFFICIAL

well as with intense anxiety, depression and anger. As a result they can be regular users of psychiatric and acute hospital emergency services.

Contributing factors Men and women may experience different stressors, in particular women are more at risk of experiencing domestic abuse or sexual violence which has a strong impact on their mental health.

 A quarter of women will experience domestic abuse in their lifetime and research suggests that 35% to 75% of abused women experience depression or anxiety disorders;  Estimates suggest that 50-60% of women within mental health services have experienced domestic violence and 70% of female psychiatric inpatients and 80% of those in secure settings have histories of physical or sexual abuse;  Problem drinking is higher amongst men than women. Problem drinking is heavily associated with mental illness (from anxiety and depression through to schizophrenia) and personality difficulties;  Heavy drinkers are more than twice as likely to die from suicide as non- drinkers. Between 16% and 45% of suicides are thought to be linked to alcohol and 50% of those 'presenting with self-harm' are regular excessive drinkers.

Research by Women’s Aid70 highlighted that women experiencing domestic abuse are up to fifteen times more likely to misuse alcohol and nine times more likely to misuse other drugs than women generally.

Some women are introduced to substances by their abusive partners as a way of increasing control over them; and when a woman’s partner is also her supplier, it will be particularly difficult for her to end the relationship. When a woman seeks support, information or treatment for her substance misuse, her partner may become even more abusive, or may actively prevent or discourage her attendance at a substance misuse service.

Women whose partners misuse substances may minimise or excuse their abuse on those grounds; it is important to emphasise that even if substance use ceases, the violence and abuse usually continues.

Women with problematic substance use who also experience domestic abuse are particularly likely to feel isolated and doubly stigmatised.

They may find it even harder than other women to report or even to name their experience as domestic abuse; and when they do, are in a particularly vulnerable position, and may be unable to access any suitable sources of support. In most areas, specialist refuge provision for women with drug or alcohol issues is

70 Principles of Good Practice for working with women experiencing domestic violence: Guidance for those working in the Drug and Alcohol sectors (Women’s Aid 2005)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 114 OFFICIAL

not available; but all refuge organisations will offer support and information, and will assist women who have been abused in accessing appropriate service provision.

Abuse and violence are of major relevance to the wider public health agenda. 71 Local authorities, that have the responsibility for public health, should note that this evidence clearly links the experience of extensive physical and sexual abuse with being disabled, alcohol dependent, drug dependent and a regular smoker.

The Department of Health evidences that violence is associated with significant mortality and morbidity,72 including injuries, chronic physical illness, poor reproductive and sexual health, adverse perinatal outcomes, substance misuse, mental illness and suicidal behaviour.

It states that the risk of violence in people with serious mental illness such as schizophrenia has consistently been shown, using different study designs in different settings, to be elevated by substance use.

Evidence from a Swedish cohort suggests that the risk of violence is ‘minimal’ in people with schizophrenia without co-morbid substance use; it is only the presence of substance misuse that increases the risk of violence. Therefore mental illness alone is not a reliable predictor of violence, and more research is required on the contextual and situational factors that precede the violent incident

A national inquiry73 into suicide and homicide by people with mental health conditions also found that substance use can cause or exacerbate psychotic symptoms. A reported history of drug and alcohol misuse in those with psychosis was examined. There was a significant increase in the number of homicides by people with psychosis who also had a history of drug misuse. There was also a significant increase in the number of homicides by people with psychosis who also had a history of alcohol misuse.

Both studies note that further research would be required to examine cause and effect.

As discussed in the Families section, violence experienced in childhood or adulthood is associated with the subsequent development of mental illnesses.

Childhood physical and sexual abuse is associated with adult onset common mental disorders and psychosis and it has been estimated that between a quarter and a

71 Commissioning services for women and children who have experienced violence or abuse – a guide for health commissioners, Department of Health (2011) 72 Public Mental Health Priorities: Investing in the Evidence, Annual Report of the Chief Medical Officer, Department of Health, (2013) 73 National Confidential Inquiry into Suicide & Homicide by people with Mental Illness (2010)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 115 OFFICIAL

third of the burden of adult psychiatric disorders is attributable to the effect of childhood abuse.74

In addition, being a victim of sexual or domestic violence in adulthood is associated with the onset and persistence of depression, anxiety, eating disorders, substance misuse disorders, psychotic disorders and suicide attempts.

The recent Department of Health guidance for improving the mental health of children and young people75 reinforces that experiencing or witnessing violence and abuse or severe neglect has a major impact on the growing child and on long term chronic problems into adulthood.

Many mental health service users of all ages have problems directly attributable to severe neglect and/or trauma in the early years. Some vulnerable children and young people are more likely to have been affected during childhood and adolescence – including those who are adopted, looked-after children, those in contact with the youth justice system and substance misusing young people.

The guidance states that provision of mental health support should not be based solely on clinical diagnosis, but on the presenting needs of the child or young person and the level of professional or family concern. Some children and young people will benefit from services which tackle problems across all family members, including adult mental health, substance misuse issues or complex cases that do not have a clear clinical diagnosis.

There is an expectation that the national Troubled Families Programme (delivered in Cornwall under the name Together for Families) will provide a means of identifying underlying health problems once intensive work with the family is underway.

Priority health problems that the programme is advised to consider include:

 Emotional and mental health problems  Drug and alcohol misuse  Long term health conditions  Health problems caused by domestic abuse  Under 18 conceptions

74 Public Mental Health Priorities: Investing in the Evidence, Annual Report of the Chief Medical Officer, Department of Health (2013) 75 Future in Mind: Promoting, protecting and improving our children and young people’s mental health and wellbeing, Department of Health (2015)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 116 OFFICIAL

How does this impact locally? The recent Mental Health Needs Assessment76 for Cornwall confirmed that mental health conditions are highly co-morbid with alcohol and drug abuse and recommended a greater exploration of the joint delivery of co-morbid services such as drug and alcohol and mental health issues.

 Of those with a mental health condition, 11% (12,069 people) are estimated to also have alcohol dependency, this equates to 2.6% of Cornwall’s total adult population;  Alcohol dependency is most evident in those with externalising conditions such as problem gambling and anti-social personality disorder, and those with highly co-morbid disorders (two other mental health problems), such as depressive disorder, panic disorder, borderline personality disorder, generalised anxiety disorder, psychosis and anti-social personality disorder.

Reviewing the same time period, 18% of service users in structured alcohol treatment had dual diagnosis, which equates to 192 people.

Although it is unclear from this analysis what the nature of the alcohol dependency among this population is, the large difference (11,395 people) between the number in alcohol treatment and the estimated number in need suggests there is a huge unmet alcohol treatment need among those with mental health problems.

There are an estimated 26,700 people in Cornwall drinking at higher risk levels. Taking the number above of 12,069 people who have a mental health problem and are also predicted to have alcohol dependency this equates to 45% of estimated high risk drinkers.

Mental Health and Community Safety Research Project The project sought to identify what is known about the impact of mental health conditions and ways in which we could improve the approach within community safety settings, focused particularly on our top two priorities of domestic abuse and alcohol, but also included anti-social behaviour, drugs and reoffending. It was also supported by a detailed literature review.

The key findings are presented here and the full report is available on request from Amethyst.

Although the rate of depression in Cornwall is in-line with the national average, Cornwall has higher rates of mixed anxiety and depression. We also have higher levels of new cases of psychosis, people being treated by early intervention teams and people receiving assertive outreach services.

76 Mental Health Needs Assessment, Kernow Clinical Commissioning Group (April 2014)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 117 OFFICIAL

The suicide rate has been increasing and is higher than the national rate. There is a rising trend amongst those who are not engaged in secondary mental health care.

Cornwall has higher levels of concurrent contact with mental health and drug/ alcohol misuse services compared with nearest neighbours and national rates.

Dual Diagnosis CIPFA England Cornwall East Riding Northum- Nearest Neighbour of Yorks berland Drug misuse 21.0% 27.5% 20.7% 18.5% Alcohol misuse 20.0% 23.5% 18.6% 15.4%

Despite this, comparison between the prevalence estimate of people with mental health conditions and drug and/or alcohol problems and the actual number accessing treatment services indicates a significant gap.

For those in structured treatment for drug or alcohol problems, 30% had concerns about their mental health but only 7% were currently involved with mental health services. Self-rated improvement of emotional health while in contact with drug and alcohol services was high.

46 individuals – referred 30% from mental health Concerns about their services for drug or alcohol mental health misuse needs

18% - Taking 7% prescribed/non-prescribed Currently involved with drugs for mental health services psychological/emotional problems

10% 10% Currently receiving Previous involvement with treatment from MH mental health services services for reasons other than substance misuse

10% 10% Deliberately harmed Deliberately overdosed in themselves in the past their past

Over a third of domestic abuse/sexual violence victims are recorded as having one or more mental health problems. Victims of abuse were more likely to have multiple mental health problems. They were also more likely to have mental health problems such as anxiety/phobia/panic/PTSD/OCD.

In commissioned services (DASV, DAAT), mental health problems are common in combination with domestic abuse or drug and alcohol problems but only a

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 118 OFFICIAL

small proportion of individuals have mental health problems in combination with both domestic abuse and drug and alcohol problems.

Prevalence of the “toxic trio” was much higher, however, in the offender population. Approximately half of the Liaison and Diversion caseload had a suspected or diagnosed mental health problem alongside a drug or alcohol problem and a history of being an abuse victim.

Just under a third of adult offenders have mental health issues77, of which two thirds had also identified alcohol and/or drug problems and a history of abusive relationships.

Amongst youth offenders the key finding was the high proportion of individuals recorded as coming to terms with a past event which has increased from 2014 to 2015.

Mental health problems are common amongst individuals on the Anti-social Behaviour Team caseload and is often part of a picture of wider and complex needs.

A survey with staff across a range of community safety services found that experiences of successfully referring into mental health services were mixed, with dual diagnosis, increasing thresholds, ease of contact and unclear pathways being described as the barriers.

The survey also found that:

 Half of all respondents felt their confidence in identifying mental health problems was adequate;  A third felt they had adequate confidence making referrals to mental health services;  A quarter of respondents identified more training, possible shadowing opportunities and more detailed information of thresholds and referral pathways as potential means of improving the knowledge, skills and confidence.

As part of the project the delivery of Mental Health First Aid (MHFA) training was evaluated. MHFA is a nationally recognised and accredited two day course which looks at mental health and wellbeing, depression, anxiety, suicide and psychosis, with brief looks at eating disorder and self-harm.

The course looks at how to recognise the signs and symptoms of common mental health problems and to look at ways to help and intervene with individuals who are experiencing mental health distress. This course was made available to all

77 As determined by two mental health indicators that can be extracted from OASys – history of self- harm / suicide attempts and current psychiatric problems (recorded as none, some or significant). This reflects legacy data from the last Devon and Cornwall Probation Trust caseload snapshot in March 2014, prior to transition of offender management services. Offender level data is no longer shared.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 119 OFFICIAL

community safety staff and commissioned services. At the point of writing 155 people had undertaken the training.

 Before and after scores for confidence and knowledge when dealing with people with a mental health problem increased by 59% and 62% respectively for those who completed the training.

The report made a number of recommendations to improve outcomes across all of our strategies, in summary:

 Improve skills and confidence in the workforce to identify, assess and refer people with complex needs, through continuation of MHFA and other complementary accredited training;  Improved understanding of service demands of adults and young people with complex needs, including an agreed mental health assessment within each service’s assessment and better identification and capture of the impact of Adverse Childhood Experiences (ACEs);  System improvement in children’s, families and adult services, including improving information to navigate pathways and reviewing system failures.

It notes that the risk is that we are not able to deliver our strategies and priorities without a continued focus upon mental health but we do not commission mental health services.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 120 OFFICIAL

Families Key findings Parental drug and alcohol use  Witnessing alcohol and/or drug use is identified as one of the key Adverse Childhood Experiences (ACEs) which also include poor mental health of a parent, witnessing violence /abuse and experiencing the incarceration of a parent;  Children and young people who have experienced four or more ACEs are significantly more likely to adopt unhealthy behaviours themselves and more likely to establish homes with similar harmful behaviours;  There are 700 people in drug and alcohol treatment (27% of the population total) that are living with children, which is in line with the national average. These households are recorded as having a total of 1,300 children;  Living with children has a positive impact on treatment outcomes for parents, for all drug groups, but the level of successful completions amongst drug users (opiates and non-opiates) living with children has declined.

Together for Families Programme  It is likely that the families of many of the people in treatment (where there are children in the household) would be eligible for the Together for Families programme due to the prevalence of other programme criteria within this cohort, but engagement in the programme is low at just under 10%;  The pathway between drug and alcohol services and the Together for Families programme has taken some time to establish and is not currently resulting in referrals in either direction or engagement of eligible families;  The Complex Families Index indicates that families in the locality areas of Penwith and Restormel, particularly in areas categorised as deprived, are most likely to present complex multiple needs and these areas are where we would expect to identify the greatest numbers of eligible families;  Overall the priority Community Network Areas identified are: Bodmin, Penzance, Marazion and St Just (West Penwith), St Austell and Mevagissey, St Blazey, Fowey and Lostwithiel, Camborne and Redruth.

Transitions and young adults in treatment  The established structured transition protocol and process ensures that young people are safely and successfully transferred into adult services;  Young people in the adult service who had previously engaged with the young people’s service showed higher levels of multiple need. Key themes include previous traumatic events, homelessness, having been in care and mental health conditions;  85% of young people in the adult drug and alcohol service were not previously known to the young people’s service, despite the majority starting using before the age of 18. How we identify and engage these young people remains a challenge.

Recommendations  Support earlier identification and intervention through embedding routine screening for drug and alcohol problems in all health, children and family services and Child and Adolescent Mental Health Services (CAMHS);

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 121 OFFICIAL

 Develop and deliver targeted interventions to build resilience and reduce harm for children and young people most at risk of Adverse Childhood Experiences, including parental substance use and domestic abuse;  Improve the effectiveness of the Together for Families pathway and establish the impact that this is having on outcomes for families;  Undertake a robust evaluation of the new residential unit for young people and families, and continue to develop interventions using a co-production model.

The impacts of parental substance use National research shows that substance misuse is often a burden not just on the user, but also on other family members, including spouses, parents, siblings and children.

Dependent children are especially affected – albeit differently at different ages – by a parent’s substance problem, since parents’ ability to rear, protect and care for their children, attend to their health, feed them and financially support them may be greatly diminished by their drug and/or alcohol use. Furthermore, being preoccupied about substance supplies can compromise parents’ abilities to be consistent with their parenting and emotionally responsive to their children’s needs.

Brandon et al.78 looked into 47 serious case reviews and found that families shared many characteristics with domestic abuse, mental health conditions and drug and alcohol problems being most prevalent among parents and carers. This was reinforced in the findings of the Munro Review of Child Protection (2011) and ‘A Deeper Analysis of the Findings into the Serious Case Review of Daniel Pelka’.

Witnessing alcohol and/or drug use is identified as one of the key Adverse Childhood Experiences (ACEs), which also include poor mental health of a parent, witnessing violence /abuse and experiencing the incarceration of a parent.

Those people with four or more ACEs are significantly more likely to adopt unhealthy behaviours which could themselves lead to mental health illnesses and diseases in later life.79

Specifically people in this group are:   4 times more likely to be a high-risk drinker;  6 times more likely to have had or caused unintended teenage pregnancy  6 times more likely to smoke e-cigarettes or tobacco;  6 times more likely to have had sex under the age of 16 years;

78 Brandon, M. et al. (2008) Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003–2005, DCSF RR023. 79 Welsh Adverse Childhood Experiences (ACE) Study: Adverse Childhood Experiences and their impact on health-harming behaviours in the Welsh adult population, Public Health Wales NHS Trust (2015)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 122 OFFICIAL

 11 times more likely to have smoked cannabis;  14 times more likely to have been a victim of violence over the last 12 months;  15 times more likely to have committed violence against another person in the last 12 months;  16 times more likely to have used crack cocaine or heroin;  20 times more likely to have been incarcerated at any point in their lifetime.

Significantly, the research also shows that people who have experienced ACEs are more likely to establish homes with similar harmful behaviours. This research shows the importance of early intervention and support for families to reduce the risk and impacts of ACE.

In particular, it shows the importance of early identification and intervention for mental health amongst young people, highlighting the need to approach mental health problems with a broader awareness of potential contributing factors and other co-existing needs.

Living with children Just over a quarter of individuals in treatment are living with children under the age of 18, and this is similar to the national average for all drug groups.

% in National Drug group People treatment % Opiate 369 29% 28% Non-opiate 45 29% 24% Non-opiate and alcohol 90 26% 22% Alcohol 193 25% 24% Total 697 27%

Source: DOMES Q2 2016/17

 Halo records the number of children living with people in treatment, and for the current treatment population the total is just under 1,300 children.

Living with children has a positive impact on treatment outcomes for parents, for all drug groups, with those living with their children more likely to complete treatment successfully than the population average. Conversely, clients who are parents but not living with their children are less likely to complete treatment successfully.

The level of successful completions amongst drug users (opiates and non- opiates) living with children has declined, however, and to a greater degree than the overall treatment population. For alcohol users, the level of successful completions amongst those living with children are unchanged.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 123 OFFICIAL

Effective communication and collaboration between services in touch with families, where family members are engaged in drug and alcohol treatment, are important to ensure that the wider needs of the family are a key consideration of joint service interventions.

Early intervention through a “whole family” approach is a strong feature in the new Children and Young People Partnership Plan One Vision80, particularly supporting one of their Priority Outcome 1: Strengthening children, young people, their families and communities

Effective referral pathways and joint working arrangements between alcohol/drug services and children/family services where alcohol or drug misuse is a factor was identified as a commissioning priority further to the last needs assessment.

One of the key delivery mechanisms is the local Troubled Families Programme, provided locally under the name Together for Families. The DAAT has worked alongside the programme since its inception to identify families where drug and alcohol problems are a factor, provide family interventions and monitor outcomes.

One Vision identifies the programme as the principal means of identifying children and families most at risk of ACEs, in particular neglect and domestic abuse.

The Plan also recognises the causal link between the emotional wellbeing and mental health of children and young people and parental alcohol and drug misuse.

Funding of Family Workers in treatment services in 2017-18 through the Together for Families programme will provide parenting and family interventions for families being affected by problem drinking and other drug taking and will report back in the next assessment.

Together for Families Programme The national Troubled Families Programme, known in Cornwall as the Together for Families Programme, is now in Phase 2 of delivery which involved a broadening of the eligibility criteria and a significant increase in the number of eligible families. The programme is currently co-ordinated through Cornwall Council’s Education,

80 One Vision: Partnership Plan for the Children and Young People Transformation Plan 2017-2020, Cornwall Council (2017), currently being consulted on.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 124 OFFICIAL

Health and Social Care Directorate and governance sits with the Health and Wellbeing Board.

 Cornwall is expected to identify, engage and achieve positive outcomes for 4,050 families between April 2015 and March 2020.

Phase 1 of the Together for Families programme worked with 1,450 families, against the original government set target of 1,270 families, with 85% of families achieving successful outcomes according to set criteria.

There are 6 criteria identified for Phase 2 of the programme:

 Parent and children involved in crime and anti-social behaviour  Children who have not been attending school regularly  Children who need help  Families affected by domestic violence and abuse  Parents and children with a range of health problems, including mental health and drug and alcohol problems  Adults out of work/at risk of financial exclusion; young people at risk of worklessness

The financial framework81 for the expanded programme (2015-2020) outlines the additional elements of the programme and includes new requirements to produce a Family Outcomes Plan and a framework by which to evidence positive outcomes. The Together for Families Programme has expanded the eligibility criteria in the Family Outcomes Framework to include ‘an individual currently undergoing or who has undergone treatment for a drug and alcohol issue in the last 12 months’.

In order to ensure that all individuals receive the right support, the pathway requires two processes to be in place:

 Households in which an individual is already receiving drug or alcohol treatment and additional programme criteria are met by the family are entered onto the programme. This process has been hampered by a lack of clarity about the “whole family” offer and consent to share information;  Families referred to the programme through other routes should be screened, using accredited screening tools, for drug and alcohol needs and referred to specialist services where this is required. Since the move to a keyworker-led model, this is not being co-ordinated.

Currently neither process is resulting in engagement of eligible families.

The first process will be managed by specialist Drug and Alcohol services. The Service Level Agreement between the Together for Families Programme and Safer Cornwall’s Drug and Alcohol Services states that specialist services will check all

81 Financial Framework for the Expanded Troubled Families Programme (Department for Communities and Local Government, last updated March 2015)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 125 OFFICIAL

new clients for programme eligibility and seek explicit consent for individuals to be involved. They will then take on the role of key worker, and information on the family will be reported to the programme team.

This process has only recently got underway and there have yet to be any families entered onto the programme through this process. This is supported by a regular data matching process, undertaken by Amethyst in a secure environment, which checks families that have met other criteria against the caseload for drug and alcohol services, and acts as an engagement ‘prompt’ for specialist services.

Phase 1 of the programme funded a number of Together for Families Advocates to engage and support families on the programme, and co-ordinate contact with services. Advocates were trained in Identification and Brief Advice (IBA) to enable them to undertake basic alcohol screening.

This is one of the simplest and most effective interventions aimed at individuals who are at risk through drinking above the guidelines, but not typically seeking help for an alcohol problem. It includes screening for problem drinking using an accredited tool, identification of the level of problem and brief advice to reduce alcohol-related harm (or onward referral for more intensive intervention if required).

 Three referrals to specialist servicse were received from the programme in financial year 2015/16.

With the move to a keyworker-led model, the SLA provides a more general commitment to workforce development opportunities, enabling staff involved in delivery of the programme to access the appropriate training for the role, including screening and brief interventions training.

The development of a single family assessment, which is one of the features of the delayed implementation of the proposed Phase 2 model, could provide the opportunity further imbed drug and alcohol screening across programme partners.

National context The government evaluation of Phase 1 of the programme found that:

 11% of all families included an adult assessed by a keyworker as dependent on alcohol;  5% had a clinical diagnosis of alcohol dependency; and  4% were receiving treatment for alcohol dependency.

The picture for drug use is similar:

 11% included an adult with a keyworker assessment of dependence on non- prescription drugs;  6% with a clinical diagnosis of dependence on non-prescription drugs  4% receiving treatment for drug dependency.

In addition, 12% of families included a young person with substance misuse issues that reach the threshold for structured treatment.

The report does not give information on the concurrence of these issues, or how many of the young people were undergoing treatment. The information provided by

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 126 OFFICIAL

local authorities comes from a variety of sources and there may be deficiencies in some of the quality of the data.

Drug and Alcohol Needs recorded by Council Services  In the 12 month period to 30th June 2016, Action for Children’s Family Intervention Project supported 294 children on the Together for Families Programme. They identified that of these children only two needed to reduce or stop using harmful substances and a further nine required protection from poor care associated with parental substance misuse;  The Early Help Hub does not have any recording mechanism for referrals to specialist drug and alcohol services. It is therefore not possible to know if referrals are being made;  Cross-referencing individuals that are already part of the programme with people who are currently in contact with drug and alcohol treatment services indicate that, of the 188 young people in YZUP, 22% (42 young people) have been identified as being part of the programme. Furthermore 29 adults on the Together for Families Programme have engaged in structured treatment within the past year82, and a further 111 have been in treatment since 2012.

Wider needs of individuals in Drug and Alcohol services 353 individuals with current open episodes of structured treatment have children living with them. It is likely that many of these individuals would be eligible for the programme due to the prevalence of other programme criteria within this cohort, but engagement in the programme is low at just under 10% (32 people).

 63% were unemployed, or economically inactive on presentation to treatment;  4% are recorded as having a disability and 13% cited low self-ratings of psychological health at their last TOP;  3% were recorded as having a housing problem;  Police data shows that 4% were charged with or suspected of commiting domestic abuse in 2016 and 3% committed a crime in 2015/16.

Young people in treatment for drug and alcohol issues also face other vulnerabilities:

 29% are involved with Childrens Social Care;83  24% are affected by domestic abuse;  24% have an identified Mental Health Problem;  20% are not in education, employment or training;  20% are affected by others substance misuse;  13% are involved in offending or anti-social behaviour.

82 In the 12 month period to October 2016 83 Looked after Child, Child in Need or subject to a Child Protection Plan.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 127 OFFICIAL

The families of 22% of young people engaged with YZUP are currently on the Programme and although this appears to be a significant percentage, given that across Cornwall approximately 1% of all households are on the programme, the high levels of multiple need suggest that this should be higher.

Engagement and Outcomes Overall 25% of all families that have been involved in the Together for Families Programme were provided with intervention through the Family Intervention Project (FIP), 10% worked with Together for Families Advocate (Phase 1) and 20% have been supported by a Together for Families Employment Advisor (TFEA).

A review of engagement levels of the families that are known to drug and alcohol services indicates that lower levels of FIP engagement for these families but are getting higher than average levels of support for advocates and TFEAs.

Of the 29 adults that have been involved in the programme:

 3 (10%) have also received an intervention from the Family Intervention Programme;  8 (28%) engaged with a Together for Families Advocate;  10 (34%) received support from a TFEA.

Of the 42 programme families that contain young people referred to specialist drug and alcohol services:

 11% received FIP engagement;  36% engaged with a Together for Families Advocate  40% received support from a TFEA.

8% of families in Phase 2 of the Programme have achieved a Payment by Results claim (where they have met all relevant criteria to be counted as “turned around”). In our identified cohort of 29 adults and 42 young people, where one or more family members are in drug and alcohol treatment, 3 families achieved Payment by Results claims but the numbers are too small to be draw further conclusions.

Identifying families with multiple needs The Complex Families Index was developed by Amethyst in 2011, originally to inform the drug treatment needs assessment process. This methodology has since been utilised within a range of annual needs assessment processes, including for the Together for Families Programme, to identify geographical areas of high multiple need, map against services delivered and highlight potential unmet need in local populations at a small area level.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 128 OFFICIAL

It started as a combined small area measure84 that identified geographical areas that are most likely to experience co-morbidity of domestic abuse with parental drug use and mental health issues.

The 2015/16 Together for Families Needs Assessment featured a version of the Complex Families Index based upon small area measures for 7 key themes reflecting Phase Two eligibility criteria.

This year this has been further refined to incorporate at least one indicator for each of the six areas on the programme and now includes:

 Youth Crime Offences  Pupils persistently absent from school  Child in Need Plans  Individuals claiming an Out of Work Benefit.  Domestic Abuse victims recorded by the Police  Individuals in Drug and Alcohol Treatment  Mood and Anxiety disorders  Households with children in Housing Need on the Homechoice housing register

Each indicator is expressed as an index85 in relation to Cornwall and then averaged to give a single combined index for each area. Each indicator is weighted equally.

Table 1 shows the 15 areas in Cornwall with the highest combined index score. The colours within the index identifies where an LSOA is ranked within each variable (i.e. if an area is red it is in a top 5% for that variable). The table also includes the number of families identified as eligible for Phase One of the programme.

Table 2 shows the additional areas where the largest clusters of families were identified for Phase One, but were not identified as areas of high multiple need using the matrix.

This includes several areas that were previously identified in the 2015/16 Needs assessment and correlates highly with the Index of Multiple Deprivation.

 The two areas within the top 15 scores that have not previously featured in either index are St Blazey Gate, Biscovey and Eden Project, and Camelford South. These areas have had a higher than average number of Children in Need cases and youth offenders.

84 The geography used is Lower Super Output Area, or LSOA, which typically contains 1,500 people 85 Where an index of 100 means the area has exactly the same prevalence as Cornwall overall; less than 100 indicates lower prevalence and more than 100 indicates higher prevalence.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 129 OFFICIAL

Table 1: areas with highest combined index score Drug and Eligible Youth Attendanc Children OOW Domestic Mental Housing 2011 LSOA Local Name Alcohol Families n Crime e Issues in Need Benefits Abuse Health Need treatment

St Austell Poltair 10

Bodmin Town Centre and 14 Berryfields Penzance Treneere 28

Camborne Pengegon 23

St Blazey West 22

Falmouth Old Hill 19

Penzance St Clare and Town 20

Newquay Town Centre 6

Camborne Dolcoath and 13 Tuckingmill St Blazey Gate, Biscovey and 7 Eden Project Liskeard Town Centre East, 9 Sungirt, Plymouth Road Camelford South 21

St Austell Penwinnick and 7 Town Centre Camborne North Parade and 10 Rosewarne Gardens Kinsman Estate and Monument 13 Way

Key Top 5% Top 10% Top 20%

Table 2: areas (excluding those above) with the highest numbers of families identified as eligible for Phase Two Drug and Eligible Youth Attendanc Children OOW Domestic Mental Housing 2011 LSOA Local Name Alcohol Families Crime e Issues in Need Benefits Abuse Health Need treatment

Hayle South and High Lanes 25 Redruth North, Close Hill, 21 Strawberry Fields and Treleigh St Columb Major South 21 St Austell Alexandra Road and 20 East Hill Bodmin Halgavor Road and 19 Beacon St Dennis South 18

Bude East 18

Illogan East Pool Park 17

Stenalees West and Bugle 16 Launceston College and 16 Stourscombe Penryn town, Saracen Way 15 and Glasney Falmouth Laburnum Close, 15 Acacia Road, Draceana Avenue Liskeard Charter Way and Lake 15 Lane Roche South and St Wenn 15 Truro Trelander East and 15 Penair

Key Top 5% Top 10% Top 20%

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 131 OFFICIAL

The distribution of eligible families for Phase Two was compared with the Complex Families Index to highlight any areas where we may find clusters of families that have not previously been engaged / targeted by the programme.

This highlighted that generally, there is a strong significant relationship between the number of eligible families for Phase Two and the Complex Families Index score for Phase Two meaning that in general the programme worked with the highest numbers of families in the areas estimated to have the greatest need, this can be seen by the large numbers of white areas where the number of identified families are within the predicted range (shown in white in map 2).

There are some exceptions, however:

 In some of the areas such as Newquay Town Centre, St Austell Poltair, St Blazey Gate, Biscovey and Eden Project, Truro Highertown and Malabar, Liskeard Lamellion and Old Road, and Launceston St Stephens., there appears to be relatively few eligible families considering the multiple areas of need identified within the matrix;  Areas where there are a high number of identified families and low complexity scores are Hayle South and High Lanes, St Column Major South, Launceston College and Stourscombe and Penzance Treneere.

Looking at town level shows a surprising level of need in the North and East of the Cornwall. The highest average levels of need are found in St Blazey, Camelford and Bodmin. This is in part as these towns do not have any LSOAs which have lower levels of need to reduce the average.

Despite this, the index indicates that at locality level, families in Penwith and Restormel, particularly in areas categorised as deprived, are most likely to present complex multiple needs and these areas are where we would expect to identify the greatest numbers of eligible families.

The priority Community Network Areas identified are:

1. Bodmin 1. Penzance, Marazion and St Just (West Penwith) 2. St Austell and Mevagissey 3. St Blazey, Fowey and Lostwithiel 4. Camborne and Redruth

Map 1 shows combined complex needs index scores. This shows higher levels of need in urban areas and slightly higher levels of need in the west of Cornwall.

Map 2 shows the areas with a significant difference between the actual number of Phase 2 families identified and the number predicted by the complex needs index score. Negative residuals (in green) have fewer identified families than the index would predict whereas positive residuals (red) have more than expected identified families.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 134 OFFICIAL

Transitions and young adults in treatment Supporting young adults who need to move from young person’s services into adult treatment services is an important process to manage successfully.

Adult treatment services are set-up to deal with the whole spectrum of age groups from 18-plus and therefore this phase of change can be difficult for a young adult to cope with as they reach their late teens. Barriers such as a change of support worker and venue can lead to disengagement with services.

To facilitate this and to ensure that people were in the most age appropriate service, a structured transition protocol and process was introduced in 2010.

In order to combat this, services in Cornwall have, in the past, retained clients in young people’s services after they reached the age of 18. At the end financial year 2015/16 YZUP had 5 clients with an open modality that were over the age of 18, 10% of the young people treatment population. Four of these young adults were 19 or 20 years of age and one was 24.

YZUP, the young person’s drug and alcohol service, will retain a client over the age of 19 if there are specific reasons such as mental health issues or if the client displays cognitive learning difficulties.

While transitions are no longer an issue for treatment service providers, there is evidence to suggest that they may be in other services. Our case study86 demonstrates what problems can be caused in situations when a transition between young person and adult services doesn’t work effectively.

As this picture has improved, services attention is now being drawn to a cohort of young adults presenting to treatment with established drug and/or alcohol problems, having previously not been known to young people’s services.

The 2011 Young Persons Needs Assessment identified that the majority of young adults in adult services had never previously been known to YZUP, despite having started using prior to 18 years of age. It was recommended that the young people’s service explores how they could attract young drug users, particularly opiate users, into treatment at an earlier age.

In 2010/11 there were 254 young adults in adult treatment services (drugs and/or alcohol), of which 85% (217 young people) had never presented previously to YZUP. The latest data appears to indicate an unchanged picture.

 In 2015/16, numbers are very similar, there were 225 young adults aged 18 to 24 years engaged in our adult service, of which 78% had never presented previously to YZUP.

86 See Appendix A Case Study 1 “J”

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 135 OFFICIAL

Referral routes for young adults into adult services, for the period April 2013 to March 2016 are shown below.

 Total referrals for this group have dropped by a fifth since 2013/14, down to 97 in 2015/16;  The majority of referrals for these young people not known to YZUP are self referrals (43%), followed by referrals through the Criminal Justice System (25%).

Whilst referrals through Criminal Justice routes have declined slightly in 2015/16, this still represents a large proportion of the presenting cohort that are likely to have been displaying escalating criminal tendencies and anti-social behaviours linked with their substance misuse in the years prior to their referral.

Of the 59 clients making up the CJS referrals, 7 (12%) have been previously known to the Youth Offending Service (YOS). As the pathway between the YOS and YZUP is well established and appears to be working well, we might assume that their substance use was not a factor in their offending and/or that it did not reach the threshold for specialist treatment.

The following chart depicts the age of first use (by primary substance) for the 178 young adults who have been referred into treatment services during 2015/16 and the first half of 2016/17.

Of this group 44% (78 young people) are non-opiate users, 36% (64 young people) are alcohol users. Opiate users make up the remaining 20% of the group with 36 users.

As you would expect, the chart identifies that the teenage years up to and including 18 are critical for our service users, as this is when they are most likely to begin experimenting with substances. Over 70% of these individuals began using their substance of choice under the age of 18.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 136 OFFICIAL

This can be broken down by substance as follows:

 Alcohol – 97%  Non-opiates – 72%  Opiates – 36%

The alcohol and non-opiate groups are the most prominent prior to the age of 18, based on age of first use of primary substance. Opiate use becomes more prevalent from the age of 18 onwards; opiate users are most likely to first use at 18. Non-opiate users are most likely to begin using between the ages of 14 and 16. All substance groups show a dip in the age of fist use at 17; this is most pronounced in the opiate and alcohol categories and possibly indicates an issue around disclosure.

Complexity factors for young adults referred into the adult service over the 12 month period to October 2016 were reviewed. We also looked at four factors known to impact upon successful engagement and completion of treatment; mental health, housing problems, unemployment/worklessness and injecting status.

 This showed that for housing, unemployment and injecting status, young people who had previously been known to YZUP were more likely to be experiencing problems with these issues;  Those clients with a mental health issue were equally proportionally represented within both cohorts;  Nine out of ten clients appearing in adult services that were previously known to YZUP demonstrate no change or an escalation in their substance misuse.

A review of a dip sample of 17 cases highlighted a number of key themes, including coming to terms with a past life event and mental health problems.

4 homeless or care leavers 4 clients have sufferred traumatic 4 clients present event in formative with dual years diagnosis 9 clients demonstrate a 3 clients have history of erratic undergone a tier engagement 4 intervention

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 137 OFFICIAL

Social Impact Key findings Housing and homelessness  Housing is a critical component to successful treatment outcomes. Housing issues have a marked negative impact on successful completion and exacerbate the risk of relapse, particularly after prison release and rehab;  Housing stability, associated with improvements in quality of life, is a positive outcome in itself for some;  DCLG figures for 2016 indicates that the rough sleeper count for Cornwall has risen by 50% since the last count 12 months ago, identifying 99 individuals. As a Local Authority, Cornwall has the 3rd highest number of rough sleepers and is ranked in the worst decile for the rate per 1,000 households;  Problems with mental health, alcohol and drugs are the biggest issues being faced by the homeless community nationally and this is also reflected in our local cohort;  One in five people presented to treatment with a housing need, of which around half were homeless. Homelessness has seen a small rise year on year and whilst these are not large numbers, clients presenting in housing need are becoming more complex and requiring a lot of additional support. The rise in vulnerable females is a particular concern;  Housing outcomes are good locally. The vast majority of people exiting the treatment system successfully have no reported housing need, which means that any presenting housing problems are generally resolved;  Completion rates for people presenting to treatment in supported housing, however, are very low and this requires further investigation;  Although we have complex needs housing provision, some of the very complex clients are banned from all provision due to previous behaviour. Threats to and withdrawal of funding will further reduce housing options for the most vulnerable clients;  Over the last year, we have seen a marked rise in reports of homeless drug and alcohol users, anti-social behaviour caused by street drinkers and problems with drug litter. This has highlighted safeguarding concerns for some particularly vulnerable adults with complex needs.

Gypsy, travelling and migrant worker communities  Cornwall’s Gypsy and Traveller Liaison Officer believes there to be around 1,100 men, women and children with a culture or way of life as a Roma Gypsy, Irish Traveller or New Traveller in Cornwall. There is very limited literature on the health needs of this population;  Based on those accessing treatment, drug and alcohol issues are three times more prevalent amongst Gypsies and Travellers. They are more likely to be heroin users; at around a third, the proportion of problem drinkers in this group is similar to the wider treatment population. Dual diagnosis is more common amongst this cohort.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 138 OFFICIAL

Worklessness  Employment is one of the strongest positive factors in successful completion and has a key role to play in sustaining recovery; it should be an integral element in drug and alcohol treatment;  Huge changes in the welfare system (including Universal Credit, the Benefit Cap, Social Housing rents provisions and the under 35s Single Room Rate) have been and will continue to provide significant challenges for people with drug and alcohol problems. Public Health England recognises that during engagement with employment support client focus has been on maintaining benefits and avoiding sanctions as opposed to meaningful activity;  Cornwall has a strong track record of effective partnership working between drug and alcohol services and employment service providers. A range of local and national employment initiatives are being delivered, including interventions to support those furthest from the workplace;  People leaving treatment are less likely than the national average to achieve 10 days of paid employment in the month before leaving treatment successfully. The proportion of people achieving this has also declined for both opiate and non-opiate users over the last two years but has remained stable for problem drinkers. This could be due to the gap in ESF funded projects that supports those furthest from employment.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 139 OFFICIAL

Homelessness and housing need The government has recognised housing as a critical component to successful treatment outcomes for many years. The National Drugs Strategy87 stated that housing had a key role to play in maintaining recovery. Also the review of the National Strategy in 201388 moved the recovery focus and the requirements of partners very much towards housing and employment initiatives required to deliver sustained recovery.

The Public Health Evidence Review on treatment outcomes highlights that housing problems have a marked negative impact on treatment outcomes and exacerbate the risk that someone will relapse after treatment, particularly after prison release and residential rehabilitation. This review also highlighted a variation in housing difficulty, with less access in areas of high housing cost and high demand.89

The recently published DWP Independent Review on the impact of drug and alcohol addiction on employment outcomes refers to housing 39 times, highlighting its importance to achieving recovery from addiction as well as facilitating progression in other areas of life such as that of employment.

The review states that ‘It is difficult for someone to make progress in treatment of dependence, and sustain their recovery, if they do not have stable, suitable housing’ and that ‘having a housing problem hampers engagement in addiction treatment and reduces the likelihood of successfully completing it, or of subsequently going on to find employment.’

The report went on to say that ‘housing issues were particularly significant in predicting that opiate clients would not be in employment’.90

Despite the importance of appropriate housing options, however, there are many changes in the wider landscape that will impact on the delivery of housing and homelessness services locally, such as:

The Welfare Reform and Work Act 2016 is impacting on the housing sector in a variety of ways, for example through Universal Credit, the Benefit Cap; the under 35s Single Room Rate and the Local Housing Allowance Exemption which currently benefits supported housing providers.

87 Drug Strategy – Reducing demand, restricting supply, building recovery: supporting people to live a drug free life, Home Office (2010) 88 Drug Strategy Annual Review: delivering within a new landscape, Home Office (2013) 89 ‘Public Health Evidence Review; An evidence Review of the outcomes that can be expected of drug misuse treatment in England’, Public Health England (2017) 90 ‘An Independent Review into the impact on employment outcomes of drug or alcohol addiction, and obesity’, DWP (2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 140 OFFICIAL

The Homeless Reduction Bill 2016/17 is currently going through parliament and is expected to be the biggest change in homelessness legislation since 1977.

It is anticipated that by October 2017 Local Authorities will have additional duties to prevent and relieve homelessness for up to 112 days. The detail of this Bill or additional resources to Local Authorities to support the new requirements have not yet been confirmed.

What has been achieved? Over the past 9 years in Cornwall, the DAAT has worked closely with supported housing commissioners and providers in analysing need and developing a staged model of supported accommodation that best meets the identified needs of those with drug and/or alcohol issues at various stages of their treatment/recovery journey. These services, although having sustained massive budget cuts in recent years, are crucial in supporting clients with complex needs through their treatment journey towards recovery.

The roll out of the naloxone programme (which started in Cosgarne Hall in December 2009) to all complex needs service providers in April 2016 has resulted in 38 lives being saved since its inception, 13 of which were in the year to date.

This programme forms a key part of the DAAT’s strategy in Cornwall to reduce the number of drug related deaths, which has risen exponentially across the country in recent years. Potentially the widespread naloxone programme has prevented numbers of deaths from escalating as much in Cornwall as elsewhere in the country.

The DAAT has also supported the development of a pathway for those in Tier 4 residential rehabilitation services to ensure clients find suitable accommodation on completion of their programme. Cornwall Housing Limited, St Petroc’s and the West Cornwall Stonham complex needs service, Addaction Chy and Bosence Farm have also all contributed to the development and delivery of this pathway.

Since September 2016, 36 clients have utilised this pathway process. The largest number moved into supported housing (11 people), 8 people moved into private rented accommodation and 8 moved in with family/friends. 1 person left early and ended up rough sleeping so was linked in with St Petroc’s Outreach and 2 left Addaction Chy and sofa surfed with friends.

The DAAT and Addaction regularly engage with the Homeless Hospital Discharge protocol advisor. Between 2014 and 2016, 450 homeless patients were discharged from hospital with a support plan in place and on third were safely discharged into accommodation, which generated £280,500 savings for NHS.

A local Rough Sleeper Strategy for Cornwall is being developed by CHL who have secured £850,000 from reserves to support the development of the work with rough sleepers in Cornwall. Additionally, Cornwall has successfully secured £292,000 from the DCLG Rough Sleeper programme through a joint bid between Cornwall Housing Limited, Coastline Housing and St Petroc’s.

This bid will support the development and delivery of a Homeless Prevention Outreach service and will formulate an offer to prevent rough sleepers returning to the streets. This project is also intended to engender greater churn in supported housing by facilitating Housing First and a Private Sector Access Scheme. This

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 141 OFFICIAL

work will expand on the No Second Night Out and other Rough Sleeper initiatives previously implemented.

Cornwall Housing Limited has recently tried different approaches to tackling housing difficulties and provided accommodation for two homeless drug users, with agreed support packages provided by the treatment provider and the outreach service.

This accommodation was provided away from damaging networks in an attempt to remove them from ‘temptation’. So far, however, this has had very limited success. In relation to location of accommodation, the Public Health Review highlighted two studies with contradictory findings: one stated that living further from drug treatment and other services achieved poorer outcomes whilst the other study said those living further away achieved better outcomes.

Regardless, access to good transport links is consistently rated by drug users to be associated with positive treatment outcomes. These case studies also highlight the need for the type of intensive support that would come with the Housing First approach. The review also found that longer term housing support is required to enable people to maintain appropriate housing.

The Public Health Evidence Review identified the following essential components of a homelessness response:

 Suitable housing should be available at important points in an individual’s pathway, particularly where it is known that failure to provide this is likely to result in homelessness, withdrawal from treatment, greater drug use or relapse;  The pathway should be defined by the individual’s needs and choice and should be personalised rather than prescribed by policy, programmes or processes;  Assistance is likely to be needed to access and sustain appropriate housing along the recovery journey, including provision for those who continue to use drugs. Integrated approaches to meeting housing and other needs are more likely to enable navigation through an often complex system of housing;  Treatment, health care, social care and other support will help to achieve better outcomes;  Housing stability, associated with improvements in quality of life, is a positive outcome in itself for some – even if their drug use continues it is less likely to increase and people are more likely to access services. Housing stability is a particularly important outcome for people who have a long history of homelessness including rough sleeping, and for people with multiple and complex needs;  Achieving housing outcomes necessitates consideration of income, including addressing debt, and enabling access to, and support to sustain, employment. Bearing this in mind, housing must be affordable.

Housing needs and data The housing status of clients accessing treatment in Cornwall is recorded on the National Drugs Treatment Monitoring System (NDTMS), at the point of presentation to treatment and at regular intervals during a client’s treatment journey and on exit from the treatment system through the Treatment Outcomes Profile (TOP).

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 142 OFFICIAL

Housing need and homelessness data are also captured by Cornwall Housing Limited through client presentations at Housing Options services and rough sleeper counts. St Petroc’s outreach service also gathers information about rough sleepers from across Cornwall.

Additionally, outcome evidence gathered by the Education, Health and Social Care commissioning team highlights details of access to supported accommodation and the progress made by clients during their time in such support services.

Homelessness In autumn 2015, the national rough sleeping counts91 and estimates in England identified 3,569 people and this was an increase of 30% compared with the previous year, continuing an established rising trend.

Levels of rough sleeping in Cornwall have been consistently measured over the past 6 years. The autumn 2015 count in Cornwall identified 65 individuals, which was a rise of almost two thirds compared with 2014. Cornwall was ranked in the worst quartile for rate of rough sleepers per 1,000 households.

The DCLG figures for Cornwall for 2016 indicates that the rough sleeper count has risen again by over 50% since the last count 12 months ago, now identifying 99 individuals. Cornwall has risen from the 5th to the 3rd Local Authority with the highest numbers of rough sleepers.

The chart (right) shows the numbers of rough sleepers identified in the Cornwall counts over the past 7 years.

Most were male (although this time the percentage of females rose from 10% to 17%) and in the 35-54 age range. Truro and Penzance were the areas where the most rough sleepers were counted, accounting for around half the total for Cornwall.

91 Rough Sleeping Statistics Autumn 2016, England (DCLG, 2017). Rough sleeping counts and estimates are single night snapshots of the number of people sleeping rough in local authority areas. The rough sleeping figures are now established as a consistent time series, since 2010, and provide a reliable way of assessing changes over the years.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 143 OFFICIAL

One rough sleeper was under 17 years and 4 were over 65 years. The majority of rough sleepers had been sleeping rough between 1-6 months or over a year. The table below highlights the percentage change in rough sleeping over the 6 years that it has been consistently counted.

% change in RS estimates in Cornwall on previous year 2011 2012 2013 2014 2015 2016 23% -38% 54% 48% 63% 52%

In addition to this single night count on the 13th November there is also a rough sleeping survey carried out during the month of October.

In October 2016, 126 single people stated they were homeless. Of these 74 claimed to have slept rough, 20 slept in a tent, 6 slept in car and 13 stayed with family or friends.

One of the questions in the survey considered an individual’s last accommodation and the most common ones cited were private rented and supported accommodation, 25% and 20% respectively. Additional analysis of their situation prior to rough sleeping could be an indicator of services and support required.

In the rough sleeper survey, 26% stated that they had an issue with drugs and 12% stated that they got support with this issue. Similarly 29% declared an issue with alcohol with 17% getting support. This lack of support seemed to be a particular issue between 1-6 months of rough sleeping. After 6 months of rough sleeping there appeared to be a decline in numbers stating that drugs or alcohol were causing problems. Perhaps by this stage they started to normalise their chaotic drug and alcohol use.

A snapshot of the outreach caseload for St Petroc's Society92 also provides some insight into one group of 130 single homeless clients. The information was gathered at around the same time of the rough sleeper count, in November 2016, and there will be a significant cross-over between the two groups.

Clients are predominantly 30% male and in the 18-44 Rough sleepers age range. Compared with 25% St Petroc's the rough sleeper profile, 20% there is a greater proportion in the under 35 age group in 15% contact with St Petroc’s. 10%

5%

0% 17 and 18-24 25-34 35-44 45-54 55-64 65+ under

92 St Petroc's Society provides accommodation, support, advice, training and resettlement services to single homeless people in Cornwall

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 144 OFFICIAL

There have been anecdotal comments from St Petroc’s that some clients are refusing access to the Cold Weather Provision as they are not meeting their needs by enabling them to drink or use drugs.

Historically the Society has rarely worked with clients under the age of 18 but their latest report says that there have been more approaches from under 18s in recent months. There was one being actively worked with in November 2016. The Society expects to see an increase in clients aged 18 to 34 struggling to find accommodation due to the changes in housing benefit.

Clients aged 65 and over accounted for 5% of the active caseload and, although still small numbers, this is an increase on previous years. Traditionally this age range has been accommodated through the Local Authority as they would have been “priority need” due to age. There has also been an abundance of ‘hard to let’ older persons accommodation available through the housing register.

Problems with mental health, alcohol and drugs are the biggest issues being faced by the homeless community nationally and this is reflected in our local cohort.

 78% (101 clients) reported that they felt that they suffered from mental health issues. Two thirds, however, had no formal diagnosis. 52 clients reported having physical health issues;  52% (68 clients) reported that they felt that they had an alcohol issue, of which 21 clients reported using alcohol every day;  28% (36 clients) stated that they had a drug problem. Cannabis is the most commonly used illegal drug (69% of those who disclosed a drug problem) with heroin and crack/cocaine also being frequently used (42% and 39% respectively). Note that clients may have disclosed use of more than one drug.

Complex needs commissioned services There are 285 units of complex needs services across Cornwall. This includes all staged provision, which accommodates clients when they are still using substances, through their recovery journey and into other provision that supports them when they are clean and dry. In the first two quarters of 2015/16 these services reported 93% occupancy. Waiting lists run around a total of 150 people.

St Austell and the Camborne, Pool, Redruth area have the largest numbers of complex needs services, St Austell having the highest number of stage 1 units. Interestingly, St Austell had one of the lowest numbers of rough sleepers reported in a large town at the last count, 6 compared with 25 in Penzance and 26 in Truro.

In the first two quarters of 2016/17, 162 clients were refused access to this accommodation and this was for a multitude of reasons, but the main ones were that were considered to be too high risk or their level of emotional and mental health needs were too high.

Although 63% clients were reported to leave in a planned way, 34% left in an unplanned way and for 5% this was not stated. 48% of the early exits were evictions; 13% were said to be due to substance misuse issues.

It is not clear, however, to what degree substance misuse contributed to the evictions or other stated reasons such as disengagement from support, breach of

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 145 OFFICIAL

tenancy, anti-social behaviour or violent or threatening behaviour. Further analysis of this cohort could enhance our understanding of their needs.

The breakdown of exit reasons can be seen in the next chart.

Accommodation needs in the treatment population The housing status of clients accessing treatment in Cornwall is established during the comprehensive assessment process for new clients and is reported on the National Drugs Treatment Monitoring System (NDTMS).

2016/17 Accommodation need 2015/16 2014/15 2013/14 YTD NFA/acute housing need 8% 7% 6% 6% Housing problem 9% 9% 11% 16% No housing problem 81% 82% 81% 76% Not completed 1% 2% 2% 2% Presentations in year 993 1,397 1,245 1,314

Any housing problem 17% 16% 17% 22% Employment status recorded 99% 98% 98% 98%

 This year, 17% of people presented to treatment with a housing need; the level of overall housing need has reduced compared with 2013/14 but there has been little change over the last couple of years;  Just under one in ten people present to treatment in acute housing need (NFA/homeless) and this has seen a small rise year on year; conversely fewer people are presenting with a (non-acute) housing need.

Addaction reports that although there are not large increases in numbers, those clients presenting in housing need are becoming increasingly complex, requiring a lot of housing support as part of the treatment intervention. They also reported a particular increase in vulnerable females sleeping rough which

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 146 OFFICIAL

reflects the findings of the recent rough sleeper count. Many of these clients are banned from all services across the county with few or no options available to them.

The review found that prevalence of housing Opiates problems varies by drug 11% 18% 70% type and region but average Non- 12% of opiate users and 5% 8% 11% 80% non-opiate users present as opiates homeless. Alcohol 5% 88% only 5% Our local figures appear to be in line with the national 0% 20% 40% 60% 80% 100% average for opiate users but slightly higher than average NFA Housing problem No housing problem for non-opiate users.

 In people terms, the number of people presenting NFA has increased from 83 in 2013/14 to 96 in 2015/16 and projected to reach around 100 in 2016/17;  Homelessness is more common amongst opiate users (11%) but this cohort is the only one to see a slight reduction in the level of NFA presentations compared with 2013/14 (-2%).

Additionally, data is captured through regular Treatment Outcomes Profile93 assessments completed during a client’s treatment journey and on exit from the treatment system.

The TOP records whether the client has a housing need and/or is at risk of eviction at the time of the exit assessment.

The latest quarterly DOMES report94 indicates that the vast majority of people exiting the treatment system in Cornwall have no reported housing need (around 95%) and this is in line with national average.

Further analysis of our local data shows that the proportion exiting treatment successfully, with no reported housing need, has declined for both opiate and non-opiate users since 2014/15 but it has remained stable for problem drinkers.

This trend will need to be closely monitored as we are aware that resolution of housing issues not only predicts successful treatment outcomes but also successful outcomes in other areas of life such as employment.

93 The Treatment Outcomes Profile (TOP) measures change and progress in key areas of the lives of people being treated in your drug and alcohol services. 94 Diagnostic Outcomes Monitoring Executive Summary or DOMES; a detailed performance report covering the whole treatment system provided by Public Health England Quarterly

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 147 OFFICIAL

Comparing reported housing need on exit with recorded need on presentation shows that for the majority, pre-existing housing problems are resolved by the time they leave the treatment system.

Housing need outcome on exit

Accommodation need on No At risk of Housing presentation to treatment housing Total eviction need needs NFA 2% 22% 76% 41 Housing problem 2% 19% 79% 53 No housing problem 0% 2% 97% 632 Exits in year 1% 4% 95% 726

The table above shows all successful completions from April 2015 to date (18 months) where an exit TOP assessment provided details of housing need on exit, related to their presenting housing need.

 Overall 4% of people report having a housing need on successful completion and exit from treatment, which equates to around 30 people. A more detailed look at this small sample could give us greater insight into the reasons for their lack of housing progress enabling us to make recommendations to housing commissioners and providers;  Three out of every four people presenting to treatment as NFA had no reported housing need on successful completion and exit from treatment. Outcomes are similar for those presenting to treatment with housing need;

More detailed information about housing status was captured in Halo for around 50% of all people leaving treatment in the last 18 months.

 Looking across all outcomes (so not just successful completions) indicates that successful completion rates for people presenting to treatment in supported accommodation are very low at only 15% (compared with 32% for the whole population of drug users). This also represents a decline from last year.

Limitations and Gaps Although there seems to be a reduction in housing need of those presenting to treatment, there is an increasing cohort of complex individuals, including females, where finding accommodation is becoming an ever increasing challenge.

Although there are 285 complex needs units, only 44 of these are stage 1 services that will accommodate those who have current issues with drugs and alcohol. Many clients are either being refused access due to high levels of presenting need or are being asked to leave for a variety of reasons. Some of the very complex clients are banned from all provision due to previous behaviour. We are seeing escalating rough sleeping numbers year on year.

Although 17% of the rough sleepers counted were female there is no female only provision for people requiring stage 1 accommodation. Treatment providers are reporting increased complex and vulnerable females sleeping rough and who are also banned from all provision. Bosvean in Launceston is the only female only

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 148 OFFICIAL

provision and it is stage 3 so accommodates clients that are more advanced in their recovery journey.

The Welfare Reform and Work Act 2016 is having a massive impact on the housing sector. Universal Credit, the Benefit Cap and the under 35s Single Room Rate is already causing both Private Landlords and Registered Social Landlords to reconsider accepting clients on benefits, especially those under the age of 35 years, further limiting the options for this cohort. Supported Housing services are currently exempt from the Local Housing Allowance cap but are anxious about their long term security as the current intensive housing management funding will in future be subject to local commissioning processes.

Continual threats to funding is adding to the uncertainty for these complex needs providers and causing them to re-evaluate their position in delivering a service to this complex client group.

In using hard to let properties to accommodate drug users could have limited effectiveness in Cornwall if clients do not continue to have easy access to treatment and other support and very accessible transport links.

Street life: impacts on communities Over the last year, we have seen a marked rise in reports of homeless drug and alcohol users, anti-social behaviour caused by street drinkers and problems with drug litter. This has highlighted safeguarding concerns for some particularly vulnerable adults with complex needs. Although this behaviour is not always connected to homelessness there are cohorts of homeless people within these populations.95

This is against a backdrop of a huge rise in homelessness generally. Both local and national data indicate that problems with mental health conditions, alcohol and drugs are the biggest issues being faced by the homeless community.

Trends in anti-social behaviour are discussed in more detail in the next section on Alcohol, Crime and Disorder.

The overall trend in anti-social behaviour reported to the police has been fairly flat for several years but saw a small rise last year and has continued to rise this year. The greatest percentage rise is in street drinking with rowdy or nuisance behaviour.

Street drinking incidents make up 6% of the total number of anti-social behaviour incidents recorded, however due to its nature they are a visible type of incident, which causes concern amongst local residents and affects their feelings of safety in their local area. This has been reflected in resident surveys that have been conducted over the past 3 years.

95 Anti-Social Behaviour in Truro, Alex Arthur, Amethyst October 2016

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 149 OFFICIAL

Although anti-social behaviour in combination with a range of other issues are being experienced to some extent across Cormwall, the impact on some communities in has been particularly significant, with strong concerns expressed by residents, elected members and local businesses. Some examples are detailed below.

Truro  Increased prevalence of rough sleeping, including car parks and outside business premises;  Deaths of vulnerable homeless people;  These have been matched by a combined outreach intervention involving Police, Addaction and the Council’s Anti-social Behaviour Team, that is being developed with the assistance of Localism and homelessness services and will need to continue;  A multi-agency tasking group is being established to address the needs of individuals affected by multiple problems.

Penzance  In summer/autumn 2016, a homeless community was residing behind the Fire Station in unsafe and unsanitary conditions. The crew at Penzance fire station delivered fire safety and overdose prevention advice and then joined up with Breadline to issue homeless welfare packs;  The 15-20 rough sleepers that were congregating there have since been dispersed, and views are mixed as to whether or not this was a success. One criticism was that the response focused on moving people on rather than trying to engage individuals in services;  A subsequent call out to an overdose in Penzance bus station because the ambulance service was too far away has given rise to consideration of the Fire and Rescue Service staff carrying naloxone in future.

St Austell  There have been a number of reports of injecting in public toilets, needle finds and recently a needle stick injury to a minor after the discovery of a discarded needle in a park;  The devolution of the public toilets introduced a payment mechanism to some toilets which resulted in the safe disposal bins for needles being shut behind locked doors and requiring payment to access;  A group of homeless drug and alcohol users from St Austell have been moved to Camborne, thereby increasing difficulty in follow-up intervention work and an example of shifting a problem rather then helping to solve.

The combination of these responses has highlighted the need for a co-ordinated response between enforcement and assistance in local areas, to prevent future occurences and meet the statutory requirement to protect vulnerable people.

The needle find policy, which triggers waste management, cleansing and assertive outreach has been updated to ensure that it reflects the changes happening through devolution of waste management, cleansing and toilets to local areas, as the transfer occurrred without the changes being reflected within the communtiy safety response.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 150 OFFICIAL

As this is a constantly changing picture, the pathway and response must be kept under review to ensure that they are delivering the required outcomes and reflecting community safety and public health priorities.

Gypsy, travelling and migrant worker communities Cornwall’s Gypsy and Traveller Liaison Officer believes there to be around 1,100 men, women and children with a culture or way of life as a Roma Gypsy, Irish Traveller or New Traveller in Cornwall spread across the 3 authorised sites; 100 private sites; 10 unauthorised sites and some bricks and mortar provision.

There is very limited literature on the health needs of this population.,In Cornwall Southern Horizons UK96 carried out a needs assessment but this focused entirely on their accommodation needs as opposed to support needs.

A Race Equality Foundation briefing paper on the health of Gypsies and Travellers in the UK highlighted that alcohol consumption was often used as a coping strategy and drug use was widely reported among young Travellers although this was feared by the elder Traveller population.

She also reiterated that there has been little research into the extent of substance misuse amongst Gypsy and Traveller populations in the UK but that anecdotally evidence suggests that it is on the increase as in other communities, especially if families have been re-housed on run-down estates or where there is a high incidence of unemployment or depression.97

The South West Public Health observatory, in their report in 2011 on the Health and wellbeing of Travellers and Gypsies in the South West observed that there were still concerns over the provision of services for drugs and alcohol and other health issues to this population. They also reported that literature in this area is still very limited, making it difficult to draw conclusions although the health of this population is still said to be worse than the national average.98

96 Southern Horizons UK Limited (2015) Supporting an assessment of the accommodation needs of Gypsies and Travellers in Cornwall 97 ‘The Health of Gypsies and Traveller in the UK; Health briefing 12’, Race Equality Foundation, Matthews, Zoe (November 2008) 98 ‘Health and Wellbeing of Gypsies and Travellers in the South West’, South West Public Health Observatory (October 2011)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 151 OFFICIAL

Profile of Gypsies and Travellers in the treatment system This analysis considered all ‘open’ drug and alcohol clients from 1st April 2014 to 31st August 2016. During this time there were 7,088 people in the treatment system; 43 of these were Gypsies and Travellers.

 Based on those accessing treatment, drug and alcohol issues are three times more prevalent amongst Gypsies and Travellers.

Gypsy & Traveller Gypsy & Traveller Whole Population (persons) (%) Population in Cornwall 549,400 1,100 0.2% Number in treatment 7088 43 0.6% % 1.3% 3.9%

Gypsies and Travellers are accessing treatment from a range of diverse locations and not just one or two sites. The green dots on the map below show the spread of referrals.

35% All The cohort in treatment does not 30% include anyone under the age of Gypsies & Travellers 19 years but generally service 25% users are more skewed towards 20% the ‘younger’ end, 19-44 years, 15% than the treatment population as 10% a whole. 5%

0% 18 & 19-24 25-34 35-44 45-54 55-64 65+ under

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 152 OFFICIAL

The gender split for Gypsies and Travellers accessing treatment is very similar to the main treatment cohort with a third female and two thirds male.

A slightly lower percentage of the Gypsy and Traveller cohort in treatment are parents when compared with the main cohort (19% against 22%), with an average of 2 children (similar to the treatment population average).

In the Gypsy and Traveller cohort, one in four is recorded as having a dual diagnosis, which is what we would expect based on national research.99 The prevalence of dual diagnosis in the whole treatment population is just over one in ten, which is much lower than expected.

Putting the national statistics aside, this indicates that dual diagnosis is more common amongst the Gypsy and Traveller cohort.

Dual Dual diagnosis Diagnosis (persons) (%) Treatment Population 826 11.7% Gypsies & Travellers in treatment 10 23.3%

Prevalence of recorded disability is similar to the main treatment population.

Substance profile and time in treatment Gypsies and Travellers in the treatment population are more likely to be heroin users and engaged in treatment for a moderate period of time (6 months to 4 years).

Gypsies & travellers Drug Group All in treatment Alcohol 37% 33% Non opiates 12% 7% Non opiates and alcohol 16% 17% Opiates 35% 43%

Time in All Gypsies & Travellers treatment Persons % Persons % 0-6 months 4,128 58% 14 33% 7-12 months 991 14% 10 23% 1-2 years 742 10% 8 19% 2-4 years 612 9% 7 16% 2+ years 615 9% 4 9% Total 7,088 43

99 ‘Mental Health facts and statistics’ Mind (2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 153 OFFICIAL

Specialist support Cornwall Council’s adult commissioning team currently commissions a Gypsy and Traveller support worker through the complex needs prevention services. Around 100 clients are being supported each quarter across authorised and unauthorised sites.

 During the first six months of 2016/17, the Gypsy and Traveller support worker reported that 14 people she was working with had issues with drugs or alcohol, with the majority (10/14) having accessed appropriate treatment services and reduced their intake of drugs and/or alcohol;  43 people are managing their mental health and symptoms have reduced or they have accessed services to support with these mental health needs;  112 people have been helped to manage their physical health and access to primary healthcare;  14 people have reduced their access to emergency services and 8 people have reduced their hospital admissions;  21 people have reduced their offending and anti-social behaviour;  29 people are complying with statutory orders.

This is clearly a very valuable service, supporting Gypsies and Travellers to access various mainstream services that they may not otherwise access. It is noted that any further cuts to the prevention budget will place this support service at risk.

Both the Gypsy and Traveller workers and the strategic Gypsy and Traveller Group have identified a gap left by the withdrawal of police support – when this was provided, it was considered to be a very valued resource to the residents and support services accessing the sites.

Worklessness The government has recognised employment as a key component to successful treatment outcomes for many years. The National Drugs Strategy100 stated that employment had a key role to play in maintaining recovery. Also the review of the National Strategy in 2013101 moved the recovery focus and the requirements of partners very much towards housing and employment initiatives required to deliver sustained recovery.

The recently published Department for Work and Pensions Independent Review102 on the impact of drug and alcohol addiction on employment outcomes highlights

100 Drug Strategy; Reducing demand, restricting supply, building recovery: Supporting people to live a drug free life (Home Office, 2010) 101 Drug Strategy Annual Review: delivering within a new landscape (Home Office, 2013) 102 An Independent Review into the impact on employment outcomes of drug or alcohol addiction, and obesity (2016), DWP

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 154 OFFICIAL

that employment needs to be a more integral element of addiction treatment. There are several recommendations about how to make this possible which includes work with employers and significant changes to the benefit system ensuring the offer of support that is much more robust.

The Welfare Reform and Work Act 2016 received Royal assent on 16 March 2016 building on the measures introduced in the Welfare Reform Act 2012. This includes many elements such as Universal Credit, the Benefit Cap, Social Housing rents provisions and the under 35s Single Room Rate as well as Troubled Families and Life Chances provisions. It also extends to the State Pension with changes set out in the Pensions Act 2014 that are now being introduced.

The government’s aim with the reforms is to encourage claimants to take more responsibility and make the benefits and tax credits systems fairer and simpler by:

 Creating the right incentives to get more people into work  Protecting the most vulnerable in our society  Delivering a welfare system that is affordable and fair to the tax payers as well as benefit claimants

The government is planning to deliver a new Health and Work programme that clients with drug and alcohol issues will need to be enabled to access. This will mean that the ambitions, aspirations and needs of those with drug and alcohol issues will be supported by more active, integrated and individualised support that wraps around them. This is intended to improve their health and wellbeing, benefit our economy and enable more people to reach their potential.

The Work Routes programme is a newly commissioned service delivered by Reed in partnership. It may be appropriate for some treatment clients to participate in this programme as part of their journey back to work as it includes work experience and in work support.

For those clients who are further from the labour market, the Big Lottery ESF Programme is starting in 2017. Pluss103 have been awarded the contract in Truro and Redruth. Change Coaches and Community Engagement workers will be recruited to implement this contract.

As a Core Partner for Pluss, Addaction will be delivering the new Big Lottery/ESF funded Employability programme, Positive People from March 2017 to December 2019. This contract is for the Coast to Coast region of Cornwall which includes Truro, Camborne/Pool/Redruth and Falmouth. The Addaction employability service will be delivered to over 250 participants by two Change Coaches and a Community Engagement Trainee.

103 Pluss is an award-winning Social Enterprise that supports thousands of people with disabilities and other disadvantages move towards and into employment each year.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 155 OFFICIAL

The programme is aimed at unemployed and economically inactive individuals who have significant barriers to work such as disabilities, mental health issues, drug and alcohol and offending backgrounds. By securing a key role in the partnership Addaction has ensured that a dedicated, specialist end-to-end route is available for people with substance misuse issues.

Change Coaches will work with participants to agree and regularly review an action plan which will target progression in terms of training, job search and employment. There will be access to a substantial pot of money to engage other partners to deliver specialist interventions and to cover participants travel expenses. The Big Lottery is currently making their final decisions about which Lead Partners have been successful in the remaining three geographic areas of Cornwall and the announcement is anticipated in early February 2017.

Additionally, employment support for those with drug and alcohol issues will be further enhanced by the new team of Disability Employment Advisors (DEAs) across Cornwall. Their key role is to upskill work coaches and work with partner organisations to meet client needs. Under this banner they will be aiming to build relationships with organisations such as Addaction.

They will also look for any gaps in provision/support that may be filled through joint working with Job Centre Plus (JCP) provision. Their particular target group will be clients on Employment Support Allowance (ESA) but they could also include those recovering from addiction but requiring further support – ie.on Job Seekers Allowance, Universal Credit or Income Support.

All claimants aged between 18-65 will be engaged with an employment provider at some point and next year’s new delivery processes will ‘expect’ all to have claimant commitments , with many taking forward ‘activities’

Achievements so far In Cornwall since 2009, a lot of partnership work has been undertaken by DAAT, JCP, treatment and Work Programme providers. This included the development of pathways between JCP and other employment providers and treatment services, using the TPR1 and TPR2 processes. Single points of contact were established across providers and some excellent relationships were formed between treatment, JCP and Work Programme provider staff.

In addition drug and alcohol training programmes were rolled out across JCP and other employment providers, including Basic Drug Awareness, Alcohol Identification and Brief Advice; Young People’s Substance Use Screening Tool; Mental Health First Aid and Motivational Interviewing.

Some of this work greatly enhanced the relationships between treatment and employment teams and subsequently supported positive outcomes for clients.

The experience described in the case study (below) evidences a more positive outcome to what is reported as a typical experience in the Public Health Evidence Review. Participants said experiences with JCP were rarely positive, with unfriendly staff and unwelcoming attitudes, often showing few signs of knowledge about drug use and recovery.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 156 OFFICIAL

Case study This case study, which can be read in full in Appendix E, highlights an individual, L, with a long term, successful teaching career, who after deteriorating mental and physical health and the development of an alcohol addiction ended up signed off sick from work.

This challenging period lasted for many years where L fell in and out of treatment. L reported that the dehumanised benefit system and stressful appeals processes exacerbated his drug and alcohol issues. However, L also reported that positive engagement and structure with the Addaction Life Skills Team and a positive relationship with his JCP Advisor in Cornwall supported L to manage more recent challenging benefit issues.

Additionally, these relationships also helped L develop his volunteering work in order to make a sustainable re-entry into the world of employment.

Finally, the Cornwall Works with Families programme through the last tranche of ESF funding achieved employment outcomes for clients and the Government’s Troubled Families agenda, known as Together for Families in Cornwall has worked with clients with drug and alcohol issues. There were Addaction, DWP and Council Advocates supporting this programme.

Employment needs in the treatment population The employment status of clients accessing treatment in Cornwall is established during the comprehensive assessment process for new clients and is reported on the National Drugs Treatment Monitoring System (NDTMS).

 Three out of four people were not in work when they started treatment and this has remained fairly constant over the last four years;  The balance between economically inactive and unemployed has switched, however, with a decline in those presenting simply as unemployed and an increase in people presenting as economically inactive, and thus further from the workplace. This is the case across all types of substance use. This reflects the overall population trend of reduced JCP claimants. Either claimants have moved from JSA to ESA or they have stopped claiming beneifts altogether. Addaction has anecdotal evidence of the latter due to changes in benefit processes etc;  There has been a small uplift of 3% since 2013/14 in the proportion of people in employment presenting to treatment but little change over the last two years. The rise relates to non-opiate users (+6%) and problem drinkers (+4%) only.

Note that data completeness has declined significantly from 95% in 2013/14 to 78% in the year to date, which means that the results should be regarded as estimates. The HALO electronic case management system has undergone significant changes in recent months and employment status is now as an optional field.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 157 OFFICIAL

2016/17 Employment need on presentation 2015/16 2014/15 2013/14 YTD Economically inactive 41% 39% 34% 33% Employed 21% 20% 20% 18% In education 1% 1% 1% 1% Not known 1% 1% 2% 2% Other 4% 6% 5% 5% Unemployed/NEET 32% 33% 39% 42% Total presentations in year 993 1,397 1,245 1,314

Not in work 73% 72% 73% 75% Employment status recorded 78% 81% 91% 95%

The majority who are economically inactive are recorded as long term sick or disabled (80%) with the remainder split fairly evenly between retirees and homemakers.

Although overall, problem Opiates 40% 42% 13% drinkers are most likely to Non- be employed when they 37% 34% 23% present to treatment, if they opiates are not in work they are Alcohol 45% 22% 27% more likely to be only economically inactive rather than unemployed, with a 0% 20% 40% 60% 80% 100% slightly higher proportion Economically inactive Unemployed/NEET of retirees (18%). Employed In education Other/not known Additionally, data is captured through regular Treatment Outcomes Profile104 assessments completed during a client’s treatment journey and on exit from the treatment system.

The TOP records the number of days of paid employment in the preceding 28 day period; a positive outcome is considered to be at least 10 days in the last 28.

The latest quarterly DOMES report105 indicates that those exiting the treatment system in Cornwall are less likely than the national average to meet this target. However, the DOMES report also indicates that Cornwall is within the anticipated range for our complexity group.

104 The Treatment Outcomes Profile (TOP) measures change and progress in key areas of the lives of people being treated in your drug and alcohol services. 105 Diagnostic Outcomes Monitoring Executive Summary or DOMES; a detailed performance report covering the whole treatment system provided by Public Health England Quarterly

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 158 OFFICIAL

15% of opiate users and 21% of non-opiate users who left treatment successfully had engaged in 10 or more days of paid work in the 28 days preceding their exit assessment – compared with 23% and 34% nationally.

Figures for problem drinkers are not included within this section of the DOMES report. Our local data, however, indicates that 29% of problem drinkers leaving treatment successfully engaged in paid employment in the 28 preceding days.

Further analysis of our local data shows that the proportion engaged in 10+ days paid work has declined for both opiate and non-opiate users since 2014/15 but it has remained stable for problem drinkers.

Comparing engagement in paid work on exit with employment status on presentation shows that in the majority of cases there is no change (i.e. a person presenting as out of work remains out of work) but where there is a change, it is more likely to be negative than positive. Many drug and alcohol clients will require intensive support to help them return to the workplace.

There has previously been support in place through ESF funding but this funding ended and the new services are not yet in place. This means that no new referrals have been taken for clients to access such support since December 2014 which may explain low numbers of clients returning to the workplace.

The next table shows all successful completions from April 2015 to date (18 months) where an exit TOP assessment provided details of engagement in paid work in the preceding 28 days, related to their presenting employment status.

Employment outcome on exit

Employment status on Paid Paid Paid presentation to treatment Days Total Days = 0 Days <10 >=10 Employed 34% 7% 59% 140 In education 60% 20% 20% 5 Economically inactive 92% 2% 6% 260 Unemployed/NEET 81% 4% 15% 213 Total 74% 4% 22% 766 150 people were excluded from this analysis due to no employment status being recorded at presentation to treatment.

 10% of people who presented to treatment out of work had moved into employment at exit (10+ days);  A third of people who presented to treatment in work had not engaged in any paid work in the preceding 28 days when they exited treatment.

This is what we would expect to see. Many people present to treatment at the start of a crisis point. The threat of losing a job can act as a trigger seeking help and, once a person has recognised their problems and committed to recovery, things often get worse before they get better – holding down a job at the same time is not always feasible and can even slow down progress.

We would anticipate that many of those within the 34% will go back into work in the 2-3 months following successful completion but this is the next step and leaving treatment is an important stepping stone along the way.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 159 OFFICIAL

This is supported by the Public Health Evidence Review, where it said that employment rates tend to remain static during treatment with the largest gains in employment levels being evident in those who exited treatment successfully, with increases for both opiate and non- opiate users.106

Limitations and Gaps Although, Cornwall is not achieving as high employment outcomes as nationally, it has been recognised that many clients are making positive steps towards employment during their recovery from drug and/ or alcohol issues.

Many are participating in structured day programmes, life skills activities, peer mentoring and volunteering. The current NDTMS and JCP data systems are limited and do not capture such levels of progress. These limitations have been highlighted by Dame Carol Black in her Independent Review into the employment outcomes of drug or alcohol addiction and obesity (2016),107 with a recommendation for government to adopt an expanded recovery measure to include work and meaningful activity (including volunteering) .

Additionally, there is a lack of data gathered about longer term outcomes and sustained employment or recovery outcomes of service users. This facility would also to help us understand if clients, once completing their treatment programme then manage to engage or re-engage with work.

Some of the partnership work carried out previously had limited success, such as the TPR processes as very few clients were counted as accessing services using these pathways. Clearly additional measures are required to maximise and monitor employment or progress towards employment for a larger cohort of clients with drug and alcohol issues. Dame Carol Black recommended peer mentors to enhance engagement and disclosure.

Since the development and delivery of these extensive pieces of partnership work, there have been many changes to the benefit system and to employment and treatment contracts and teams. Due to all these changes most of these previous work streams need to be updated; new relationships between new providers need to be formed; new service maps and pathways need to be developed and training is required to be delivered to both treatment staff around the benefit changes and to employment staff around the needs of those with drug and alcohol issues.

Changes to the welfare system are having and will continue to have a significant impact on clients with drug and alcohol issues affecting their

106 Public Health Evidence Review; An evidence Review of the outcomes that can be expected of drug misuse treatment in England, Public Health England (2017) 107 An Independent Review into the impact on employment outcomes of drug or alcohol addiction, and obesity, DWP (2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 160 OFFICIAL

housing and homelessness status, their mental health, their levels of debt and their ability to work, which all have an impact on their treatment outcomes.

In the Public Health Evidence Review the welfare reforms and sanction regime was said to have shaped participants engagement with employment support, resulting in a focus on maintaining benefits and avoiding a sanction. Even in areas where JCP coaches were located with treatment teams and viewed positively, the focus was still on sanction avoidance.

The Public Health Evidence Review also highlighted that despite provisions in the Rehabilitation of Offenders Act, those with criminal records still felt excluded from the job market.108

108 Public Health Evidence Review; An evidence Review of the outcomes that can be expected of drug misuse treatment in England, Public Health England (2017)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 161 OFFICIAL

Alcohol, crime and disorder Key findings Crime and anti-social behaviour  15% of all reported crime in 2015/16 was recorded as linked to alcohol; this rises to 30% for violent crime. The number of crimes recorded as alcohol- related has dropped year on year;  There is evidence, however, to suggest that police data may under-report alcohol-related assaults;  7 out of 10 presentations to Emergency and Minor Injuries services for assault were recorded as linked to alcohol, with around 50% of those not being reported to the police. Patterns of time and day clearly link the vast majority of assaults to the night time economy;  Hotspots for alcohol-related violence are concentrated in larger town centres, with notable hotspots in Newquay, Truro, Penzance, Camborne and St Austell. Over three quarters of alcohol-related violence occurs between 9pm and 5am reinforcing the link to the Evening and Night Time Economy;  Following a sustained period of relative stability, anti-social behaviour has seen a gradual rise within the last two years. The greatest percentage rise is in street drinking with rowdy or nuisance behaviour;  Street drinking incidents make up only 6% of the total number of anti-social behaviour incidents recorded, however due to its nature it is very visible and this causes concern amongst local residents and affects their feelings of safety in their local area;  The main hotspots for alcohol-related anti-social behaviour are Truro, Camborne, Newquay, St Austell, Penzance and Bodmin; the number of incidents in Camborne and Penzance in particular more than doubling over the last couple of years;  There are increasing reports of vulnerable adults with complex needs, homeless drug and alcohol users and associated problems with drug litter and anti-social behaviour.

Road Traffic Collisions and Drink Driving  The Local Alcohol Profiles for England (LAPE)109 highlight that incidence of alcohol related road traffic collisions in Cornwall is exceptionally high, higher than both the national and the South West rate (which is also above the national rate);  Local evidence found that alcohol impairment was a major factor in incidents involving pedestrians, and young car drivers and passengers aged 17-24  Over the period reviewed, the number of drink driving offences showed a significant fall, dropping by more than a quarter between 2011/12 and 2015/16. This is in line with national trends.

109 The Local Alcohol Profiles for England are part of a series of products by Public Health England that provide local data alongside national comparisons to support local health improvement.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 162 OFFICIAL

 The decreasing trend could be interpreted as suggesting that the message concerning the dangers of drink driving is having a positive impact on the behaviours of the public, although it is possible that reporting may have become inconsistent compared to previous years due to reductions in the number of enforcement staff.

Reoffending  Whilst recorded alcohol-related crime continues to reduce year on year, problem drinking is consistently one of the most common complexity factors affecting the health, wellbeing and behaviour of both victims and offenders, and appears to be more problematic in Cornwall than the national average;  The Police are due to launch a new diversion scheme (Pathfinder Scheme) which will have alcohol as one of its behaviour change areas, and the Police and Crime Commisisoner is commissioning a new regional Restorative Justice service from October 2017;  Further to the transition of offender management services, there has been no progress with either the public sector National Probation Service or private sector Community Rehabilitation Company in re-establishing information sharing arrangements, leaving a gap in the evidence base around the needs of adult offenders;  Based on limited data provided by the Community Rehabilitation Company, identification of drug and alcohol related needs have significantly declined and this could signify a skills gap to screen, identify and refer drug and alcohol related needs appropriately, but could also be a reflection of a lack of capacity;  Almost half of the 900 people accessing the (mental health) Liaison and Diversion service in courts and police custody were identified as having an alcohol problem. Although three quarters of this group were not in current contact with specialist services, no onward referral was made in 9 out of 10 cases;  For the first time, the rate of referrals into treatment through criminal justice routes is comparable with national rates. The proportion of people in treatment for alcohol that are in contact with the criminal justice system is above the national average;  Offenders presenting with alcohol problems, however (either alcohol only or combined with non-opiates), are less likely to complete treatment successfully with our local CJS Team than the national average.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 163 OFFICIAL

Alcohol-related crime Nationally, around half of all violent incidents the victim believed the offender(s) to be under the influence of alcohol at the time of the offence. This increases in incidents between strangers, in the evening and night, at weekends, and in public places. This is also the case in 17% of incidents of partner abuse.

Long-term trends in alcohol consumption have tended to follow those for violent crime: an increase in the second half of the twentieth century, before more recent periods of decline.

Alcohol misuse places a strain on our emergency services and a significant cost burden on society; latest estimates show that the cost of alcohol-related crime nationally is £11 billion.

The relationship between alcohol and violence is complex, and is characterised by the interaction of a range of factors, including:

 The psycho-pharmacological effects of alcohol, including increased risk taking, impulsive behaviour, heightened emotionality and other effects of intoxication;  The individual characteristics of perpetrators, such as age, gender and predisposition towards aggression;  Situational factors related to the environment in which alcohol is consumed; and  Societal attitudes and values towards drunkenness and what is acceptable behaviour while under the influence of alcohol.

Reducing the availability of alcohol, providing targeted treatment and brief advice, and prevention approaches that build life skills and resilience can be effective in reducing alcohol harm.

Good partnership working has been found to underpin the successful implementation of interventions, and sharing data on acute harms across health, criminal justice and local authority platforms can also inform crime prevention activity.

Preventing alcohol-related crime and disorder Preventing alcohol-related crime and disorder requires a three-pronged approach. All those with a stake in the evening and night time economy have a responsibility to securing the effectiveness of this approach:

1. Improving local intelligence so that decisions taken about the sale of alcohol and the management of the evening and night time economy are based on reliable data and the latest evidence; including expecting more local NHS trusts to share information about alcohol-related violence to support licensing decisions taken by local authorities and the police, adopting the success of the Cardiff Model

2. Establishing effective local partnerships where all those involved in the operation and management of the evening and night time economy work together, so that people can enjoy a safe night out without fear of becoming a victim of alcohol-related crime or disorder, whilst also enabling local

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 164 OFFICIAL

economies to grow;

This included launching a new round of Local Alcohol Action Areas, including Cornwall.

“The new programme will strengthen the capacity and capability of local areas to build effective partnerships, address alcohol-related harms by focusing on a number of core challenges, and provide access to experts and advice, and will work with industry partners to support businesses locally to continue to take action to prevent crime”

3. Equipping the police and local authorities with the right powers so they can prevent problems and take swift and decisive action after they have occurred.

“Preventing alcohol-related crime and disorder requires concerted action by all with a stake in the successful operation of the evening and night time economy”

Violent assaults Alcohol is associated with a range of crimes but plays a particular factor in violent crime. Recorded alcohol-related crime, including violence related to the Night Time Economy, continues to reduce year on year.

 There were 1,144 offences recorded as being alcohol-related in 2015/16, accounting for 15% of all reported crime overall. This was a drop (both in number and proportion of the crime total) compared with the previous year, and there has been a further drop in 2016/17;  30% of violent crime is recorded as alcohol-related;  Hotspots for alcohol-related violence are concentrated in larger town centres, with notable hotspots in Newquay, Truro, Penzance, Camborne and St Austell. Over three quarters of alcohol-related violence occurs between 9pm and 5am reinforcing the link to the Evening and Night Time Economy.

There is evidence to suggest that police data may under-report alcohol-related assaults. The Local Alcohol Profiles for England show that admissions to hospital for alcohol-related unintentional injuries for both men and women have consistently tracked at a rate significantly higher than the national rate. The rate for men is roughly three times that of women, with key factors including risky drinking, violence and disorder and vulnerable disinhibited behaviour.

Emergency Departments (EDs) can contribute distinctively and effectively to violence prevention by working with Community Safety Partnerships (CSPs) and by collecting and sharing anonymised data about violent assaults where the victim has presented at ED for treatment.

These data can be used to enhance the effectiveness of targeted policing and licensing operations and contribute to reductions in violence and future violence- related attendances at EDs.

Five EDs across the Devon and Cornwall Peninsula have installed the Assault Related Injuries Database, ARID, for this purpose – these are Royal Cornwall

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 165 OFFICIAL

Hospital (Truro), Derriford (Plymouth), North Devon (Barnstaple), South Devon (Torbay) and Royal Devon and Exeter (Exeter). Five Minor Injury Units in Cornwall have installed ARID which is now giving us a clearer picture of assaults.

It should be noted that the data presented will be focused very much on incident locations in and around the Emergency Departments that use ARID – ARID is used solely to collect information about victims of assault and alcohol related injuries attending Emergency Departments in Truro, Exeter, Barnstaple, Torbay, Plymouth, Camborne/Redruth, Penzance, Newquay, Bude/Stratton and St Austell so does not present a comprehensive picture for Devon and Cornwall.

It does not include any victims of assault who may have consulted their GP about their injuries instead or attended a Minor Injuries Unit not covered or any of the other hospitals.

Data has been collected by the ED reception staff and shared electronically with local CSPs via Linxs Consultancy since around the end of 2010.

The ARID data collection includes anonymised data about the patient and the incident, including location, use of weapons, alcohol and whether or not the police were involved.

Historically the data has been utilised by local CSPs in a variety of ways.

Currently, monthly reports are provided to police and council licensing departments to assist with operational targeting of premises where there are repeat incidents, or other issues such as under age drinking or weapon use identified. ARID data is also one of the supporting data sets for the HaLO tool. In addition, an annual overview of the data is produced and shared with Safer Cornwall.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 166 OFFICIAL

In the 2016 calendar year, a total of 447 people were recorded on ARID as attending the Emergency Departments in Truro and five MIUs in Cornwall after being assaulted, an extra 30 people recorded they had an alcohol-related injury.

 Where it was an assault related injury 205 victims (46%) said that they had reported the assault to the police or had an officer in attendance;  214 (48%) victims had not reported or it was not known if they had reported the assault to the Police and it is not known if they intend to report it, highlighting the potential gap in our knowledge of violent crime;  Over two thirds of assaults were said to have involved alcohol (70%);  Patterns of time and day emphasise the link between assaults and the night time economy, with the majority of assaults happening over the weekend and between the hours of 21:00 and 04:00. 86% of assaults occurring in this time period were said to be alcohol-related;  Use of weapons is uncommon and in the majority of cases (78%) the injury was caused by part of the assailant’s body (punch, kick, headbutt, etc), 9 were said to have been bitten. 25 (6%) of assaults involved glass, 19 of which were bottles, and a knife was used in 7 assaults;  Generally the majority of assaults were committed by a stranger (51%). Where the assault took place in the home, however, they would mostly come within the definition of domestic abuse (partner/ex-partner or relative);  Younger adults aged 18-24 are more likely to be victims, 38% or 169 people; the next highest reported group is 25-34 with 28% of the total. Police recorded crime also shows 18-24 as the most represented group of victims;  138 (31%) of all victims reported being assaulted in or immediately outside a specific named premises. Only 33% of those recorded at specific premises said they had reported it to the police or had police in attendance;  There were 11 incidents of assaults recorded as having taken place at school or college, with only 3 of them reported to the police and 3 others intending to report.

The full report is available from Amethyst on request.

ARID Devon and Cornwall Briefing Paper: Male Victims of Domestic Abuse (2016) During 2016 Linxs Consultancy (the software design and management agency who support ARID110) was commissioned to undertake domestic abuse analysis for the City of Liverpool111.

This revealed that almost 1 in 5 of Police recorded domestic abuse crime victims were male. Crime Survey for England and Wales estimates have indicated that the proportion may actually be even higher.112

110 Assault Related Injuries Database 111 Report compiled by Dr David Wright, Linxs Consultancy (2016) 112 Office for National Statistics: Intimate Personal Violence and Partner Abuse 2012/13 (2014)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 167 OFFICIAL

ARID collects anonymised information from patients at ED (and MIU) reception who have presented as a result of being assaulted. The data collected includes assailant relationship and location, thus enabling the presence of domestic abuse within this cohort to be examined.

This does not necessarily capture all assaults, as some patients will not admit to being assaulted (or the fact will be disclosed later in the treatment journey).

It should be noted that, whilst the focus of these findings is on the prevalence of male victimisation and supports the provision of services for men, the vast majority of victims are female.

The main findings from the December 2015 to November 2016 data in Devon and Cornwall were:

 12% of ARID recorded assault presentations appear to involve domestic abuse. This is defined as the assault being committed by either a partner, ex- partner or relative;  33% of domestic abuse cases involved a male victim.  However, in just 40% of these cases was the assault said to have been committed by a partner or ex-partner (intimate relationship). In 60% the assault was committed by a relative.  The presentation was perceived by the receptionist to be alcohol-related in 54% of assaults against male victims. This compares to 49% of all domestic abuse victims in the 12 month sample, suggesting that alcohol is slightly more likely to be a factor in male presentations.  In just 52% of cases the male victim was assaulted in the home, with a further 27% occurring on the street or in licensed premises. Again, there is a discrepancy here with the domestic abuse sample as a whole, with 61% of all domestic abuse victims assaulted in the home;  Assaults were most likely to occur in the evening, or early morning with 8pm to 3.30am accounting for 72% of assaults.  Over half of all male victims were under the age of 30;  Data about the alleged perpetrator is not specifically collected through ARID but there is a further information box which can contain ‘incident narrative’. In numerous cases the perpetrator was identified as a parent, sibling or son/daughter.

Learning Points  Endorsing the findings from the Liverpool study, an examination of ARID data shows that a substantial proportion of domestic abuse victims are male;  It is necessary to adopt a broad definition of domestic abuse and ensure that this influences service design. It should not be seen as occurring purely between those in intimate relationships, or located solely within the home;  The male cohort shows that the majority of assaults were committed by relatives (rather than partners) with almost half outside of the home environment. Domestic abuse can be committed by children, siblings, parents and other relatives.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 168 OFFICIAL

Anti-Social Behaviour The 1998 Crime and Disorder Act states that a person is regarded as behaving anti- socially if they have acted “in a manner that caused or was likely to cause harassment, alarm or distress to one or more persons not of the same household”.

The definition is open to interpretation as what causes harassment, alarm or distress can be quite different from one person to another.

Police recording of anti-social behaviour has seen some significant changes in recent years so patterns and trends are reported with the caveat that some of the changes may be administrative rather than changes in behaviour.

Anti-social behaviour is assessed by Safer Cornwall as presenting a moderate risk and threat to our communities.

Trends in police reported incidents Police recorded Anti-Social Behaviour has followed a fairly consistent reducing path since 2008/09, with some significant changes in recording practice having an influence over the years. This trend has plateaued over the last three years.

Anti-social behaviour reported to the police is recorded under a specific set of categories.

This analysis focuses on the types of incident most likely to be linked to alcohol: rowdy/inconsiderate behaviour, street drinking with rowdy or nuisance behaviour and street drinking.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 169 OFFICIAL

Jan-Dec Jan-Dec Change Breakdown by type Change n 2016 2015 % Abandoned Vehicles 63 64 -1 -2% Animal Problems 52 49 3 6% Begging/Vagrancy 175 140 35 25% Fireworks 51 51 0 0% Littering/Drugs Paraphernalia 58 75 -17 -23% Malicious/Nuisance Communications 555 497 58 12% Noise 64 78 -14 -18% Prostitution Related Activity 1 2 Rowdy Nuisance Neighbours 2,329 2,400 -71 -3% Rowdy/Inconsiderate Behaviour 8,145 7,901 244 3% Street Drinking Only 39 35 4 11% Street Drinking With Rowdy Or Nuisance 841 708 133 19% Behaviour Trespass 76 63 13 21% Vehicle 1,173 1,146 27 2% Total police recorded ASB 13,622 13,209 413 3%

For the purposes of trend analysis, rowdy/inconsiderate behaviour and street drinking with rowdy or nuisance behaviour were grouped together.

These two types of ASB account for two thirds of all ASB incidents reported to the police.

Street drinking incidents make up 6% of the total number of anti-social behaviour incidents recorded, however due to its nature they are a visible type of incident, which causes concern amongst local residents and affects their feelings of safety in their local area. This has been reflected in resident surveys that have been conducted over the past 3 years.

The overall trend has been fairly flat 10,000 Dec-16, 8,977 for several years but started to 9,000 8,000 Mar-16, 8,825 increase in January 2015 and has 7,000 Mar-15, 8,494 continued to rise at a moderate pace 6,000 5,000 since then. There was a 4% rise 4,000 overall in 2015/16 compared with the 3,000 2,000 previous year and in the last 12 Cornwall

12 month rolling 12 month total 1,000 months there has been a further rise 0

of 2%. The greatest percentage

Jun-13 Jun-14 Jun-16

rise is in street drinking with Jun-15

Mar-13 Mar-14 Mar-15 Mar-16

Dec-13 Dec-14 Dec-15 Dec-16

Sep-13 Sep-14 Sep-15 Sep-16 rowdy or nuisance behaviour.

The greatest increases in street drinking incidents have been seen in the main population centres of Cornwall with the number of incidents in Camborne, Falmouth and Penzance in particular more than doubling over the last couple of years.

Comparing current levels of anti-social behaviour, in our chosen types most likely to be linked to alcohol, across all towns with a population of 9,500 or above, identifies Truro, Camborne, Newquay, St Austell, Penzance and Bodmin as the most significant hotspots.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 170 OFFICIAL

Rowdy/nuisance Towns Types: Rowdy/inconsiderate behaviour and street drinking with rowdy or nuisance behaviour Highest volume of reported  Truro, Camborne, Newquay, St Austell and incidents (top 5) Penzance Highest rate per 1000  Truro, Camborne, Bodmin, Newquay and Penzance population (top 5)  Truro, Camborne, Newquay, Bodmin, Penzance, St Overall highest prevalence Austell (St Austell ranked joint 4th with Bodmin and Penzance)  Truro (+215/31%), Bodmin (+129/32%) and Highest increase Camborne (+126 /20%) Street drinking Towns Types: Street drinking (only) and Street drinking with rowdy or nuisance behaviour Highest volume of reported  Truro, St Austell, Camborne, Newquay and incidents (top 5) Penzance Highest rate per 1000  Truro, Camborne, St Austell, Newquay and population (top 5) Penzance  Truro, Camborne, St Austell, Newquay and Overall highest prevalence Penzance (St Austell ranked joint 2nd with Camborne)

Highest increase  Truro (+83/100%)

Enforcement Drink Banning Orders (DBO) could be issued by the court without an application therefore the terms of the order were sometimes too wide and were not proportionate to the crime committed. This meant the orders were difficult to enforce. They were replaced by Criminal Behaviour Orders in 2014.

 Since the legislation changed in 2014 35 alcohol-related Criminal Behaviour Orders have been successfully obtained in Cornwall.

Those who are issued with a Criminal Behaviour Order will normally have a number of services involved with them before an application is made as well as receiving warnings in relation to their behaviour. Specific conditions are included within the order to address the individual’s nuisance behaviour and can contain positive requirements, such as engagement with treatment services, unlike the DBO or previous ASBOs.

Road Traffic Collisions and Drink Driving Safer Cornwall have identified road traffic collisions (all causes) as an area of risk due to rising numbers of collisions resulting in serious injury and numbers and trends are routinely monitored as part of the partnership’s performance framework.

Reducing road traffic collisions are the top priority for the Cornwall Fire and Rescue Service, due to the demand that attendance places on resources and the impact on the community in terms of death and injury. Detailed analysis is undertaken

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 171 OFFICIAL

annually for the Risk Based Evidence Profile that underpins service planning and delivery each year.

The Local Alcohol Profiles for England (LAPE)113 highlight that incidence of alcohol related road traffic collisions in Cornwall is exceptionally high, higher than both the national and the South West rate (which is also above the national rate).

The following analysis examines all Road Traffic Collisions (RTCs) in which alcohol was a contributing factor. Not all of the incidents will have been the result of drink driving as items will appear within the data where there has been a collision between a pedestrian and a car in which the pedestrian was under the influence of alcohol, rather than the driver.

 The two year period from January 2013 to December 2014 saw 194 such incidents recorded resulting in 255 injuries, 10 (1 in 20) of which were fatal.

The analysis identified five areas114 in Cornwall which accounted for one in five of the alcohol-related incidents reviewed (40 of the total 194 incidents).

The following section provides a basic analysis of these areas:

# Area Incidents 1 This area lies to the east of Newquay containing St 10 reported alcohol related RTCs Columb Major and Summercourt. over the two years between 2013 and 2014 resulting in nine It contains an approximate 8 mile stretch of the A39, injuries, 2 of them serious. the main link between Newquay and other towns on the north coast such as Wadebridge, Padstow and

113 The Local Alcohol Profiles for England are part of a series of products by Public Health England that provide local data alongside national comparisons to support local health improvement. 114 Middle Layer Super Output Area (MSOA) which typically contains around 7,000 residents.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 172 OFFICIAL

# Area Incidents Camelford. The area also contains a small stretch of the A30 around Fraddon and Indian Queens. 2 This area is situated immediately to the East of This area has experienced 8 Newquay and contains stretches of two of the main incidents, resulting in 12 roads servicing the town, the A3059 which services injuries. Newquay Airport and towns to the north and the A3058 which links with Cornwall’s main arterial route - the A30. 3 This area is immediately to the south and east of the 8 incidents have been recorded tourist areas of Wadebridge and Padstow and within within this area, resulting in 2 half an hour’s drive of Newquay with the direct road serious and 8 slight injuries. link of the A39.

4 This area contains the area around Wadebridge and 8 incidents have been recorded Padstow to the north and south, containing the here, with 9 injuries, one of popular tourist destinations of Port Isaac and which was fatal and another Polzeath. serious.

7 miles of the A39 runs through this area, linking to Newquay and South West Cornwall and Camelford to the north.

5 The fifth most hazardous area forms the town centre Over the two year period 7 of Penzance, including the ferry port link to Scilly. incidents and 9 injuries have been recorded. The area suffers with a high level of socio-economic deprivation, sitting inside the top 20% most deprived areas in the UK. There is a busy one-way traffic system in place which may appear confusing to those unfamiliar with the area which is also adjacent to the railway and bus stations.

The four areas seeing the most incidents all sit in a line along the north coast corridor between Newquay and the Wadebridge/Padstow area.

Newquay is Cornwall’s primary tourist hotspot during the summer with a population estimated to increase five-fold to approximately 100,000 people115 during the busy summer months. At this time both numbers of cars on the road and numbers of pedestrians, within the town and on the outskirts, will rise. The town has a cumulative impact policy in place relating to the licensing and sales of alcohol.

Incidents are most likely to occur during the period from the beginning of June to the end of August.

115 ‘Insiders guide to Newquay’, Visitcornwall (2015)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 173 OFFICIAL

Where do most collisions occur? As part of the Cornwall Fire, Rescue and Community Safety Service Risk Based Evidence Profile116 (RBEP 2016), Cormac’s Engineering Design Group have analysed the A and B Roads for the local authority in terms of their collision history and produced the a “top ten” (right).

The majority of the A30 and A38 are trunk roads and are maintained by Highways England and therefore were not included in the analysis.

116 Risk Based Evidence Profile 2016, Cornwall Fire, Rescue and Community Safety Service

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 174 OFFICIAL

 The RBEP found that alcohol impairment was a major factor in incidents involving pedestrians, and young car drivers and passengers aged 17-24

As would be expected, most incidents happen over the busy weekend period, between the hours of 8pm and 4am, when the majority of people would be taking advantage of what Cornwall’s Night Time Economy has to offer. 60% of all RTCs falling within this time range and more than half (58%) of all incidents occur on a Friday, Saturday or Sunday.

Public transport has traditionally been limited in Cornwall, with provision of buses generally not extending past midnight and a train service that only extends as far as Newquay branching from the mainline to the south of the county.

By substituting the locations of the alcohol-related RTCs as a proxy for the locations of the drink driving incidents from Devon and Cornwall Police we can approximate that the police have recorded incidents where drivers are under the influence of alcohol 112 times during 2015/16 in these areas.

The high proportion of local residents amongst drink drive offenders (discussed in the next section) suggest that tourism is not the over-riding factor, in terms of who is offending. It is worth noting, however, that a temporarily increased population is likely to lead to busier roads especially around areas such as Newquay and therefore chances of an accident are increased due to the higher volume in traffic. There are also likely to be a higher number of events held in these areas during the summer tourist season that would also be attended by local people.

Drink driving National statistics indicate that up to 340 people were killed in drink drive accidents in the UK in 2015117 and 14% of all deaths in road traffic collisions in 2013 involved at least one driver over the drink drive limit.118 Further research has suggested that accident victims that have been drinking are more likely to receive serious injuries than those that have not.119

Data provided by Devon and Cornwall Police provided the total number of drink driving offences recorded in Cornwall for the period April 2011 to March 2016, with a breakdown of number of offenders and their area of residence. The data also provided figures for repeat offences by year over the same period.

The graph shows the declining trend in number of offences and offenders over the 5-year period.

117 ‘Reported Road Casualties Great Britain: 2014 Annual Report’, Department for transport (2014) 118 ‘How to prevent alcohol-related accidents’, Drinkaware 119 ‘Alcohol effects on Motor Vehicle Crash Injury’, Alcoholism, clinical and experimental research’, Waller, PF (April 2003)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 175 OFFICIAL

It is debatable how much of this relates to reduced enforcement activity after enforcement staff reductions.

There was no information about date or time of offence so we are unable to examine any seasonal trends.

The data did not include any brought to justice outcomes, which means that we are unable to measure the effectiveness of any rehabilitative measures.

In general, since the start of the data being recorded in April 2011, the number of drink driving Offences has shown a decreasing trend and has dropped by more than a quarter, from a total of 728 in 2011/12 down to 530 in 2015/16.

The number of offenders being caught more than once in the same year is relatively low, and numbers have been reducing since April 2011. 80-85% of the offenders recorded live in Cornwall and, of the rest, the largest proportion live in Devon.

The total number of offenders from outside of Devon and Cornwall fluctuates at between 3-9% of the total, it is not known whether any of these individuals was holidaying in Cornwall at the time the offence was committed.

The graph shows the estimated number of reported drink drive accidents for Great Britain120 as a whole over the same period. We can see a similar declining trend between 2011 and 2014 with a small increase in 2015.

120 Reported drinking and driving (RAS51)’, Department for Transport (September 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 176 OFFICIAL

A declining national trend has been apparent over the past 40 years, seeing deaths and serious injuries reduce by almost three-quarters.121

The majority of repeat offenders also come from Cornwall and the five-year period between 2011 and 2016 has seen this trend increase by over 10%. While total repeat offences have varied, fluctuating between a high of 69 offenders in 2011/12 and a low of 33 offenders in 2014/15.

The decreasing trend in terms of number of offences locally and accidents nationally since 2011/12 could be interpreted as suggesting that the message concerning the dangers of drink driving is having a positive impact on the behaviours of the

121 ‘Reported Road Casualties Great Britain: annual Report 2014’, Deparment for Transport (September 2015)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 177 OFFICIAL

public, although it is possible that reporting may have become inconsistent compared to previous years due to reductions in the number of enforcement staff.

The varying nature in the numbers of repeat offenders seems to indicate that there is more to look at in terms of rehabilitation and sentencing for offenders, however the low numbers in terms of offenders living outside Cornwall may be an indication that seasonality and the impact of tourism might not be a serious issue that is worth pursuing. Better data around the timings of the offences would allow us to explore this theory in more detail.

Overall, more information is required before we can make a more certain assessment of the impact of drink driving in Cornwall, ideally we would like to have data around sentencing, driving awareness course attendance by those that have been caught drink-driving and information relating to when the offences occurred.

Reoffending Fundamental changes have taken place in the last couple of years in policy, legislation and service delivery structure for the management of offenders under the Transforming Rehabilitation agenda. Although this presented massive challenges in terms of business continuity, we had hoped that it would present opportunities to improve and move towards a more integrated working model with the new service providers, as well as improving information recorded, information sharing and the evaluation of delivery.

Offender management is now split between a public sector National Probation Service that works with high risk offenders, predominantly those managed under MAPPA122, and a network of private sector regional Community Rehabilitation Companies (CRCs) that work with the remainder of the offender population.

The Dorset, Devon and Cornwall CRC has been operational since June 2014 and is working alongside existing services but within a changing environment. The expansion of supervision arrangements to include short term custody prisoners from 1 February 2015 (under the new Offender Rehabiliation Bill), coupled with a new sentencing framework, and lower than anticipated funding income from the Ministry of Justice, has resulted in significant changes in how offenders are managed in the community, with the key implication being more offenders to manage with a lot fewer dedicated resources.

Further to the split of offender management services under Transforming Rehabilitation, Integrated Offender Management schemes are managed by private

122 Multi Agency Public Protection Arrangements (MAPPA) is the name given to arrangements in England and Wales for the "responsible authorities" tasked with the management of registered sex offenders, violent and other types of sexual offenders, and offenders who pose a serious risk of harm to the public

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 178 OFFICIAL

sector Community Rehabilitation Companies. At 33%, the reoffending rate for Dorset, Devon and Cornwall is in line with the national average.

45% 40% Average 34% 35% 30% 25% 20% 15% 10% 5% 0%

It is important to note that information sharing arrangements with offender management services have not been reinstated post-transition and this leaves a gap in the evidence base around the needs of adult offenders.

This issue is highlighted in our local Reducing Reoffending Strategy and one of the key strategy objectives identified is to:

 Collect and share good quality local data to inform local needs assessment and to monitor performance and outcomes.

Identification Historically we have examined the extent of drug and alcohol problems identified through offender assessments undertaken by Probation services and compared this with those in contact with community treatment services. This has consistently identified a gap, with a significant number of offenders assessed as having a drug and/or alcohol problem, but not engaged in treatment. The rates of engagement for non-opiate users were lowest – in 2013/14 when this could last be established it was 21% for structured treatment only, 44% including non-structured interventions.

Prior to the new arrangements for offender management being established in 2014, offenders were managed by Devon and Cornwall Probation Trust.

Drugs Alcohol Criminogenic needs relating to drugs 70% Drugs average Alcohol average and alcohol amongst offenders under 60% supervision by Probation remained 50% fairly static over the 5 years

40% preceding the new arrangements

30% being put in place, with averages of 37% and 58% respectively. 20% 10% 0% 2009/10 2010/11 2011/12 2012/13 2013/14

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 179 OFFICIAL

Some limited information on Thinking 73% offender needs across the Attitudes 53% cohort supervised by the CRC Alcohol 36% was provided for this Relationships 32% assessment. Emotional 29% Lifestyle 28% Of the 723 offenders on the ETE 27% current caseload that have had Finance 20% an assessment, 36% (257 Drugs 15% individuals) are identified as Accommodation 14% having a criminogenic drug- related need. 0% 20% 40% 60% 80% This appears to show a reduced level of need compared with previous years but the extent to which the cohort has changed means that we cannot make a robust comparison.

Similarly drug-related needs have also seen a significant drop in reported levels, down to 15%. Concerns have been raised by the Needs Assessment Expert Group that the drop in identification of drug and alcohol-related needs could signify a skills gap to screen, identify and refer drug and alcohol related needs appropriately; particularly when considered alongside other measures of problem alcohol use in offenders (such as the Liaison and Diversion Service).

Figures are provided for 3 key cohorts - Engage (low risk) and Change (Medium risk and Turnaround, a small cohort of the most prolific offenders) in East and West Cornwall. Alcohol issues show less variation than drugs across the different cohorts.

Those at medium risk engaged with the Change programme are most likely to have a problem at 46% but Turnaround is also above average at 41%. Prevalence of criminogenic risk factors are higher across most types of need in the West of Cornwall – 43% of offenders in the West have a alcohol-related need, compared with only 28% in the East of Cornwall.

We are unable to ascertain at present the nature of the alcohol use (for example, binge or dependent), any associated risk factors or the levels of engagement with community treatment services. It is understood that some research nationally is planned that will examine the cross over between the two cohorts and effectiveness of engagement.

Liaison and Diversion Service The Liaison and Diversion service gives screening assessments to all-age defendants and detainees in the courts and police custody with suspected mental health, learning disability, drug or alcohol problems. It began as a trial in 2013.

This service also extends to any individuals who the police come into contact with who they suspect also falls into this category.

Data collected by the service provides a further measure of the prevalence of problem drug use in the offender population, particularly in combination with other needs. Data was made available to us that included anonymised information for approximately 900 individuals referred to the service from 1 April 2015 to 31

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 180 OFFICIAL

March 2016. The data is recorded against fields in a national NHS recording framework.

 Alcohol and drug problems were common with levels of 48% and 28% of the total cohort respectively;  Nearly three quarters (73%) of individuals had current or previous contact with mental health services and this was higher still (79%) amongst those identified as having drug and alcohol problems;  1 in 5 had been a victim of abuse (domestic and/or sexual, either as a child or an adult);  26% were suspected or charged with violence against the person;  The percentage of people with depression (23%) is almost equal to the PHE estimate of all people in Cornwall with any mental health problems (24%). 27% were recorded as having two mental health problems;  A quarter (24%) were at risk of suicide.

20% 77% Abuse Victim Male

73% Current/previous contact 23% with mental health Depressive Illness services 899

40% 60% Drug misuse Alcohol misuse

43% 45% Renting a house or flat Unemployed

Of those individuals identified as having Unknown an alcohol problem, 45% had been in 17% contact with specialist treatment No Yes, 38% services, either currently or previously. previously 21% Yes, Where an individual was not in current current contact with specialist 24% treatment services, the following intervention outcomes were recorded:

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 181 OFFICIAL

 In almost 9 out of 10 cases, no referral was made. The majority of these were recorded as intervention “Not Applicable, no need identified” which appears to be contradictory to the assessment of increasing risk, higher risk or dependent drinking; this requires further clarification;  Only 4% were referred for specialist treatment; referrals were highest for those assessed as drinking at higher risk levels (8%);  8% were given advice;  3% refused help with their alcohol problem.

Advice Advice n= 15 n= 5

No No Referral Referral referral Increasing risk referral Higher risk n= 1 n= 9 n= 81 n=100 n= 91 n=109

R efused R efused n= 3 n= 4

Advice n= 2

No Referral referral Dependent n= 1 n= 49 n=54

R efused n= 1

Of those individuals identified as having an alcohol problem two thirds had either previous or current contact with mental health services, with the greatest proportion for the higher risk drinkers (70%) and the lowest for dependent drinkers (61%).Those recorded as ‘dependent’ drinkers had the highest percentage of current contact with mental health services (29%).

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 182 OFFICIAL

Youth Offending Service Drug and alcohol problems are an area where the numbers of individuals with high or medium risk score has increased. All individuals had tobacco, alcohol and cannabis as a medium or high risk with other drugs identified but not at high levels and at lower levels than 2014.

Substance misuse 2015 2014 (n=30) (n=19) Tobacco 100% 95% Alcohol 100% 95% Cannabis 100% 100% Substance misuse is perceived as positive/ essential to life 57% 68% Ecstasy 30% 37% Amphetamines 20% 42% Cocaine 13% 16% Solvents 10% 11% Risky behaviour/ Poly drug use 10% 16% Tranquilizers 7% 16% Methadone 3% 5%

Criminal Justice clients in treatment At the start of 2014/15, the criminal justice drug and alcohol team were identified as a separate entity from Addaction adult services. Offenders in treatment were previously recorded within community treatment episodes rather than as a separate criminal justice function.

In the first year, the number of people showing as in treatment with the team saw steady month on month growth (as would be expected), and the proportion of clients in contact with the Criminal Justice System (CJS) steadily increased.

The impact of this stabilised the following year and the level of growth has matched the growth seen across the whole treatment population, with the proportion in contact with the CJS staying relatively stable.

 At the end of September 2016, 25% the rates for Cornwall were % CJS National below the national average 20% for drug users (opiates and 15% non-opiates) but above for alcohol users (both alcohol 10% only and in combination with non-opiates); 5% 0% Opiate Non-opiate Alcohol Non-opiate and alcohol

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 183 OFFICIAL

Referral and engagement The local rate of referrals into treatment via the Criminal Justice System (CJS)123 has been lower than the national average for the last ten years. In the last needs assessment cycle, however, we reported that the gap had narrowed.

In 2015/16 24% of referrals into treatment were through a CJS route and for the first time this was in line with the national average of 22%.

Note, however, that over 35% CIOS National the same time period the 30% proportion of CJS 25% referrals nationally has dropped, albeit not to an 20% equivalent degree. 15% 10% Performance metrics with 5% respect to how quickly 0% CJS referrals are 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 picked up in the system compare favourably with the national average, although the low numbers mean that this fluctuates.

Treatment outcomes Successful completions amongst CJS clients are lower than the wider treatment population.

Drug group CJS All National Opiates 4.9% 7.9% 5.0% Non-opiates 60.0% 25.5% 39.5% Non-opiates and alcohol 26.9% 22.6% 37.0% Alcohol 26.3% 25.4% 40.9%

 Local outcomes for offenders are in line with the national average for opiates and non-opiates;  Offenders presenting with alcohol problems, however (either alcohol only or combined with non-opiates), are less likely to complete treatment successfully with our local CJS Team than the national average.

The number of re-presentations to treatment by offenders following a successful completion outcome is too low to make any comparisons - there were less than 5 individuals in the last 12 month period.

123 Referred via the Criminal Justice System means referred through a police custody or court based referral scheme, prison or the probation/CRC service

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 184 OFFICIAL

The Police and Crime Plan In 2016, the newly elected Devon and Cornwall Police and Crime Commissioner (PCC), Alison Hernandez (Conservative), held a consultation process to engage with public and partners as she tested and compiled her priorities into a new Policing plan.124

The new “Police and Crime Plan 2017-20 for Devon, Cornwall and The Isles of Scilly” was finalised and published in January 2017. In the PCC’s own publicity125, these were listed as the key points in the plan:

 Connecting our communities and the police – through a new Local Policing Promise to ensure policing in the local area is ‘Accessible, Responsive, Informative and Supportive’

 Preventing and deterring crime – so we can stop people becoming victims of crime and help them move on with their lives

 Protecting people at risk of abuse and those who are vulnerable – safeguarding the vulnerable and keeping them safe from harm

 Providing high quality and timely support to victims of crime to help them recover and to get justice by improving the criminal justice system

 Getting the best out of the police – making best use of our resources, supporting and developing our workforce and working well in partnership with others.

“This plan provides a direction to help communities become safer, more resilient and better connected and makes a Local Policing Promise to ensure that policing is accessible, responsive, informative and supportive.

My aim is to have excellent policing, better co-ordination with the wider public services and resilient self-supporting communities. In that way we can all play our part in keeping each other safe.

Devon and Cornwall Police is already a good force. Through better connection, clear direction and appropriate investment it can be one of the very best in the country. By freeing over £10m from reserves, by striving for further efficiencies, by raising money through the policing precept (Council Tax) and changing other spending priorities, I have provided the Chief Constable with the funds to be one of the only Forces in the country to increase its number of officers.”126

124 ‘Safe, resilient and connected communities: The Police and Crime 2017-2020 Plan for Devon, Cornwall and the Isles of Scilly’, Office of the Police and Crime Commissioner, Devon and Cornwall (January 2017) 125 OPCC Press Release, (January 2017) 126 Devon and Cornwall Police and Crime Commissioner, Alison Hernandez (2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 185 OFFICIAL

Here are some of the details most relevant to this Alcohol Needs Assessment, which guarantees a strong connection to the work of Community Safety Partnerships and the Peninsula Strategic Assessment:

Devon and Cornwall and the Isles of Scilly is one of the safest places in the country, a number of things contribute to this:

 Effective policing approaches and a dedicated and well trained workforce,  Co-ordinated and focused activity across public and voluntary sector organisations,  The strong sense of community in Devon, Cornwall and the Isles of Scilly.

Vulnerabilities The Police and Crime Commissioner wants to focus especially on those that are most vulnerable. People can be more vulnerable because of their ethnicity, age, a disability, where they live (for example living in rural or isolated locations), who they live with or for a range of other personal reasons or external factors.

Vulnerability must be thought about broadly – recognising that people become vulnerable for a range of reasons and that people will not always recognise themselves as being vulnerable.

Community Safety Partnership Priorities The plan recognises and reflects the important issues identified in the Peninsula Strategic Assessment, which were drawn together from the community safety strategic assessments undertaken by the 4 strategic community safety partnerships (CSPs) across the Peninsula.

The Peninsula Strategic Assessment provides a formal process that assesses threat, risk and harm in relation to crime, anti-social behaviour and disorder issues to identify emerging concerns and ongoing challenges.

It highlights the main threats to Devon and Cornwall as domestic abuse and sexual violence, alcohol-related harm, providing an effective response to serious organised crime and the demands generated by mental ill health and families with complex multiple needs.

Commissioning The PCC will work through, and with, partners including CSPs to commission high quality services to help protect people who are at risk of abuse in our communities and those who are vulnerable. The PCC will actively work with partners in health and local authorities, and through Health and Wellbeing Boards and CSPs, to jointly assess commissioning needs for services that support vulnerable people and those who are at risk of abuse – in particular people experiencing domestic abuse, sexual offences and exploitation.

The PCC will publish her 2017-2020 PCC Commissioning Intentions Plan by early 2017 following the budget confirmation and establish multi-year funding streams for commissioned services to improve service stability.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 186 OFFICIAL

Anti-Social Behaviour Working closely with partners to tackle anti-social behaviour (ASB), the PCC recognises the impact that continued, severe and persistent ASB has on individuals and communities, and the feeling of safety. At times these may be complex, long running issues – involving a range of partners, all trying to resolve matters.

The respective roles, responsibilities and actions of those trying to tackle antisocial behaviour are not always clear to the public. This creates confusion. There is a complex – and often changing - network of powers and legislative tools potentially available to the police and partners to try to resolve antisocial behaviour.

 The Chief Constable and the police will continue to play an active role through Community Safety Partnerships and their work with partners in trying to resolve continued, severe and persistent antisocial behaviour.  The PCC will review existing support services for victims of continued, severe and persistent antisocial behaviour.

Night Time Economy Playing a supportive role in keeping night-time economy areas safe, many towns and cities across Devon, Cornwall and the Isles of Scilly benefit from vibrant, popular night-time economies – all year round or during the busy tourist season. This activity is a welcome contribution to the mixed economy and supports the local area’s prosperity - but they do bring challenges for policing and community safety.

Drinking a lot of alcohol makes some people more vulnerable to becoming victims of crime and, sometimes, more likely to commit crime – in particular crimes linked to violence, criminal damage and public order.

The impact of alcohol on safety within communities is well recognised within the Peninsula Strategic Assessment and the PCC and the Chief Constable are committed to working with partners on this important issue. Joint work to manage risk has been delivered successfully for many years – but this comes at a cost. Businesses are now taking a much more active role in managing the night- time economy and promoting responsible drinking – which is a positive development.

The PCC and Chief Constable are particularly concerned about the extent to which people who have drunk too much can become victims of crime – in particular sexual offences.

 The Chief Constable will continue to work in partnership with local authorities, businesses, health and other agencies to protect the public and those working in the night-time economy.  The Chief Constable will support licensing activities to tackle irresponsible licensing practices.  The PCC and the Chief Constable will work with local authorities to support alcohol strategies and initiatives.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 187 OFFICIAL

In particular:  Championing schemes which help to reduce crime and harm linked to alcohol, such as Best Bar None and street pastors  Supporting Help-zone schemes and the roll-out of the Drinkaware Crew scheme (piloted in Devon and Cornwall) in university locations and others areas where a need is demonstrated  Endorsing late night levy proposals from local councils and guaranteeing to recycle collected funds to support local initiatives linked to reducing harm in the night-time economy.

Preventative Interventions

The PCC and the Chief Constable are fully committed to a preventative approach that is focused on three key areas:

 Prevention in early years - drawing on national best practice and evidence work will be developed with partners to more actively focus on those at risk of becoming offenders, in particular children and young people due to their circumstances, past experiences or mental ill health. The PCC and Chief Constable will work together with partners to scope a comprehensive package of early help aimed at preventing future offending with a focus on children and young people, families who are identified as at risk and those with complex needs such as mental ill health.

 Deterring future crime. The PCC and the Chief Constable are committed to taking a partnership and multi-agency approach and to targeting more resources at working with offenders to stop them from reoffending. They will also support the prison service in its efforts to deliver appropriate rehabilitation to offenders serving a custodial sentence. More resources will be targeted at first time entrants to the criminal justice system (CJS) and those at an early stage of their criminal pathway, by launching a new offender diversion service.

 Delayed charging and diversion127 - the PCC wants to invest in activity that helps change the behaviour of criminals at an early stage. She is developing a scheme that will be: supported by victims; require commitment and engagement of offenders and ensure that when offenders do not engage they are subject to normal criminal justice sanctions.

This delayed charging and diversion scheme, which offers some offenders (subject to strict eligibility criteria) the opportunity to undertake victim-led reparation, including the potential for restorative solutions, as well as an agreed programme of rehabilitative work during a four month period.

127 Known elsewhere as the GPS scheme

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 188 OFFICIAL

The rehabilitative work could, for example, include elements of drugs and alcohol work delivered by existing services, co-ordinated by trained scheme facilitators. Successful completion of the programme of work would enable the offender to avoid criminal charge.

Evidence shows the opportunities provided by the scheme can be the watershed which allows the offender to improve their life chances, reducing their negative impact on society and over utilisation of local services.

By April 2017 the PCC and the Chief Constable will launch a new two year pilot delayed charge and diversion scheme – creating an alternative pathway through which an offender (victim led and subject to strict eligibility criteria) can enter into a contract with the police to address the underlying causes of offending (such as addiction or mental ill health). Successful completion of that contract would provide an alternative to facing a criminal charge. The pilot will run for two years and will be evaluated by the University of Cambridge.

Greater intervention with people who regularly commit crime will receive greater focus and additional investment to deal with regular and persistent offenders, disrupting their criminal lifestyle and stopping them causing more harm to communities.

By March 2017 the Chief Constable will set a prevention strategy detailing the force’s approach to prevention and how it will be delivered across the organisation and through the alliance with Dorset.

The PCC will work with health and local authority partners to consider developing an integrated commissioning model for offenders which identifies gaps in existing services. This could help reduce reoffending risks, reduce duplication and enable the commissioning of additional services where needed – reporting by September 2017 to inform the development of early help packages.

Commissioning Intentions The PCC will work with local authorities, other partners and the voluntary and charitable sector, to commission high quality services to help protect vulnerable people. The 2017-2020 PCC Commissioning Intentions Plan will also establish multi-year funding streams for commissioned services to improve service stability.

Victim strategy The PCC and Chief Constable will work together and with victims, local partners, service providers and local police officers and police staff to develop a joint victim strategy, setting out how an end-to-end wrap-around support service for victims of crime can be delivered. The victim strategy will focus on:

 Providing a high quality, caring and timely service to all victims of crime – putting the person before the process at all times (including launch of the online Track My Crime service by the end of 2017)  Reducing levels of repeat victimisation – protecting victims from further trauma and helping them to recover

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 189 OFFICIAL

 Improving our approach to restorative justice  Jointly with partners, help develop a responsive and supportive victim focused criminal justice system  Actively promote the Victim Care Unit to frontline officers and externally.  The PCC and Chief Constable will publish a joint victim strategy by September 2017. The strategy will be informed by discussions with victims, local partners, service providers and local police officers and police staff.

Restorative Justice A victim led approach to restorative justice – the establishment and embedding of a new victim led restorative justice (RJ) process is a key feature of work under this priority.

As well as identifying local needs, and commissioning high quality services to meet those needs, the Police and Crime Plan will embed the culture of RJ across the police service and ensure that the right systems and processes are put in place to meet demand.

The new restorative justice operating model and system must:

 Identify local needs and commission appropriate services to deliver RJ – working with the voluntary and charitable sectors as well as statutory partners  Establish required capacity, systems and processes within the police service to meet the demands of victims for restorative justice services  Be fully embedded within policing culture and be well understood throughout the police service  The PCC will work with the Chief Constable and local partners to launch, establish and embed a new victim led restorative justice process in Devon, Cornwall and the Isles of Scilly by the end of 2017.

Partnerships The PCC and the Chief Constable will work closely with and support a broad range of partnership activities, including working with CSPs, safeguarding boards, mental health services and health and wellbeing boards on issues such as vulnerability, violence and the prevention of suicides – championing their work, challenging action and working with them to solve problems, prevent crime and harm and to support victims and their families.

GPS Pathfinder This is a new delayed charge and diversion scheme, broader than previous local custody based diversion schemes used before Conditional Cautioning was introduced, which is due to commence on 01/04/17. It will be delivered in the 6 Devon and Cornwall Custodies, using a Police manager and 13 keyworkers.

Based on a more recent project in Durham, it is designed to be a voluntary adult offender scheme, resulting in an exit from the Criminal Justice System if clients comply, without a criminal conviction. It will identify “critical pathways”, and intervene in an offender’s underlying behaviour, in order to reduce or stop further offending. Clients have four months to demonstrate engagement, which will entail addressing issues as assessed by GPS staff, with their support.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 190 OFFICIAL

It is acknowledged that sometimes a traditional criminal justice punitive sentence can result in deteriorating behaviour and reoffending, whereas successfully addressing the root cause is more likely to reduce offending. The scheme will use the deferred prosecution aspect to enhance motivation, enabling the offender to keep within the boundaries of their contract, knowing that the police could continue the prosecution if the offender does not comply.

The majority of crime is committed by a minority of offenders who commit offences at the lowest level, due to these underlying issues. Offending behaviour may escalate unless effective behaviour change intervention takes place.

These are the “critical pathways” that are often present in low or medium level offenders:

 Alcohol dependency  Substance misuse  Mental or Physical Health  Accommodation  Finances  Employment  Relationships and support  Attitudes and Behaviour

Addressing these issues may prevent further re-offending, improve the wellbeing the individual, people close to them, and the wider community.

Each person will agree a bespoke four month “contract” along these lines:

1. No re-offending within a time period (mandatory); 2. Participation in Restorative Justice/community resolution if appropriate; 3. Attendance at assessments re critical pathway; 4. Attendance at appointments re critical pathway; 5. Carry out community/voluntary work (18-36 hours).

In Durham, several offenders are continuing to volunteer within the community after being allocated 18-36 hours of community work – some have stayed on at foodbanks to help out, some have remained in manual labour and some have continued working at charity shops. This benefits not only the community but also the individual who improves their self-worth and confidence.

The programme is aimed at stopping reoffending before it begins or escalates. It gives the offender the opportunity to give something back to the community in which they have offended, whilst addressing the personal issues which may have caused the offending.

This is seen as a potentially more effective disposal and intervention than Cautions or FPNs (giving a ticket) neither of which address behavioural causes and contexts. Instead, GPS Pathfinder keyworkers will aim to take time to get to know the person and identify what their issues are, and then work with the person to address those issues along with local specialist partner agencies.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 191 OFFICIAL

In assessing the similar project in Durham, delivered under the name Checkpoint, the HMIC128 have stated that such schemes are “an exceptional offender management system.”

This scheme will be based on the observation that traditional disposals often make someone’s bad situation worse; if someone is suffering financially then giving them a fine is not the answer; or if someone has a chaotic lifestyle, issuing a caution will not change their situation.

Instead, initially spending an hour allowing a supportive keyworker to ask them assessment questions about their life can identify the root causes of offending so that options and support can be identified. This could help them address their issues, and should prevent re-offending. This will aim to treat people as individuals, enabling them to change their lives for the better, rather than just feeling judged.

The scheme will cover a range of low level offences. It is hoped that it will be academically trialled and evaluated.

128 Her Majesty’s Inspectorate of Constabulary; referenced in the presentation of the evaluation of the Checkpoint scheme (Durham County Council, Safer and Stronger Overview and Scrutiny Committee, October 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 192 OFFICIAL

Licensing and Retail Key findings  We have achieved national recognition for our innovative work as part of the national HaLO (Health as a Licensing Objective) pilot, supporting greater involvement by health in licensing decisions;  As a result of our contribution to and participation in the HaLO pilot, we have successfully bid to become a Local Alcohol Action Area (LAAA) in round 2 of the scheme, with the action plan fully embedded within our local Alcohol Strategy;  The main aims for Cornwall as a LAAA2 are: o To continue to expand the Cornwall HaLO dataset and tool; o To embed it in operational use; o To improve Licensing practice use of health related evidence in forming conditions and objections, in order to improve Licensing practice and make customers and localities more safe; o To contribute to the drive to reduce alcohol related violence; o To contribute to the drive to reduce the harmful impact of alcohol on localities and communities; o To identify and support problematic drinkers through support and (where necessary) enforcement; and o To contribute to reducing alcohol related hospital admissions.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 193 OFFICIAL

Health as a Licensing Objective (HaLO) During early 2016 Public Health England (PHE) ran the HaLO pilot, designed to ascertain whether health data can be legitimately brought to bear in Licensing cases. Local Health bodies have been a Licensing Responsible Authority since 2011, but few areas in England have managed to use health data effectively in this arena.

Up to now the only data seen as relevant has been assault presentation data collected in Emergency Departments, which can be placed alongside named premises in known incidents, or ambulance data. Not all of this is consistently available to all areas, and even when it is, it has to be handled carefully, as incidents are not necessarily the responsibility of a licensed premises who may have correctly and responsibly called the emergency services.

Nine areas of the country were invited to participate, with the objective of pooling health data into a relevant and accessible resource, in such a way that premises could be seen in the wider context of alcohol related health issues in their locality, as well as the burden on the NHS and emergency services.

It was hoped that this would give Public Health a voice in Licensing cases, allowing premises and Licensing Authorities to learn more about the locations and contexts that need to be considered in setting Licenses and Conditions. If this was unsuccessful, either because data was inaccessible, or because data could not be effectively used in Hearings, then Public Health England could help the Government to form better legislation.

In addition, this would help to feed into the debate about whether health and wellbeing need to be specifically mentioned in the Licensing Objectives, part of the Licensing Act 2003 – the legislation that governs the evidence used in all Licensing Hearings. At present there are four Licensing Objectives:

1. The prevention of crime and disorder 2. Public safety 3. Prevention of public nuisance, and 4. The protection of children from harm

Scotland already has a fifth; Protecting and improving public health.

Cornwall (as one of 9 areas) was invited to participate in that pilot, on the basis of having a respected Alcohol Needs Assessment process in place, undertaken by Cornwall DAAT and the Community Safety Intelligence Team, Amethyst. This also helped to give a rural aspect to the pilot scheme, which otherwise majored on Northern Urban areas.

The scheme ran swiftly from early 2016 to report, which is due in early 2017, and will be written by PHE and Sunderland University.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 194 OFFICIAL

Cornwall HaLO Data Tool Using the data gathered as part of the project and that which was already available for Cornwall, Amethyst built an evidence-based tool which can be used to determine the potential risk that the availability of alcohol currently poses in any given location in Cornwall.

The user simply has to type in a post code and will be presented with a risk level based on 5 Key Indicators, and an array of additional health-related data which may be relevant to that case. Each indicator is presented based upon the rate within the local population and converted to a risk level, measured against the Cornwall average.

The 5 Key Indicators are:  Alcohol-related hospital admissions  Referrals into alcohol treatment  Alcohol related violence  Anti-Social Behaviour (ASB)/street drinking  Alcohol-related road traffic collisions

These are presented together in a matrix to illustrate the indicative risk level in any given area of Cornwall. This process has allowed us to identify the 25 highest risk LSOAs (lower super output area which comprises a resident population of approximately 1500 to 2000 people), so that resources can be targeted to these cases specifically.

HaLO Workshop Test Cases In order to test the potential of the tool and how the process of using the data in the licensing arena could work the Cornwall DAAT and Amethyst ran a workshop for Licensing Committee members. Attendees included representatives from:

 Cornwall Council Department of Public Health  Cornwall Council Licensing Officers  Cornwall Council Legal Department  Cornwall Council Adult Care  PHE/Sunderland University  Devon and Cornwall Police Licensing Team

The workshop introduced the data tool, and then ran through theoretical test cases based on two prominent licensed premises in Cornwall.

Initially, the presentation included representations of the background data and risk levels in a table.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 195 OFFICIAL

Supporting indicators were then introduced in order to provide further context:

Levels of Increasing Risk and Higher Risk Drinking 457 Total people based upon Cornwall rate of 22.8% of people

% of the population aged 16+ that binge drink, modelled Binge Drinking Adults % Aged 16+ 21.9 18.8 20.0 estimate 2006-2008

Other alcohol related crime 24.4 5.76 424 Non-violent crimes April 2013 to March 2015

Reported incidents where alcohol/Night Time Economy is a Noise Complaints 16.5 1.41 1170

factor, April 2014 to March 2015 Effect on local area

ED/MIU Attendances due to Alcohol Related 6.0 1.57 382 Recorded attendances April 2013 to March 2015 Assault Incidents of Domestic Abuse reported to police, April 2014 Domestic Abuse 264.7 82 322 to March 2016 No. of Morning After Pills dispensed from Pharmacies per Morning After Pill Administered from Pharmacy 12.1 2 502 1000 population aged under 25, 2015/2016

Recorded cases per 10,000 population aged under 65, STIs Contracted 110 to 149 4 314 January to September 2015

Secondly, information was presented through the use of mapping which compared the immediate area, in which the premises sat, with its surroundings in respect of the key data indicators.

The example to the right compares the LSOAs comprising the town centre of Falmouth, one of Cornwall’s four Cumulative Impact Zones (CIZs) which is designed to limit licensing objectives being compromised

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 196 OFFICIAL

through the over-saturation of an area with outlets which sell alcohol. The map assigns a colour to each LSOA based upon the recorded incidents of street drinking and rowdy/nuisance behaviour, where red (very high) is double the Cornwall average or more.

During the presentation of the case studies, participants were asked to consider a number of questions relating to the potential use of this concept for future licensing meetings and whether a fifth Licensing Objective was necessary.

Feedback from the event was very positive with members voicing support for the new, easily accessible way in which the data had been presented, with an encouragement to use this data in partnership with other Responsible Authorities.

Although generally it wasn’t felt that a 5th Licensing Objective was needed, with updated guidance perhaps better specifying the health implications, in each test case it was already found possible to suggest conditions that could be applied to a licence based on this health data.

Moving Forward The Cornwall HaLO tool was presented to the Licensing Act Committee, who approved its use in Hearings. This will involve a learning process about how to identify relevant evidence and communicate it to Committees.

This allows prioritisation of Licensing applications for which there is potential for relevant health input, conditions or objections, working alongside other Responsible Authorities. The HaLO tool also highlights a number of supporting alcohol related health indicators, which may be relevant to a Licensing application.

The tool will also prove invaluable in reviewing Cumulative Impact Zones, which will then help to create a level playing field for all premises in those areas, taking local health impact into consideration.

Cornwall’s HaLO data tool was invited to be demonstrated at the HaLO end of pilot event at PHE in London, and was then presented at the PHE National Licensing Network, The House of Lords Pre-legislative Committee, and the Local Government Association Licensing Conference.

Other arenas are also expressing an interest in the tool, such as Trading Standards, Planning, and for use in the wider Alcohol Needs assessment.

Cases HaLO data has now been used to help to impose restrictions on a town centre bar, preventing them from serving customers at tables and chairs in a pedestrianised area, in one of the violence hotspots in Cornwall.

The approach has also been helpful in enabling negotiations with a major festival, in order to increase welfare and safeguarding policies and provision.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 197 OFFICIAL

Local Alcohol Action Area Phase 2 In January 2017, Cornwall’s bid to become an LAAA area for the next 2 years was accepted, and announced on the Home Office website.129

The programme is intended to tackle alcohol-related crime and health harms, and to support the evolution towards a more diverse night-time economy.

The Home Office stated that:

“Alcohol-related crime and disorder costs an estimated £11 billion per year in England and Wales, and the government wants to support local communities in reducing the scenes of drunkenness and violence that blight communities, particularly at night.

The programme will run for 2 years and LAAA areas will also be put in touch with mentors who have successfully tackled the issues that they face and will come together to problem solve and share best practice.”

Background LAAA2 is a national scheme, led by the Home Office, supported by Public Health England, and promoted by Sarah Newton, Truro MP, Parliamentary Under Secretary of State at the Home Office for Vulnerability, Safeguarding and Countering Extremism.

LAAA’s three overall aims are:

1. Preventing alcohol-related crime and disorder; 2. Reducing alcohol-related health harms; 3. Generating economic growth by creating a vibrant and diverse night time economy.

The first LAAA phase was undertaken by the Coalition Government, out of which came initial attempts to incorporate health data into the Alcohol Licensing processes, via Local Authority Public Health Departments in their role as Licensing Responsible Authorities. When this yielded some successes, that aspect was broadened into the ‘Health as a Licensing Objective’ (HaLO) pilot scheme.

In that project we successfully gathered alcohol related health data, which began to introduce Public Health as a voice in alcohol Licensing processes and hearings. That project successfully found a way to find out what the data was telling us. Now, in this Local Alcohol Action Area scheme, Cornwall will seek to use that alcohol related data to respond to real local issues. This will be delivered, with support from

129 ‘Local alcohol action areas will tackle alcohol related harms’, Home Office (January 2017)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 198 OFFICIAL

The Home Office and national agencies, through a range of activities, guided by a 2 year Action Plan.

LAAA2 In HaLO we successfully gathered data to introduce a Health voice into Licensing processes, and in LAAA2 we will seek to cement that data (and more) into operational processes.

Cornwall applied to be an LAAA2 area in order to build on our positive contribution to the Public Health England HaLO pilot. Our application was signed off by the Head of Community Safety, the Director of Public Health and the Police and Crime Commissioner.

Nationally, the LAAA focuses on 5 challenges. Our application will target:

Challenge 1- “How can local areas improve the collection, sharing and use of data between A&E Departments, local authorities and the police?”

We intend to focus on this first area, with particular attention to the operational use of data, via the Public Health/Community Safety HaLO tool and Assault Related Injuries Database (ARID, used to collect data in ED and Minor Injuries Units across Cornwall, and shared with Safer Cornwall partners via Amethyst), with the intention of incorporating other datasets, for example South West Ambulance Service Foundation Trust data, and then applying it operationally to improve Licensing practice, reduce crime, and to identify and target where we can improve health outcomes.

Cornwall LAAA Aims Using our contribution to and participation in the HaLO pilot as the starting point, we aim:

1. To continue to expand the Cornwall HaLO dataset and tool; 2. To embed it in operational use; 3. To improve Licensing practice use of health related evidence in forming conditions and objections, in order to improve Licensing practice and make customers and localities more safe; 4. To contribute to the drive to reduce alcohol related violence; 5. To contribute to the drive to reduce the harmful impact of alcohol on localities and communities; 6. To identify and support problematic drinkers through support and (where necessary) enforcement; and 7. To contribute to reducing alcohol related hospital admissions.

The top two aims are the main focus of the Cornwall LAAA2 application, making use of data to identify and reduce alcohol related crime types and locations, and to support and rehabilitate people who are stuck in a cycle of alcohol related harm, which will reduce the burden on the NHS of alcohol related injuries and health conditions.

There will be benefits to the Night Time Economy, as a safe Licensed Trade will increase consumer confidence, which is vital in a tourist economy. The third aim will be covered by work in the Cumulative Impact Zones, in which we hope to analyse

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 199 OFFICIAL

the types of premises correlated with ASB and violence, and help Licensing Committees to develop an evidence based preference for premises of types which are not associated with disorder.

Cornwall LAAA Action Plan The full action plan is included at Appendix D.

This will be delivered, with support from The Home Office and national agencies through these activities, guided by a 2 year Action Plan, which covers these areas:

 Supporting Local Authority and Police Licensing cases;  Developing Public Health as an active Responsible Authority;  Improving operational use of ED assault data to address violence hotspots and improve Licensing practice;  Incorporation of wider datasets to enrich operational and strategic decisions, including inclusion of ambulance data into HaLO;  Better use of drink-driving and pedestrian casualty figures in Licensing and road safety processes;  Contributing alcohol related data to Trading Standards and other ‘Public Health and Protection’ processes;  Use of alcohol data to guide the development of Complex Needs Pathways, including the Troubled Families/Together for Families process, and improved use of Personalised Social Care and Health budgets;  Use of data for Alcohol Related Hospital Frequent Attender identification and outreach;  Developing a pathway for ‘Treatment Resistant Drinkers’, for both supportive and (where necessary) enforcement interventions;  Assessing the current makeup of the Night Time Economy in the 4 Cumulative Impact Zone towns (Truro, Newquay, Falmouth and Penzance) mapped alongside crime and ED data, in order to guide Licensing decisions and priorities towards a balance that reduces the likelihood of disorder and injury.

Partner responses and commitment to Cornwall’s LAAA Status “I am delighted that Cornwall has been selected for the LAAA scheme. I am sure that this will help all partners in Cornwall to deal with some of the negative impacts that alcohol can have on our towns, residents and visitors, so we can ensure that people can enjoy safe nights out.”

Alison Hernandez, the Devon and Cornwall PCC

“This is extraordinarily good news for Cornwall, that is has been successful in applying to become an LAAA. It provides an important opportunity to enhance local work to reduce the health harms related to alcohol, in specific and targeted ways.”

Richard Chidwick, PHE South West Programme Manager

We are proud of the work we’ve begun to do in Cornwall to bring health evidence into alcohol Licensing processes. This should help us to try to make people more safe. We are now very pleased to participate in the Local Alcohol Action Area scheme, and look forward to making more progress towards Cornwall becoming a more healthy and a yet more safe place to be.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 200 OFFICIAL

Kate Kennally, the Cornwall Council Chief Executive

“I have already seen the health evidence begin to make a difference in Licensing cases in areas with difficult issues to address. Hopefully our participation in the LAAA scheme will enable this to make a difference in many areas in Cornwall. The team that developed our HaLO tool in Community Safety and Public Health have done an outstanding piece of work, giving us yet another tool to help try and reduce the pressure on our health service. Now, being selected as an LAAA provides us with additional approaches that will also help us as we seek to address recent local concerns.”

Geoff Brown, Cornwall Council Communities Portfolio (previous)

“Cornwall’s contribution to the HaLO scheme has been a welcome addition to our Licensing evidence and decision making. Taking part in the LAAA scheme should enable us to take that progress further still, and begin to make a real difference to town centres and individuals in Cornwall.”

Malcolm Brown Chair of Cornwall’s Licensing Act Committee

Local Alcohol Action Areas demonstrate the Government’s commitment to work with industry, police, local authorities and other partners to make our streets safer. “Violent crimes involving alcohol have fallen over the last decade - but it is clear that alcohol misuse has a significant impact on communities across the country. "Our pubs, bars and restaurants make a valuable contribution to our economy and our society and it is important that people are able to enjoy them without the fear of becoming a victim of crime.

Sarah Newton, MP for Truro and Falmouth, Minister for Vulnerability, Safeguarding and Countering Extremism

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 201 OFFICIAL

Appendices A: IBA – Targeting the right areas B: Survey questions C: Evidence review for Nalmefene D: Alcohol Strategy/LAAA2 2017/18 Action Plan E: Case studies F: Public Health England Evidence Review G: NICE Guidelines – Map and Gap exercise H: Frequent Attenders – Case Studies

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 202 OFFICIAL

Appendix A: IBA – Targeting the right areas

The 2007 National Alcohol Strategy, “Safe Sensible Social,” highlighted the importance of early intervention. If consistently applied 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 every year, based on research by Wallace in 1988.

This is reiterated in the current (2012) National Alcohol strategy:

“Identification and Brief Advice (IBA) is a simple intervention aimed at individuals who are at risk through drinking above the guidelines, but not typically seeking help for an alcohol problem. IBA has been proven to reduce drinking, leading to improved health and reduced calls on hospital services. At least one in eight drinkers reduce their drinking as a result of IBA.”130

There is also increasing evidence of financial savings and efficiencies connected to investing in earlier interventions.

In Changing Health Choices: A review of the cost-effectiveness of individual-level behaviour change interventions131 different behaviour change needs (e.g. alcohol, obesity, exercise, smoking) were evaluated for the cost effectiveness of proven interventions against levels of need.

This demonstrated that consumption of alcohol has risen by 19% over the last three decades and over a quarter of England’s adult population (10.5 million) are drinking at hazardous levels.132

It also put the cost of alcohol-related harm to England and Wales in the region of £20 billion to £55 billion. Limiting these figures to those related to health, absenteeism and crime generates an annual cost of £12.6 billion to England annually.133 As these costs are based on historic calculations, with the increases seen in alcohol-related hospital admissions, this figure is considered to be a considerable under estimate.

In the NHS alone, alcohol related conditions cost approximately £2.7 billion in 2006 and the majority of this cost (above £2.1 billion) is related to hospital admissions. The UK Alcohol Treatment Trial134 found that evaluated alcohol therapies saved about five times what they cost to public sector resources including health and social care and criminal justice, leading to the conclusion that

130 Department of Health, 2012 131 'A review of the cost-effectiveness of individual level behaviour change interventions', NorthWest Public Health Observatory (February 2011) 132 ‘Too much of the hard stuff: what alcohol costs the NHS; The NHS Confederation Briefing. Issue 193’, Royal College of Physicians (January 2010) 133 NICE – 2010: Alcohol use disorders: preventing harmful drinking, Costing Report 134 UKATT Research Team 2005: British Medical Journal, 331:544

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 203 OFFICIAL

for every £1 spent on evidence based alcohol treatment, there is a net saving of £5 to the public sector.135

Around 98% of England’s population are registered with a general practice, so general practice can make a significant contribution to reducing alcohol- related harm. Studies have indicated that brief advice with a GP or practice nurse leads to one in eight people reducing their drinking to sensible levels.

A modelling report by the School of Health and Related Research at the University of Sheffield examined the cost-effectiveness of screening and brief interventions in three contexts: for the intervention to take place at the next GP consultation, the next registration with a new GP, or the next A&E attendance.

The brief interventions ranged between 5 and 25 minutes and the incremental cost per ‘Quality Adjusted Life Year’ ranged from £1,697 to £23,077. Within each context, screening and brief intervention were found to be cost-effective and in some scenarios, screening and brief interventions were cost saving compared to doing nothing (i.e. the intervention provided both additional health benefits and an overall reduced health service cost). From this economic analysis, NICE conclude that NHS and personal social service savings of up to £124.3 million are realisable over 30 years.

All this adds up to making investment in behaviour change training for General Practitioners and Practice Nurses beneficial for clients and for treatment system effectiveness, at a very low cost.

The report concluded by commenting that further researched evidence is needed about the cost-effectiveness of brief interventions outside Primary Care. In other words, we now know that Brief Interventions in Primary Care make a positive impact on drinking patterns, creating health benefits for patients and reducing costs to the treatment system. We can conclude that Brief Interventions (IBA) elsewhere will add to this positive effect, but no-one has yet gathered researched evidence to this effect.

This is backed up by the World Health Organisation which concluded that we know that:

 There is extensive and consistent evidence that brief advice in health care settings reduces alcohol-related harm;  There is consistent evidence that brief interventions are cost–effective;  There is consistent evidence that behavioural and pharmacological therapies are effective in treating alcohol use disorders. But that we do not know:

 The extent to which brief advice works in non-health care settings136

135 Review of the effectiveness of treatment for alcohol problems – 2006: NTA

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 204 OFFICIAL

Low level alcohol interventions sit in two broad areas:

Identification and brief advice (Tier 1) These include screening for problem drinking, identification of the level of problem and brief advice to reduce alcohol-related harm (or onward referral for more intensive intervention if required). Identification and Brief Advice can be accessed in Cornwall in a range of settings, including GP surgeries, A&E at Royal Cornwall Hospital, Treliske and pharmacies, and it is a routine part of assessment for anyone coming into contact with the Criminal Justice System.

Open access, non-care planned interventions (Tier 2) These include provision of open access facilities and outreach that provide alcohol specific advice, information, support and extended brief interventions to help people with alcohol problems to reduce harm and to provide assessment and referral into care-planned treatment for those with more serious problems.

Addaction provide a GP based service in almost every GP surgery across Cornwall, as well as a telephone helpline, and support is also available through Alcoholics Anonymous. A&E at Treliske have also provided some extended interventions and the homeless can access services through outreach at St Petroc’s and Health for Homeless.

Historically, data on people who access these types of services has not been consistently collected or monitored. This has proven difficult elsewhere as well, as seen in the SIPS research).

Cornwall DAAT has established an Alcohol Awareness (IBA) Toolkit in line with national guidelines, which forms the basis of what is being trained in Primary Care and other settings in the community. This includes the WHO identification tools AUDIT-C and AUDIT (The Alcohol Use Disorders Identification Test) as well as the Department of Health Brief Intervention advice guidance and handout.137

Guidance around Information and Brief Advice services Priorities for targeting IBA services are provided in the Department of Health Commissioning Guidance, ‘Signs for Improvement’138

This states that “IBA can be effectively implemented in a number of settings including:

136 Evidence for the effectiveness and cost-effectiveness of interventions to reduce alcohol-related harm (2009) 137 ’AUDIT Guidance’, Alcohol Learning Centre (2017) 138 'Signs for improvement - commissioning interventions to reduce alcohol-related harm', Department of Health (July 2009)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 205 OFFICIAL

 Primary Care – targeted at increasing and higher risk groups  A&E Departments – possibly with the use of alcohol liaison Nurses or alcohol Health workers  Specialist settings – e.g. maxillofacial clinics, fracture clinics, sexual health clinics  Criminal justice settings such as Probation and arrest referral schemes.”

This is then fine-tuned to identify specific populations needing more help in being encouraged to drink less:

“In Primary Care:  New registrants; Commission identification and brief advice as per the Directed Enhanced Service (DES) for all newly registered patients.  At risk groups; Consider extending coverage through a Local Enhanced Service (LES) in Primary Care to additional at risk groups such as all men aged 35-54 or those patients on existing QOF registers.”

And “In hospital settings:  IBA in A&E and specialist units (e.g. fracture clinics): Commission a specialist alcohol nurse linked to every accident and emergency unit where there is apparent local need.”

NICE guidance goes further in identifying the ‘at risk groups.’139

Evidence for the effectiveness of IBA interventions Overall bank of guidance and research:

Alcohol Learning Centre Brief Advice/IBA pages: http://www.alcohollearningcentre.org.uk/Topics/Browse/BriefAdvice/ NICE Guidance: http://guidance.nice.org.uk/PH24

a) Clarifying alcohol brief interventions: 2013 update 140

Effective brief advice:

Based on the findings of the SIPS trial, “additional brief advice or extended intervention did not show better outcomes than simple feedback plus a leaflet … it is likely that identification using a validated tool and feedback is essential – and not to be substituted by leaflets alone.”

NHS IBA monitoring:

139 ‘Alcohol-use disorders: preventing the development of hazardous and harmful Drinking’, NICE (June 2010) 140 ‘Clarifying alcohol brief interventions: 2013 update’, Alcohol Academy (2013)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 206 OFFICIAL

“‘Read codes’ are available to record IBA delivered in primary care practices. However, there has been no national data collection system for recording brief interventions delivered in England outside of primary care or the National Drug Treatment Monitoring System (NDTMS).”

IBA monitoring challenges elsewhere: “Further questions remain over the benefits of monitoring activity in other settings, particularly around the risks of creating extra time barriers for busy practitioners. However, for commissioners who are seeking to implement interventions and keep track of actual activity, there is a clear desire to establish data collection and monitoring approaches. Assessing the quality of delivery is another key consideration. A variety of approaches are being rolled out, and a recent product known as an ‘IBA tracker’ has been offered to commissioners.” b) Effectiveness of Brief Interventions in health settings141

Brief interventions for hazardous and harmful alcohol use are effective in reducing alcohol consumption, mortality, morbidity, alcohol-related injuries, alcohol-related social consequences, healthcare resource use and laboratory indicators.

Six systematic reviews demonstrated that interventions delivered in primary care are effective in reducing alcohol consumption, mortality, morbidity, alcohol-related injuries, alcohol-related social consequences, healthcare resource use and laboratory indicators (1-6).

Two systematic reviews specifically focusing on the use of brief interventions in emergency care found limited evidence for the effectiveness of brief interventions in emergency care settings (7, 8). A further review presented inconclusive evidence of the effectiveness of brief interventions in inpatient and outpatient settings (9).

1. Ashenden, R., Silagy, C., & Weller, D. (1997). A systematic review of the effectiveness of promoting lifestyle change in general practice. Family Practice, 14 (2): 160-175. 2. Ballesteros, J., Duffy, J. C., Querejeta, I., Arino, J., & Gonzalez-Pinto, A. (2004). Efficacy of brief interventions for hazardous drinkers in primary care: systematic review and meta-analyses. Alcoholism: Clinical & Experimental Research, 28 (4): 608-618. 3. Bertholet, N., Daeppen, J. B., Wietlisbach, V., Fleming, M., & Burnand, B. (2005). Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Archives of Internal Medicine, 165 (9): 986-995. 4. Kaner, E. F. S., Beyer, F., Dickinson, H. O., Pienaar, E., Campbell, F., Schlesinger, C., Heather, N., Saunders, J., & Burnand, B. (2007). Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 18;(2):CD004148.

141 ‘Evidence for BI: Overall Effectiveness’, PHEPA (April 2009)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 207 OFFICIAL

5. Poikolainen, K. (1999). Effectiveness of brief interventions to reduce alcohol intake in primary health care populations: a meta-analysis. Preventive Medicine, 28(5): 503-9. 6. (6) Whitlock, E. P., Polen, M. R., Green, C. A., Orleans, T., Klein, J., & U.S.Preventive Services Task Force (2004). Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 140 (7): 557-568. 7. D'Onofrio, G. & Degutis, L. C. (2002). Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Academic Emergency Medicine, 9(6): 627-38. 8. Havard, A., Shakeshaft, A., & Sanson-Fisher, R. (2008). Systematic review and meta-analyses of strategies targeting alcohol problems in emergency departments: interventions reduce alcohol-related injuries. Addiction, 103(3): 368- 76; discussion 377-8. 9. Emmen, M. J., Schippers, G. M., Bleijenberg, G., & Wollersheim, H. (2004). Effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting: systematic review. BMJ, 328 (7435)

c) Effectiveness of Brief Interventions for both men and women142

Brief interventions are effective in reducing alcohol consumption in both men and women.

Brief interventions are effective in reducing alcohol consumption in both men and women (1-3), with a potential trend towards increased effectiveness amongst men (4-6), although this may be influenced by the presence of assessment reactivity among female control group subjects.

1. (Ballesteros, J., Duffy, J. C., Querejeta, I., Arino, J., & Gonzalez-Pinto, A. (2004). Efficacy of brief interventions for hazardous drinkers in primary care: systematic review and meta-analyses. Alcoholism: Clinical & Experimental Research, 28 (4): 608-618. 2. Bertholet, N., Daeppen, J. B., Wietlisbach, V., Fleming, M., & Burnand, B. (2005). Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Archives of Internal Medicine, 165 (9): 986-995. 3. Whitlock, E. P., Polen, M. R., Green, C. A., Orleans, T., Klein, J., & U.S.Preventive Services Task Force (2004). Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 140 (7): 557-568.

142 Evidence for BI: Effectiveness in Men and women’, PHEPA (April 2009)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 208 OFFICIAL

4. Kahan, M., Wilson, L., & Becker, L. (1995). Effectiveness of physician-based interventions with problem drinkers: a review. Canadian Medical Association Journal, 152(6): 851-859. 5. Kaner, E. F. S., Beyer, F., Dickinson, H. O., Pienaar, E., Campbell, F., Schlesinger, C., Heather, N., Saunders, J., & Burnand, B. (2007). Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 18;(2):CD004148. 6. Poikolainen, K. (1999). Effectiveness of brief interventions to reduce alcohol intake in primary health care populations: a meta-analysis. Preventive Medicine, 28(5): 503-9. d) Very Brief Interventions are as effective as lengthier interventions143

Even very brief interventions may be effective (1) with little evidence for an additional positive impact resulting from an increased dose of intervention (2-4).

1. Whitlock, E. P., Polen, M. R., Green, C. A., Orleans, T., Klein, J., & U.S.Preventive Services Task Force (2004). Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 140 (7): 557-568. 2. Ballesteros, J., Duffy, J. C., Querejeta, I., Arino, J., & Gonzalez-Pinto, A. (2004). Efficacy of brief interventions for hazardous drinkers in primary care: systematic review and meta-analyses. Alcoholism: Clinical & Experimental Research, 28 (4): 608-618. 3. Bertholet, N., Daeppen, J. B., Wietlisbach, V., Fleming, M., & Burnand, B. (2005). Reduction of alcohol consumption by brief alcohol intervention in primary care: systematic review and meta-analysis. Archives of Internal Medicine, 165 (9): 986-995. 4. Kaner, E. F. S., Beyer, F., Dickinson, H. O., Pienaar, E., Campbell, F., Schlesinger, C., Heather, N., Saunders, J., & Burnand, B. (2007). Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 18;(2):CD004148. e) Brief Interventions effective for young people144

There is some evidence for the effectiveness of brief interventions in young people (aged up to 25 years (1-3).

1. D'Onofrio, G. & Degutis, L. C. (2002). Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Academic Emergency Medicine, 9(6): 627-38. 2. Hunter Fager, J. & Mazurek Melnyk, B. (2004). The effectiveness of intervention studies to decrease alcohol use in college undergraduate

143 ‘Evidence for BI: Dose of brief interventions’, PHEPA (April 2009) 144 ‘Evidence for BI: Brief interventions in young people’, PHEPA (April 2009)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 209 OFFICIAL

students: an integrative analysis. Worldviews on Evidence-Based Nursing, 1(2): 102-119. 3. Tait, R. J. & Hulse, G. K. (2003). A systematic review of the effectiveness of brief interventions with substance using adolescents by type of drug. Drug and Alcohol Review, 22(3): 337-346

The role of training in delivering alcohol IBA in non-medical settings Broadening the base of IBA delivery”145

“As alcohol IBA has been found effective in medical/clinical/specialist settings146, there has been a drive to expand its use beyond these contexts into a range of other settings, to encourage wider groups of professionals – such as pharmacists, educationalists, youth workers, social workers and criminal justice professionals to incorporate IBA approaches into their everyday practice.

However, whilst there is good evidence for its use and effectiveness within general practice and hospital settings, its acceptability and effectiveness in a wider range of contexts is less clear, and there are continuing problems implementing IBA even within the traditional health care contexts.147

“One of the most common responses to address apparent barriers to delivering IBA is to provide training or to suggest additional, improved training for professional workers in touch with population groups who are likely targets for IBA intervention. While there are numerous training activities and programmes, very few have been well described and evaluated. It is recognised, however, that training alone is not sufficient to ensure that IBA will be delivered.148

Training may contribute to changing professional behaviour and providing the knowledge and skills necessary to deliver IBA; but organisational factors, what Cruvinel et al. (2013) have called ‘organisational climate’, specific work context, and the wider environment are all important determinants of IBA delivery149

In other words, the emphasis has been on changing professional behaviour and more effort is needed to understand and respond to the bigger challenges posed by the need for organisational and systems change.”

“4.1 Training does not result in IBA delivery”

“4.3 Main lessons

145 ARUK June (2016) 146 Kaner et al. (2007) 147 Thom et al. (2014) 148 Babor andHiggins-Biddle, 2000; Coogle and Owens, 2015; Schmidt et al., 2015; Thom et al., 2016a 149 Nilson, 2010

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 210 OFFICIAL

A number of main messages, which echo and augment findings from other research, emerge from the study.

 IBA, in the form delivered in health care settings, may not be practicable, acceptable, or appropriate for non-health contexts. There is a need, therefore, to consider what the core elements of an IBA intervention are and the extent to which IBA can be adapted to suit different contexts and working practices;  A shift away from a standardised ‘manual’ approach towards a more flexible menu of optional training contents and methods of delivery may be required to suit the diverse and changing needs of professional groups and their organisations;  As well as imparting knowledge and skills, training content may need to pay more attention to: aspects of role security and role relevance which may need strengthening; issues around ethical dilemmas; and the current working practices of potential trainees;  Training needs to be related more directly to organisational cultures, behaviour, and development needs as well as retaining its focus on professional attitudes and behaviour. Prior to delivering training, efforts may be needed to assess and incorporate organisational factors into training programmes;  Successful training that translates into practice depends, at least partly, on planning and commissioning. Delivery of interventions post training may stand a better chance if, at the commissioning stage, consideration is given to: o what kind of training is best suited to the target group/ work context; o the extent of organisational support for the translation of training to practice; o the potential to enhance supportive structures, and o facilitate the sustainability of post training intervention.  Understanding the structure of an organisation and its position within complex local and national networks of services and care/control systems is relevant both to identifying the potential uses of IBA and to developing appropriate training;  Policy makers, commissioners, managers and employers as well as practitioners need to be convinced of the value of IBA to the client group. Different arguments, evidence and incentives are likely to be needed to appeal to those groups;  In promoting further roll out of alcohol IBA in non-health settings, longer-term planning may be useful to ensure that organisational and professional commitment is sufficient to meet the challenges, that there is an appropriate target group for the delivery of IBA, and that training and support for implementation is tailored to the specific needs and cultures of organisations, professionals and client groups.”

“The fact that training does not appear to have much impact on IBA delivery does not mean that it should be abandoned.

As Heather (2016) argues, despite the lack of research evidence for IBA implementation in non-health contexts, the critical question for evaluating the effectiveness of IBA might be: “What kind of brief intervention, delivered in what form, by what kind of professional, is most effective in reducing alcohol

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 211 OFFICIAL

consumption and/or problems in what kind of excessive drinker, in what kind of setting and circumstances?”

The question is complex and the answers will be equally complex, which implies that the development and delivery of training needs to respond to a more complex model of behaviour change than has been the case to date in most IBA training and delivery.

The findings from this project suggest that a more complex model of behaviour change requires inclusion of at least the organisational and systemic factors that are likely to influence the potential for individuals to change their behaviour. This applies to practitioners and their agencies as much as to the clients they seek to influence.”

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 212 OFFICIAL

Appendix B: Survey questions

1. What is good and most helpful about drug and alcohol services in Cornwall? 2. What is not helping or a barrier to your recovery? 3. How many people do you know who have drug problems but are not getting help? 4. Why are they not seeking help? 5. Additionally, drug related deaths are going up sharply nationally and locally. Why do you think that is? 6. What more could be done to prevent drug related deaths in Cornwall? 7. If we could change only 3 things to improve help to reduce harm and promote recovery from alcohol and drug problems, what would they be?

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 213 OFFICIAL

Appendix C: Evidence review for Nalmefene

Nalmefene (also known as Selincro) is an opioid antagonist and NICE Guidance150 recommends it as a possible treatment for people with alcohol dependence who:

 Are still drinking more than 7.5 units per day (for men) and more than 5 units per day (for women) 2 weeks after an initial assessment, and  Do not have physical withdrawal symptoms, and  Do not need to either stop drinking straight away or stop drinking completely.

Nalmefene should only be taken if the person is also having ongoing support to change their behaviour and to continue to take their treatment, to help them reduce their alcohol intake.

The manufacturer, Lundbeck, also provided a template letter for GP patients on commencement of Nalmefene prescribing summarising its purpose:

Nalmefene is recommended within its marketing authorisation, as an option for reducing alcohol consumption, for people with mild alcohol dependence:

 Who have a high drinking risk level or above (defined as alcohol consumption of ≥ 7.5 units per day for men (60g) and ≥ 5 units per day for women (40 g), according to the WHO’s drinking risk levels)  Without physical withdrawal symptoms, and  Who do not require immediate detoxification

The marketing authorisation further states that Nalmefene should:

 Be initiated only in patients who continue to have a high drinking risk level at 2 weeks after initial assessment, and that it should  Only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption.

The British Medical Journal151 guidance for clinical use states that such psychosocial support can be delivered in primary care, and this seems to be a cost effective approach to dealing with higher risk drinking.

Local Pharmaceutical Prescribing Policy in Cornwall According to the British National Formulary Guidance, Nalmefene is Red/Amber,152 locally it is listed as ‘Amber, Specialist only’.153

150 ‘Nalmefene for reducing alcohol consumption in people with alcohol dependence’, NICE (2014) 151 ‘Assessment and management of alcohol use disorders’, BMJ (February 2015) 152 ‘Alcohol Dependence (Drugs Guidance)’, Bristol, North Somerset and South Gloucestershire Health Community (December 2015) 153 ‘Cornwall joint formulary recommended choices’, NHS (2017)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 214 OFFICIAL

Psychosocial support As stated in the Lundback GP patient letter, Nalmefene should “only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption.”

Within the original research, this psychosocial element was listed as ‘The BRENDA Model’154 which has 6 components:

1. A biopsychosocial evaluation; 2. A report of findings from the evaluation given to the patient; 3. empathy; 4. Addressing patient needs; 5. Providing direct advice; and 6. Assessing patient reaction to advice and adjusting the treatment plan as needed.155

In practice, Lundbeck outlined that this meant “simple ongoing medical support and advice focused on treatment adherence and reducing alcohol consumption. It can be delivered in a routine primary care consultation by a range of staff and is similar to motivational health advice and support given to patients with common long term conditions (e.g. Type II diabetes). Some areas have utilised in surgery community alcohol workers to provide this”, and they summarised the elements of this psychosocial approach as:

 Monitoring alcohol consumption  Assessing overall progress  A review of treatment goals  Monitoring medication adherence  Providing feedback and support

No clarification has been given about capacity models, or effective treatment duration.

Discrepancies about Psychosocial Support definitions It was picked up fairly rapidly that this defined level of psychosocial support within the Nalmefene guidance contained some problematic issues. Outlines of best practice in the UK156 contain these types of definitions of psychosocial interventions:

154 ‘Nalmefene: a new approach to the treatment of alcohol dependence’, Paille, F and Herve, M (August 2014) 155 ‘The BRENDA Model: Integrating Psychosocial Treatment and Pharmacotherapy for the Treatment of Alcohol Use Disorders’, Starosta, A et al (October 2009) 156 ‘Best Practice Packages of Care P1’, PHE Alcohol Learning Resources (July 2011)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 215 OFFICIAL

 Care Cluster 1 - Harmful drinking and mild dependence – Psychosocial interventions: Brief advice should be given and assessed for effectiveness at key working sessions. If needed, a package of less intensive brief CBT/MET based treatment lasting up to 4 sessions should be offered.

 Care Cluster 2 - Moderate dependence (without complex needs) – Psychosocial interventions: A package of less intensive CBT based treatment lasting up to 4 sessions should be offered. If needed, a package of 12 weeks of CBT based treatment or a day treatment programme may be required.

Within the NICE Guidelines157 it did underline the requirement for psychosocial support, stating that Nalmefene can “… only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption …”

The committee also acknowledged that most psychosocial interventions currently provided are below the standard outlined in the NICE Guidance, and as a concession allowed the Nalmefene trials to compare with existing substandard services, rather than the evidenced best practice:

“The Committee understood that although the NICE guideline on alcohol-use disorders recommends a specific intensity, duration and frequency of psychosocial intervention, the usual psychosocial intervention provided in clinical practice was brief or extended brief interventions and that both the duration and frequency of these interventions were shorter than that recommended in the NICE guideline on alcohol-use disorders.

The Committee concluded that psychosocial intervention in the form of brief or extended brief intervention is a valid comparator for nalmefene plus psychosocial support and the most appropriate comparator for this appraisal.”158

In other words, Nalmefene was not tested against international or national psychosocial best practice guidance, but against what appeared to be on offer within treatment models that did not achieve those best practice standards.

Research into limitations and problems Since its UK registration in November 2014, independent academic researchers have continued to focus on Nalmefene’s effectiveness, the psychosocial support, and the research process behind its accreditation.

“Weak evidence on Nalmefene creates dilemmas for clinicians and poses questions for regulators and researchers” 159

157 ‘Nalmefene for reducing alcohol consumption in people with alcohol dependence’, NICE (November 2014) 158 ‘Nalmefene for reducing alcohol consumption in people with alcohol dependence (Conclusions)’, NICE (November 2014)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 216 OFFICIAL

“Efficacy data used to support the licensing of nalmefene suffer from risk of bias due to lack of specification of a priori outcome measures and sensitivity analyses, use of post-hoc sample refinement and the use of inappropriate comparators. Despite this, evidence for the efficacy of nalmefene in reducing alcohol consumption in those with alcohol dependence is, at best, modest, and of uncertain significance to individual patients. The relevance of existing trial data to routine primary care practice is doubtful.” 160

Psychosocial Mode “No data are available on the adequacy of the psychosocial intervention ‘BRENDA’ used in both arms in the Lundbeck trials. NICE guidelines recommend more intensive psychosocial support over 12 weekly sessions (of CBT, for example) in harmful drinking and mild dependence before pharmacotherapy is considered. A more intensive psychosocial intervention than BRENDA would also therefore seem an appropriate comparator.”

Conclusions “Problems with the registration, design, analysis and reporting of clinical trials of Nalmefene did not prevent it being licensed and recommended for treating alcohol dependence.”

“… It is unclear how psychosocial support will be provided and resourced in practice. These issues also give rise to dilemmas for commissioners of services.”

Commentary “… Nalmefene was licensed and recommended despite 'problems with the registration, design, analysis and reporting of clinical trials' for the drug.”161

“The Lundbeck sponsored trials also used a psychosocial intervention known as 'BRENDA', but this has been questioned since BRENDA is less intensive than the psychosocial interventions recommended by NICE for the treatment of alcohol dependence.”

Related Research Other studies into the cost effectiveness and efficacy of Namalfene found little evidence to support its use:

159 ‘Weak evidence on nalmefene creates dilemmas for clinicians and poses questions for regulators and researchers’, Addiction, UKCTAS (June 2016) 160 Post hoc sample refinement is when research is conducted which covers a wide range of samples. These are then split into small defined segments, with the resulting published research outcomes based on the best selected segments rather than the whole population sample 161 ‘Concerns over evidence for nalmefene: where next for drugs to treat dependence?’, Alcohol Policy UK (July 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 217 OFFICIAL

“the value of nalmefene for treatment of alcohol addiction is not established”162 “ … no difference between nalmefene and placebo on mortality or quality of life.”

And, “ … participants were more likely to withdraw from the study if they had received Nalmefene.”163

Increasingly it has been concluded that Nalmefene trials should have undertaken comparisons with the much cheaper, already available Naltrexone, but these trials were not performed:

“ … the existing RCTs only compared Nalmefene with placebo. However, Nalmefene has a very similar biochemical profile to Naltrexone, another opioid antagonist drug that is generic (and therefore cheap), already licensed for the treatment of alcohol dependence, and is recommended by NICE for this purpose. Indeed, the absence of this comparative data was highlighted by the German equivalent of NICE.”

“ … it remains to be seen whether the superiority of Nalmefene compared to placebo would still be evident if both were offered alongside a ‘gold standard’ psychosocial intervention.”

All of this controversy about the skewed and limited research was also reported and summarised by Drink and Drugs News:164

“New alcohol medication Selincro is steeped in controversy.”

This summary described Nalmefene as “an expensive and inappropriate medicalisation of lesser degrees of dependence based on unproven effectiveness”

This report picked up on the “after-the-event (or post hoc) sub-sampling”, and was critical of the roles of both the European Medicines Agency (EMA) and NICE in Nalmefene’s authorisation, stating that the EMA had claimed that post-hoc sampling was common and appropriate, and that NICE had argued that Naltrexone was geared towards other types of outcomes for problematic drinkers, i.e. abstinence, rather than reduced consumption.

The report concluded that "in fact, Naltrexone usually promotes reduced drinking, and does so among the same types of drinkers”, and questioned whether there had been a strategy to manipulate the market for Nalmefene.

162 ‘Cost-Effectiveness of Nalmefene: Exaggerated Expectations or Fallacy?’, Naudet et al, Alcohol and Alcoholism (September 2016) 163 ‘Nalmefene for alcohol dependence: new evidence casts doubt over NICE recommendations’, The Mental Elf (2016) 164 ‘New alcohol medication Selincro is steeped in controversy’, Drink and Drugs News (November 2016)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 218 OFFICIAL

Similarly, Findings conducted a literature review and reported on this research in late 2015,165 their conclusion was that “shortcomings in the manufacturer’s trials and the analyses on which authorisation was based have led to concerns that less severe forms of dependence are being inappropriately perhaps ineffectively medicalised, displacing psychosocial support.”

They also concluded that “another concern is that there are reasons to believe that the parent drug, Naltrexone, would be just as effective and much cheaper.”

Research Conclusion A new expensive drug has been licensed and promoted when a more universally available cheaper medication, Naltrexone,166 appears to be as effective, and when the missing ingredient in trials and treatment is NICE standard psychosocial support.167

165 ‘Risks and benefits of nalmefene in the treatment of adult alcohol dependence: as systematic literature review...’, Palpacuer et al (2015) 166 ‘Cornwall joint formulary recommended choices’, NHS (2017) 167 ‘Cornwall joint formulary recommended choices’, NHS (2017)

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 219 OFFICIAL

Appendix D: Alcohol Strategy/LAAA2 2017/18 Action Plan

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 220 OFFICIAL

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 221 OFFICIAL

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 222 OFFICIAL

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 223 OFFICIAL

Full Alcohol Strategy Action Plan 2017 Update:

“TAKING RESPONSIBILITY FOR ALCOHOL”

3 overall objectives targeting People, Services, and Communities:

1: ENABLE PEOPLE TO MAKE INFORMED CHOICES ABOUT ALCOHOL We aim to help people in Cornwall to become better informed about responsible drinking and safe alcohol intake levels, by giving relevant advice, information and support in order to reduce alcohol related harm.

2: IMPROVE SERVICES TO REDUCE THE HARMS ASSOCIATED WITH ALCOHOL We aim to reduce the risk of alcohol related harm to individuals and families by improving effective alcohol services in the community, in the NHS and hospitals, in the voluntary sector and in the Criminal Justice System, in order to reduce alcohol related hospital admissions and support recovery from problematic alcohol use.

3: PARTNERSHIPS THAT REDUCE ALCOHOL'S NEGATIVE IMPACT ON COMMUNITIES We aim to work effectively in partnerships to promote best practice around safe alcohol retail, maintaining safe localities and communities, and to have well planned responses to alcohol related issues with the long term goal of reducing disruption to the community. The Alcohol Strategy is arranged in 8 themes: 1. Advice and Information: (Jez Bayes) Helpful preventative and early intervention activities, including Identification and Brief Advice, population level messaging and targeted social marketing. 2. Children, Young People, Parents and Families: (Viv Hughes) Education, youth, family and household interventions, Including Together for Families. 3. Community Safety Schemes: (Jez Bayes) Reducing the harmful impact of alcohol on Cornish streets, including Anti-Social Behaviour (ASB), and Fire and Rescue. 4. Criminal Justice Interventions: (Miles Topham / Phil Kennedy) Appropriate interventions to reduce alcohol related offences, including diversionary and sentencing pathways. 5. Domestic Abuse and Sexual Violence: (Laura Ball) Good pathways between alcohol, domestic abuse and sexual violence services, including MARAC referrals and sentencing pathways. 6. Employment, Deprivation and Inclusion: (Marion Barton) Interventions to reduce alcohol related employment problems, including Social Care, Homelessness and Housing. 7. Health, Treatment, Aftercare and Recovery: (Kim Hager / Angela Andrews) Easy access to treatment, and effective care throughout, including hospital admissions, mental health and the treatment system. 8. Licensing, Alcohol Retail and the Night Time Economy: (Jez Bayes) Promoting and supporting a safe, responsible, successful alcohol trade, including Best Bar None and bar staff training.

Equity and diversity are key aspects of all 10 of these areas, with implications for equitable service delivery and access, encompassing such issues as gender, sexual orientation, disability, age, isolation, vulnerability, ethnicity, religion and beliefs.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 224 OFFICIAL

CIOS Alcohol Strategy 2016-19 ACTION PLAN Delegated Lead Summary: Next Action: and other Thematic Area: involved staff and agencies: 1. Advice and Information: Jez Bayes Helpful preventative and early intervention activities; Shevaughan including Identification and Brief Advice, population level messaging Tolputt and targeted social marketing. (CC Comms / PH) 1.01: Continue to promote and train early intervention, with Jez Bayes 2016 trained: To be trained: consistent use of proven screening tools in all relevant settings and Angela Andrews Fire and Rescue / Home Fire Safety CRC; services, including Health Checks. (DAAT) Checks IBA Follow Up Visitors; NPS; Treliske Hospital (AUDIT-C) via Volunteers; 1.02: Target services not yet reached for more IBA training: Video modules and Volunteer reps; Social Care Services; Within front line community and criminal justice settings outside Stonham and other Housing services; Health Visitors; healthcare; DASV services. Midwives; Within targeted health care settings and services for specified Mental Health / health conditions, as guided by the alcohol related hospital Fire and Rescue / Home Fire Safety Outlook SW / Beme; admissions evidence; Checks IBA Follow Up Visitors; Pharmacy / Primary Within any healthcare commissioning, in line with the 2014 Service to be established. Care; framework for all nurses and allied health professionals. Trading Standards / Priorities PHAP; 1.03: Deliver ongoing support to remove any barriers to IBA delivery. Target services not yet reached for Other requests more IBA training: received and banked 1.04: Evaluate findings from IBA delivery monitoring to target service Within front line community settings for follow up. commissioning, training and delivery, and to focus further intervention outside healthcare; training, e.g. Motivational Interviewing. Within targeted health care settings Monitoring System and services for specified health tba: 1.05: Reassess agencies and services trained to ensure training is conditions, as guided by the alcohol Meet with being used and screening is occurring. related hospital admissions management of evidence; trained agencies. Within any healthcare commissioning, in line with the 2014 STP process could framework for all nurses and allied fund delivery / health professionals. monitoring / Deliver ongoing support to remove evaluation / any barriers to IBA delivery; targeting?

Establish IBA delivery monitoring in SLAs and recording tools if possible:

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 225 OFFICIAL

Evaluate findings from IBA delivery monitoring to target service commissioning, training and delivery, and to focus further intervention training, e.g. Motivational Interviewing;

Reassess agencies and services trained to ensure training is being used and screening is occurring.

1.06: In partnership with Public Health, the Health and Wellbeing Jez Bayes WWYDC research Board, and the Safer Cornwall Partnership, create targeted and Shevaughan 10 Action Points for consideration in updated campaign population level alcohol social marketing campaigns, such as ‘What Tolputt material: Will Your Drink Cost?’, pedestrian road safety information, and (CC Comms / PH) evaluate how to improve the effectiveness of such messaging. Amethyst 1. Positive framed posters produce a short term improvement in responsible drinking attitudes, which could reduce an amount of immediate harmful or binge drinking during a Pub or Club visit, although this is not universal as several participants had a greater willingness to consume alcohol after seeing the posters. 2. This campaign will reduce violent tendencies in a just over a third of the participants who actually commit such acts. 3. Participants liked the visual separation of the tear, which made them think about the consequences of alcohol related violence, but some disliked the photos used, which seemed staged and unrealistic. 4. Images should feature people of the same age as the target audience. 5. Images need to avoid confusion over the transition or connection of the positive top image to the negative image consequence, and conveying unintended sexist implications about relationships. 6. Images in this campaign theme could cause distress, and so they need to be accompanied by information about how to change, or where to get support or advice. The campaign will be relatively ineffective without any guidance on how to live a healthy lifestyle, rather than just a warning to do so.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 226 OFFICIAL

7. The death of a victim was highlighted as the most effective deterrent of being involved in alcohol related violence. 8. The financial cost on emergency services lowest proportion of people agreeing this would affect their levels of drinking. 9. Effects on others was highlighted as being the most effect deterrent of alcohol use, followed by impact on self with the breakdown of a relationship being the most deterring as a consequence. 10. Repetition and presentation of material over long periods of time using a combination of sources and methods, during different periods of exposure, as well as describing the motives of the appeal. WWYDC action tba. Update WWYDC Autumn/Winter 2016 Successful Festive messaging Christmas Drink campaign delivered on social media Driving Campaign and local media. FRS / ST 1.07: Support, engage with, and locally deliver national Public Health Jez Bayes One You launched. National CMO messaging and campaigns, such as new alcohol messaging after the Shevaughan Cornwall Website. messaging? consultation period ends in April 2016, and the new ‘One You’ health Tolputt Use of PHIL/HPS. PHE update: messaging theme. (CC Comms / PH) RCS public event/media. No CMO national message funding outside ‘One You’ UKCTAS / SPHR / Sheffield? LSHTM? Winchester Uni? 1.08: Improved alcohol advice and information for vulnerable and Jez Bayes Advice for elderly updated. Promoted via CC PH hard to reach groups, such as the disabled, hearing impaired and those with learning difficulties.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 227 OFFICIAL

2. Children, Young People, Parents and Families: Viv Hughes Education, youth, family and household interventions; (Addac / YZUP) Including Together for Families. T4F 2.01: Develop effective identification and referral pathways and Kim Hager ANA / SIMP processes. Treatment ensure joint working arrangements are in place between children and commissioning and family services and specialist alcohol treatment where there are Viv Hughes SIMP processes. safeguarding issues and with local Together for Families provision Sue Clarke where alcohol or drug misuse is a factor. (Addaction)

2.02: Improve referral rates and early identification of drug and T4F / ANA / SIMP processes. Treatment alcohol use in the Together for Families programme, via an agreed commissioning and defined pathway and workforce development. A protocol for this SIMP processes. was developed three years ago but was never fully implemented with children and family services and requires revision in line with developing early help and social work offers.

2.03: Address the fears of parents with drug and alcohol problems in T4F / ANA / SIMP processes. Treatment approaching services for help at the earliest opportunity. commissioning and SIMP processes. 2.04: Support YZUP in redeveloping the alcohol themed educational In progress. Boardmasters messaging and interventions in schools and colleges, continue to Welfare and partner with Brook to deliver training about risky behaviours, and the (Including YP outreach at Festivals / Safeguarding policies Health Promotion Service Healthy Schools work. Events) and delivery.

2.05: Continue to improve the responses to young people’s alcohol In progress, but lack of A&E referrals Treatment presentations in A&E and alcohol related hospital admissions, in order to treatment. commissioning and to continue to reduce the rate of under 18 alcohol related hospital SIMP processes. admissions and A&E presentations, and reduce the number of under Analysis within Frequent Attenders 18 victims of alcohol related violence, in all A&Es serving Cornwall. process.

2.06: Continued development of the alcohol intervention and ANA / SIMP processes. Treatment treatment system for young people through the Addaction Cornwall commissioning and YZUP service, with coherent assessment and referral processes SIMP processes. between substance misuse and sexual health and screening services. 7.01: Improve the complex needs pathways between alcohol and DASV / Housing / CJS / T4F / ANA / Treatment drug services, DASV, Together for Families, Social Care, Housing, SIMP processes. commissioning and Mental Health, Hospitals, CJS, including referrals via the DV Multi SIMP processes. Agency Risk Assessment Conference (MARAC) mechanism between drug/alcohol and DASV services.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 228 OFFICIAL

3. Community Safety Schemes: Jez Bayes Co-ordinated approach in St A Action Plan Reducing the harmful impact of alcohol on Cornish streets; Marion barton localities, including DAAT, ASB, St A CIZ evidence including Anti-Social Behaviour (ASB), and Fire and Rescue. Sarah Necke Localism, CSOs, Police. Truro Action Plan Natasha Matthews (ASB) Truro, St Austell, and wherever Paula Wellings needs arise. (Road Safety) Flexible, targeted, swift responses based on local evidence. 3.01: Continued focus on early intervention and prevention as well IBA section 2. HaLO as increasing activity related to the Night Time Economy. ASB / HFSC LAAA Public Health / Licensing Section 8. Licensing SMART Training. Priority cases. 3.02: Closely monitor violence trends to ensure that there is no ANA RTS consideration in escalation of risk. In particular, ensure that the Night Time Economy Locality monitoring. targeted areas and continues to be managed effectively and best practice prevails. ‘Reducing The Strength’ – danger of hotspots. moving the problem? LAAA/CIZ processes 3.03: Continue to support the move to a coherent regional SV evaluation. ARID used within commissioning and delivery approach for the Assault Related PCC funding proposal – rejected. LAAA Public Health Injuries Database (ARID), supporting a best practice evaluation, Local funding tba. Licensing cases and leading to improved opportunities for analysis and application of Cumulative Impact intelligence in improving safety in licensed premises, and reducing the Zones. risk of violence.

3.04: Continue to improve the design and implementation of Cf. WWYDC evaluation by Plymouth Evaluation to be evaluation techniques for community safety interventions. This Uni. implemented in should build on the initiative group adopted by the Community Safety updated WWYDC Service which aims to ensure initiatives are evidence based and 2017. robustly evaluated and creates an interventions library of effective initiatives.

3.05: Address pedestrian safety when drinking alcohol, including FRS Christmas Drink Driving Road Casualty preventative communication. campaign. reduction processes. Hotspots being ‘Last Walk Home’ identified. Drinkaware approached. Evaluate the effectiveness of Court mandated

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 229 OFFICIAL

courses 3.06: Support local community schemes such as the Street Pastors SP co-ordinated publicity and ROC. and Streetsafe, in order to make best use of the limited resources recruitment campaign tbc? SP reorganisation in available, provide consistent good quality training, help different Newquay. teams to learn best practice from each other, and continue to make SP Training. Slack visitors, residents and communities safer while reducing the load on Communications Cornwall’s emergency and enforcement services. system. Boardmasters Festival Angels approach. 3.07: Monitor and apply any changes to legislation addressing Modern Crime Prevention Strategy. Police and Crime Bill alcohol related disorder. passed. Police and Crime Bill. Awaiting CIPs. Governmental policy LNLs. lead. EMROs. GRIPs. 3.08: Continue to develop referral pathways from ASB into YZUP for SIMP young people, and Criminal justice diversionary interventions and Positive Addaction for adults. Requirements CJS Diversion Ladder 3.09: Continue to address alcohol related anti-social behaviour Ongoing. offences committed by visitors to Cornwall through the ‘Follow You Home’ approach, so that parents and enforcement services in other areas of the country address disorder in Cornwall as seriously as offences committed in their home area.

3.10: Develop a two stage approach for alcohol intervention in Home All trained and in place. Awaiting ‘Living Well’ Fire Safety Checks, based on the evidenced alcohol correlated initiative, to include domestic fire risk. This will involve observational conversations in the HFSC revamp delayed within CST? HFSC. HFSC, and follow up visits for IBA using the AUDIT toolkit.

5.02: Align the new Alcohol Strategy with the new Domestic Abuse and Sexual Violence Strategy (the top two Community Safety Partnership priorities), particularly in terms of attendance at Multi- Agency Risk Assessment Conferences (MARAC) by treatment providers and IBA training for Domestic Abuse services.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 230 OFFICIAL

4. Criminal Justice Interventions: Miles Topham (Police) Appropriate interventions to reduce alcohol related offences; Lynda Edward (Addac) including diversionary and sentencing pathways. 4.01: Update and redevelop the ladder of Criminal Justice System Miles Topham MT: Working Group met Meet to compile Alcohol Diversionary interventions, to ensure that there is no to edit old interventions updated index. enforcement with a diversionary intervention pathway. list. GPS due to start CJS Diversion Ladder 01/04/17. and referral pathways. Currently recruiting. Training tba. Covering all PCC area custodies, to include alcohol assessment and diversion, and RJ. 4.02: Offender manager workforce development based on specific Carol Baines IBA training tbc identified training needs, whilst reviewing the interventions available to Kerry Nasen target problem drinking in offenders. 4.03: Improve identification, referral and engagement into specialist Carol Baines services and to identify if there are any barriers (staff or offenders) that Kerry Nasen we need to address. This is a priority for the new offender management structure under Dorset, Devon and Cornwall Community Rehabilitation Company (CRC) but also applies to the National Probation Service (NPS). 4.04: Gather good quality local data (CRC and NPS) to inform our local Carol Baines Amethyst and PCAN to reoffending needs assessment and inform the development of the packages Kerry Nasen address with NPS/CRC. required to reduce reoffending locally. Management in these services should monitor and share information about performance and outcomes. 4.05: Address the needs of offenders with complex needs in an integrated KH / MD / LB SIMP / Commissioning way in the community, including family-based interventions, to address the Sue Clarke / LE “toxic trio” of domestic abuse, mental health and problem substance use. Carol Baines Kerry Nasen 4.06: Improve successful completion rates for criminal justice clients. Lynda Edward Improved / ongoing.

4.07: Monitor and apply any changes to legislation addressing alcohol Jez Bayes See 3.07. related disorder. 7.01: Improve the complex needs pathways between alcohol and drug services, DASV, Together for Families, Social Care, Housing, Mental Health, Hospitals, CJS, including referrals via the MARAC between drug/alcohol and DASV services.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 231 OFFICIAL

5. Domestic Abuse and Sexual Violence: Laura Ball Good pathways between alcohol, domestic abuse and sexual violence (CC / DASV) services; (Twelves) including MARAC referrals and sentencing pathways. 5.01: Implement the new joint Domestic Abuse and Sexual Violence MD / LB Joint DAAT DASV protocol in Ongoing via SIMP. (DASV) DAAT protocol and greater joint working would be beneficial development. to identify the nature of the drug and/or alcohol use and whether DASH training. treatment would aid the 50% of those identified in domestic abuse MARAC engagement. services who were not known to drug and alcohol treatment services, whilst also identifying historic DASV as a barrier to alcohol treatment.

5.02: Align the new Alcohol Strategy with the new Domestic Abuse JB and Sexual Violence Strategy (the top two Community Safety LB Partnership priorities), particularly in terms of attendance at Multi- Agency Risk Assessment Conferences (MARAC) by treatment providers and IBA training for Domestic Abuse services.

5.03: Improve screening and recording in drug and alcohol and SIMP domestic abuse services to identify complex needs and enable joint MARAC working to occur.

5.04: Learn lessons from the national treatment resistant drinkers ANA Multi-agency training due April Blue Light Delivery to domestic abuse project, and implement locally. onwards. begin as training Blue Light Project delivered. Manual 7.01: Improve the complex needs pathways between alcohol and drug services, DASV, Together for Families, Social Care, Housing, Mental Health, Hospitals, CJS, including referrals via the MARAC between drug/alcohol and DASV services.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 232 OFFICIAL

6. Employment, Deprivation and Inclusion: Marion Barton (DAAT) Interventions to reduce alcohol related employment problems; JC+ including Social Care, Homelessness and Housing. Mark Vinson DCH 6.01: Continue to promote IBA in Job Centres and employment services, housing and Jez Bayes IBA Training homelessness services and debt advice services. Next phase March 2017 6.02: Ensure the new housing pathway for clients leaving residential services is Marion Barton effective in securing accommodation on completion of a rehabilitation programme. MB: Latest Needs Assessment shows continuing progress.

6.03: Continue to work with our complex needs housing providers to ensure they are Housing Outcomes: supported in their provision of accommodation to clients at all stages in their recovery journey, with a priority focus on homelessness prevention. Positive housing outcomes on exit for alcohol clients are consistently very close to 100%; meaning that nearly every 6.04: Ensure the housing pathway for Prolific and other Priority Offenders is effective person completing alcohol treatment successfully leaves with no in securing accommodation for those released from prison, who would otherwise be housing problems. The national rate in 2015/16 was 84%. homeless. Housing problems are less prevalent amongst people starting 6.05: Create more effective links and referral pathways between alcohol intervention alcohol treatment than amongst those starting any kind of drug and treatment services, and employment agencies such as Job Centres and their treatment. service providers. Around 1 in 10 alcohol clients present to treatment with a 6.06: Continue to develop the Health Promotion team’s Healthy Workplace support to housing problem (3% NFA/homeless and 6% with a less acute local employers, in training their management and staff in identifying and responding housing problem, such as being in temporary accommodation), to alcohol issues in their workforce, and putting good policies in place to address these compared with 1 in 5 for drug clients. issues without endangering employees’ careers. Employment outcomes: 6.07: Improve pathways to alcohol services for Migrant Workers in Cornwall by addressing GP registrations, interpreter services, agency links to employers, and access Levels of paid work being undertaken by alcohol clients in the to specialist agencies. month prior to leaving treatment successfully, are in line with the national average – with 7% in part-time work and 26% in full time work (compared with 5% and 25% respectively nationally).

Employment is one of the most strongly positive factors in successful completion and then sustaining recovery 7.01: Improve the complex needs pathways between alcohol and drug services, DASV, SIMP Together for Families, Social Care, Housing, Mental Health, Hospitals, CJS, including HPS / LQ referrals via the MARAC between drug/alcohol and DASV services. Pentreath

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 233 OFFICIAL

7. Health, Treatment, Aftercare and Recovery: Kim Hager Easy access to treatment, and effective care throughout; Sue Clarke including hospital admissions, mental health and the treatment system. (Addac) 7.01: Improve the complex needs pathways between alcohol and drug services, DASV, SIMP Theme 7 Covered in Together for Families, Social Care, Housing, Mental Health, Hospitals, CJS, including ANA / DNA Commissioning referrals via the MARAC between drug/alcohol and DASV services. Priorities document. 7.02: Continue the development of thorough pathways from hospitals to alcohol KH treatment services, train IBA in Hospital departments, monitor and support RCHT to ALT Stakeholders ensure that it is fully embedded, and continue developing the RCHT alcohol multi- disciplinary monthly meetings to analyse and care plan frequent attenders on a monthly basis. 7.03: Projects aimed at public messages about alcohol, treatment interventions, or ST IBA/preventative schemes need to address the population as a whole, but should JB consider catering for specific audiences, such as women and under-18s. 7.04: Monitor the balance of people in treatment for alcohol issues in Tiers 2 and 3, SIMP such that numbers don’t fall below 1,400, with a maximum of 1,000 in Tier 3. ANA 7.05: Work towards developing a consistent and effective method of investigating SW alcohol related deaths to inform lessons learnt and future practice, review drug related deaths where clients have been in treatment for alcohol problems only, and promote awareness and education around the risks of poly drug use. 7.06: Examine the unmet need for alcohol treatment for those with mental health Dual Diagnosis Pathway issues and the potential barriers to treatment, and continue to develop and implement the Dual Diagnosis strategy and action plan to aid development of joint working to improve outcomes for people affected by more than one condition. Work with other specialist providers would help to identify if those with mental health issues in domestic abuse and drug and alcohol services are accessing treatment for their mental health condition and what joint working could occur for those with complex needs. There will be a primary focus on increasing successful completions by: Examining and developing the treatment offer for the most complex service users, particularly those who are representations to treatment, to reduce these service users dropping out of treatment again; Increasing engagement of those not in contact through outreach and targeted activities, particularly people with children; Providing more information for service users about what is available. A comprehensive directory of recovery pathways published and regularly updated; Reviewing the treatment offer for people who have been in treatment for 4 years and over to assess the recovery potential and service design for this group; Reviewing the options for getting treatment to people who have difficulty with transport costs;

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 234 OFFICIAL

Including stages of constructive activity and volunteering from the outset of treatment; Clarifying the mental health offer within treatment services; Increasing the solid network of volunteer drivers and peer mentors. 7.07: Support the Health and Wellbeing Board, Public Health and NHS partners in delivering the ‘Live Well’ initiative: Alcohol is one of the 5 behaviours, that lead to the 5 diseases, that cause 75% of deaths and preventable disability in Cornwall. As such, this will need the delivery of preventative and social marketing messages, and treatment and support interventions involving Addaction Cornwall: http://www.cornwall.gov.uk/media/10418204/Public-Health-Annual-Report-2014- STP process in progress: FINAL-181214.pdf (PH) IBA Outreach Frequent Attenders Blue Light

HFSC

STP Three aims: 1. Improve the health and wellbeing of the local population. 2. Improve the quality of local health and care services. 3. Deliver financial stability in the local health and care system.

5 lifestyle behaviours contribute to 5 diseases which cause 75% of premature death and disability.

• Smoking – Higher rate of smoking attributable admissions than national average • Diet – Over a quarter of children are overweight or obese • Alcohol – Estimated 25,000 people drink at harmful levels costing £75m a year to the health and social care system • Physical inactivity – People in the most deprived areas are twice as likely to be physically inactive than the least deprived. • Social isolation – 15% of all households in Cornwall have a person over 65 living alone.

Measures of success will be:

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 235 OFFICIAL

• Healthy life expectancy at birth. • Fewer pregnant women smoking. • Fewer households in fuel poverty. • Fewer overweight children aged 10 or 11. • Fewer people admitted to hospital for smoking or alcohol related conditions.

The Plan recognises that major social factors are a big influence on demand – 20% of NHS costs are associated with avoidable risk factors to do with diet, physical activity, smoking and alcohol consumption, while alcohol related harm accounts for 4,060 hospital stays per year.

The key health outcomes and benefit expected to be achieved from changes in this area include “Alcohol consumption is reduced and related hospital admissions are lowered.”

Under a different intervention, “Prevention and self-care”, seeking to achieve “Admission avoidance for high risk groups”, it states that: “In order to reduce harm from alcohol, we could also implement an Alcohol Assertive Outreach Team as an extension to our drug and alcohol services (DAAT) to offer more intensive support.”

LAPE: Out of 20 conclusions from the Local Alcohol Profiles for England (LAPE), these Findings to be addressed within SIMP/Commissioning and in are the most important specifics to be addressed: Safer Cornwall operations and delivery. 8: Overall alcohol related episodes for under-40s are rising above the national trend, with female admissions rising more sharply than male, although males account for more Cornwall LAPE target Groups: admissions overall. Male drinking, especially the amount drunk by a proportion of men with excessively risky drinking patterns; 9: Alcohol related episodes for 40-64s overall, for men and for women are rising above the national rate which is on a level trajectory. Males account for nearly two thirds of The male drinking pattern being damagingly assumed by women; the admissions. Alcohol related RTAs in Cornwall;

12: The broad rate for Alcohol related episodes for mental and behavioural disorders Under-18s, whose risky drinking appears to be reducing in among women is slightly rising, higher than the national rate, which is on a level Cornwall, but at a slower rate than nationally; trajectory. NB: The rate for men is in line with national rates, but is roughly double that of women. Rising rates of Alcohol related cardiovascular conditions, with especially high rates among men; 13: Alcoholic liver disease episodes overall, and for men and women are rising, higher than the national rate, which is on a slower rising trajectory. NB: The rate for men is Alcohol related mental and behavioural disorders, with roughly double that of women. especially high rates among men;

14: Alcohol related unintentional injury episodes overall, and for men and women are Alcoholic liver disease, with especially high rates among men;

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 236 OFFICIAL

rising, higher than the national rate, which is on a slightly falling trajectory. NB: The rate for men is roughly three times that of women. Alcohol related unintentional injuries, with excessively high rates among men, probably caused by risky drinking, vulnerable 16: Alcohol related episodes for intentional self-poisoning overall and for men and disinhibited behaviour, and disorder. women are falling, but are much higher than the national rate, which is also on a falling trajectory. NB: Female rates of alcohol intentional self-poisoning are higher than men.

18: In the vast majority of the alcohol related and specific hospital admission conditions, the rate for men is at least double the rate for women, even when the rate for women is rising at a worse rate than national trends. This suggests gradually increasing impact from a gradual change in female drinking patterns, but it also suggests than men are twice as likely to drink in such a way that it will cause health problems that require hospital treatment.

19: Cornwall’s workforce, social cohesion, economy and welfare budget are detrimentally impacted by high benefit claimants due to alcohol.

20: Our alcohol related RTAs are exceptionally poor, worse than the SW, which is also performing worse than national rates. Blue Light Multi-agency approach to target complex ‘Treatment Resistant Drinkers’. RCHT Alcohol Liaison Team Data to be analysed to help focus Hospital and Community services and pathways on the most frequent attenders. Alcohol and Suicide in Cornwall: Contribution to ‘Towards Zero’ processes and awareness • Males: higher rate than the national average. raising. • Rate has been increasing since 2007. • 2013: 65 deaths by suicide • Highest quantities in the 45-59 age group. • Most common methods: • ‘hanging, strangulation and suffocation’ by males; • ‘poisoning by drugs/alcohol’ by females • 24% of all suicide cases were reported to have taken alcohol at the time of death.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 237 OFFICIAL

8. Licensing, Alcohol Retail and the Night Time Economy: Jez Bayes Promoting and supporting a safe, responsible, successful alcohol trade; Bob Mears including Best Bar None and bar staff training. Angie McGuinn (CC Licensing) 8.01: Continue to communicate and lobby strongly for the evidence JB MUP not on current national agenda. based policy of connecting the price of alcohol to strength (either CC PH Legislation doesn’t support local schemes. by MUP or by through targeted taxation) in any policy debates and consultations. Rachel Some interest in voluntary ‘Reducing The Strength’ type Wigglesworth initiatives.

Sarah Be aware of progress in Scotland, Ireland, Wales, EU, to see Wollaston MP when Westminster might pick up this issue again.

Sarah Newton MPs Alcohol Briefing? MP (inc. Sarah Newton) https://www.gov.uk/government/people/sarah-newton Parliamentary Under Secretary of State for Vulnerability, Safeguarding and Countering Extremism Minister responsible for: Disclosure and Barring Service, drugs, alcohol, vulnerability. 8.02: Review and continue to deliver the SMART training for bar staff, SC Content needs reviewing. To be reconfigured and in order to promote best practice and responsibility in alcohol sales. JB Incorporate HaLO. probably kept in house.

Delivery and funding needs Larger regional events reviewing, may be taken ‘in- rather than small local and house’ by Alc Strat Lead. premises events.

Evaluation process to be instigated. 8.03: Continue to develop Cornwall Licensing Forum as a series of JB tba Possibly replaced by events for dialogue and discussion about best practice, involving both LAAA steering group. trade and enforcement representatives. RA Meeting.

8.04: Support the evolution of Cornwall Best Bar None to fit in with Mick BII progress in Pz. No longer a CC priority. the national BII model and timetable, making changes designed to McDonnell Update needed. BII not making headway. create sustainability by increasing trade commitment to the scheme through sponsorship, and by making the assessment process more HaLO and LAAA processes efficient. more likely to help improve towns and NTEs. 8.05: Improve support to local schemes such as the Street Pastors and JB SP recruitment campaign tba. ROC

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 238 OFFICIAL

Streetsafe, in order to make best use of the limited resources Asc Trust Newquay reorganisation. available, provide consistent good quality training, helping different Jon Creber Boeardmasters / Festival teams to learn best practice from each other, and continue to make Angels. visitors, residents and communities more safe while reducing the load on Cornwall’s emergency and enforcement services. 8.06: Increase Public Health engagement with licensing applications JB HaLO process. Begin to present evidence and review processes using current legislation as possible, or if LAAA2 process. with other partner RAs to relevant legislation or Licensing Objectives are updated. CUMULATIVE IMPACT learn how to use HaLO APPROACH. evidence to support Conditions. Inc. Festival / Events??? 8.07: Work with the Office of the Police and Crime Commissioner to Lisa Vango PCC Crime Plan launched. ARID data to be used in engage with supermarket alcohol retailers, and to encourage a JB LAAA premises/cases national dialogue about improving alcohol legislation and No PCC/ARID regional funding. approach. enforcement.

8.09: Work with the Police and Office of the Police and Crime Lisa Vango HaLO process. Commissioner on local Night Time Economy schemes and messages, JB LAAA2 process. for example #RU2drunk and the nightclub breathalyzer schemes. CUMULATIVE IMPACT APPROACH.

Inc. Festival / Events??? 8.10: Continue to work with Community Safety colleagues as they JB / ST See Section 1.06 above. evaluate and refresh the “What Will Your Drink Cost” campaign, impacts the Night Time Economy and the wider community.

Plymouth Uni Update WWYDC Autumn/Winter 2016 review received (above). 8.11: Improve operational usability and impact of data gathered SV compiled review and recommendations (Sept 2016) submitted through the Assault Related Injuries Database in Emergency top PCC Crime Plan Consultation process. Departments and Minor Injuries Units, in order to improve practice in licensed premises, making customers less vulnerable to violence and HaLO process. health harms. LAAA2 process. CUMULATIVE IMPACT APPROACH. Consideration of including St Austell as a 5th CIZ??? 4.01: Redevelop the ladder of Criminal Justice System Alcohol MT Diversionary interventions that address alcohol related offences and violence in Cornwall.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 239 OFFICIAL

Appendix E: Case studies

Case Study 1 J Background A young woman was permanently excluded from school due to behaviour. She attended a pre-16 course at college and the Short Stay School for her GCSE work. She has been involved in some anti-social behaviour in the community and although she attends the local youth centre regularly, she finds it difficult to build relationships with professionals. Her family describes her childhood as being ‘normal’ at this stage and were supportive.

Presenting Need The young person uses Cannabis on a daily basis and has heavy usage of Amphetamine and MDMA over the summer holidays.

Interventions Delivered YZUP started their intervention with the young person with motivational interviewing and solution focussed therapy. As the young person stopped using all substances within 4 to 5 months, relapse prevention work was also undertaken.

The young person’s case was kept open on a preventative basis, due to complex issues relating to building relationships with workers, school exclusion, escalation of ASB and possible relapse.

Positive Activities: The young person took part in group work through Aspire project and was involved in the Summer Holiday activities programme.

Mental Health: YZUP made a referral to Child and Adolescent Mental Health Services (CAMHS), due to a query about whether the young person could have ADHD. It was classed as a ‘late diagnosis’ as the ADHD had apparently been present since the young person was much younger.

Housing: Due to her behaviour at home and in the community, the young person was asked to leave. She was supported by her YZUP worker to access supported accommodation.

Crime and Anti-Social Behaviour (ASB): YZUP offered support for the young person at police interviews, court hearings and advocated for in the ASB process when they were considering a full ASBO application. YZUP have been working jointly with the Youth Offending Service.

Anti-Social Behaviour: There was a massive escalation in her substance use and ASB since living in supported housing, together with a severe deterioration in her mental health .

Timeline She was sectioned under the Mental Health Act and held in hospital (out of county) until her 18th birthday when she was immediately moved to an adult unit in Cornwall. She was quickly discharged after 1 week to the care of her family and

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 240 OFFICIAL

completely after two weeks. No adult mental health support has been offered and her case was closed by Child and Adolescent Mental Health Services (CAMHS) at this time.

Art psycho-therapy intervention and daily support were provided by YZUP and were attended by the young person.

Further deterioration in her mental health later resulted in regular serious self-harm events. The YZUP worker liaised with Specialist Residential Rehab and worked to persuade the young person to visit rehab. The young person was admitted to Longreach House in Plymouth shortly after.

After nine months in a rehab unit outside of Cornwall and a diagnosis of Borderline Personality Disorder, regular fortnightly contact with YZUP worker was introduced. Although the young person was now 18, it was agreed that she would remain in the young people’s drug and alcohol service, due to the nature of Borderline Personality Disorder (BDP) and her need for consistent relationships with professionals. This approach was taken to ensure her positive outcomes continued.

The YZUP worker offers continued support to ensure the young person settled back into the community, although she has decided not to return to Cornwall.

The young person is attending a funded day programme, which gives her access to weekly counselling, daily attendance at groups, a meal each day and a bus pass. She is now living in supported accommodation specifically for those in recovery. She has also been referred to IceBreak, a personality disorder group, although nothing like this is available in Cornwall.

Challenges The mental health transition did not happen. There was poor communication when workers were seeking clarification about what needed to be done to access this support.

The young person’s chaotic behaviour resulted in hours spent by the YZUP worker supporting her in hospital. This was due to serious self-harm events, where she refused to access treatment, and advocating for support from mental health team.

There was a significant risk to self and keeping young person safe. At many points, the young person was being seen daily to ensure the risk was mitigated as far as possible.

There has been an impact on the team in terms of capacity due to the intensive one to one support and advocacy with other services. The nature and complexity of the case, together with the transitions failures have also had an emotional impact on the team.

Outcomes The young person completed nine months of rehab and now has a diagnosis of Borderline Personality Disorder.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 241 OFFICIAL

This has allowed the young person to learn to understand her behaviour and why these things have happened to her. The young person is now engaged in a day programme and started to make a new life away from Cornwall.

The young person is now able to ask for and accept support, including from her family, which is a huge accomplishment.

The young person is no longer self-harming or using substances, although she is still on her recovery journey and is now has a full time job.

Case Study Two L L had enjoyed a successful career as a tutor, working in the further and higher education sectors in the UK and delivering training overseas. Throughout these 17 years, L had struggled with his alcohol issues, and by 2011, his physical and mental health had also deteriorated and he was signed off sick. For the first time in his life, L was now claiming benefits.

As an ESA claimant, L attended a work capability assessment. His symptoms at that stage were significant – severe depression, alcohol misuse and physical pain. Despite this, L was awarded zero points and told he was fit for work. The process of appealing the decision caused L further anxiety and stress and in the end he abandoned his claim and was no longer able to claim benefits. L was in this position for 5 months and not surprisingly, his condition worsened – to such an extent that he felt he was no longer in control of his alcohol intake. L knew that he needed help and took positive action by removing himself from his current location and moving down to Cornwall.

L signed up with his local GP and was referred to Addaction to access treatment. His recovery journey included the usual ups and downs. After a number of community interventions, L was referred in to a community hospital for detox. He completed this successfully and returned to Bristol feeling ready to get back on with his life. He started looking for full-time employment but without much success, triggering further stress and anxiety and a return to drinking.

Over the next 3 years this cycle continued with regular ESA claims but due to the pressure he felt from the benefits system and his strong work ethic he would sign on JSA to pursue employment. He says he was seeking support and help but “felt totally dehumanised by the system” and the anxiety and stress experienced resulted in an increased dependence on alcohol to manage the uncomfortable feelings. In 2014, L again reached the point of people able to make a major change in his life - he returned to Cornwall and referred himself to Addaction.

After a period of engaging with Addaction’s community services L was referred to residential rehabilitation to do 3 months in depth work on his addiction issues and to develop strategies to manage his anxiety and depression. L successfully completed the programme and started claiming ESA again upon completion. Life post-rehab presented some challenges for L and he started another period of drinking. He managed to stop drinking and realised he needed more help so referred himself back in to Addaction.

L started attending the Addaction Life Skills service one day per week. As well as enjoying the activities themselves, L recognised that what he really responded to

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 242 OFFICIAL

was the structure. This has been key to his success in rehab and moving away from this has been a major factor in his lapse. Being in a learning environment again was a real boost for L and he was able to access much needed support, information, advice and specialised career guidance.

L reflects that being in a positive learning environment with people who understood addiction and who were themselves on a recovery journey was invaluable. He felt supported, accepted and valued and this enabled him to create achievable goals without the pressure, which had in past perpetuated his substance misuse issues.

Quickly he was able to create an action plan to become a volunteer within the service and work towards running life skills groups. He completed volunteer training and began to co-facilitate groups in 3 areas of Cornwall on a weekly basis. He said that as well as using his skills to work towards employment he also felt the therapeutic value was very important to his own personal journey an creating a sustainable recovery.

Things were definitely on the up for L but after about a year, his benefits were stopped due to a change in living circumstances. This could very easily have triggered a downward spiral but the progress that he had made, together with the support of his Addaction Life Skills Worker helped to keep him on an even keel. On this occasion, L began to work with a Work Advisor at his local JCP who was very supportive. This helped L to feel valued and whilst he was very upset about his financial situation he was able to work with the Advisor and Addaction Life Skills to develop a plan to develop his volunteering work further in order to make a sustainable re-entry into the world of employment.

Through the Addaction Life Skills service, L was able to access support in writing applications and his volunteering work gave him a much needed current reference. Over the coming months L was able to secure a number of part-time roles in tutoring and health and social care support.

The challenges L faced are not uncommon. We are all too aware of the flaws in a system where people who have been assessed as fit for work have to sign on for JSA in order to claim any benefits, even though they know themselves they are not well enough to accept a job in good faith. However, in L’s case the positive attitude of the JCP advisor and the structure and support offered by the Addaction Life Skills service helped him turn things around.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 243 OFFICIAL

Appendix F: Public Health England Evidence Review

The Public Health Burden of Alcohol and the Effectiveness and Cost-Effectiveness of Alcohol Control Policies, Regulation and Intervention Effectiveness Tables.

Taxing and Price Regulation:

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 244 OFFICIAL

Taxing and Price Regulation (cont’d):

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 245 OFFICIAL

Regulating Marketing:

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 246 OFFICIAL

Regulating Availability:

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 247 OFFICIAL

Providing Information and Education:

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 248 OFFICIAL

Managing The Drinking Environment:

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 249 OFFICIAL

Managing The Drinking Environment (cont’d):

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 250 OFFICIAL

Reducing Drink Driving:

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 251 OFFICIAL

Reducing Drink Driving (cont’d):

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 252 OFFICIAL

Brief Interventions and Treatment:

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 253 OFFICIAL

Brief Interventions and Treatment (cont’d):

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 254 OFFICIAL

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 255 OFFICIAL

Appendix G: NICE Guidelines – Map and Gap exercise Prevention Recommended for: Availability Gap AUDIT Screening Patients attending with New registrants at GP Need more screening in relevant physical practices; Healthchecks; wider health services and conditions e.g. Pharmacy medicine use better collection of data hypertension, gastro- reviews; RCHT in- intestinal problems, liver patients problems. Patients with relevant No routine screening takes mental health conditions: place in GP or mental e.g. anxiety, depression, health services mood disorders Those who have been No evidence of this assaulted happening in A&E or police Regular attenders for No evidence of this accidents and trauma, happening in A&E including 'falls' Regular GUM and No commissioned service emergency contraception that covers this service attenders

IBA Training should be provided Availability Gap for the following groups: IBA Primary healthcare Some practice nurses and GPs do this but it is not widespread practice

Emergency departments No evidence that this takes place

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 256 OFFICIAL

Training should be provided Availability Gap for the following groups: IBA Other healthcare services Commissioned services Other listed services do (hospital wards, outpatient in pharmacies; RCHT not currently provide IBA departments, occupational alcohol liaison team for health, sexual health, in-patients. needle and syringe exchange programmes, pharmacies, dental surgeries, antenatal clinics and those commissioned from the voluntary, community and private sector). Currently available through commissioned services in pharmacies; RCHT alcohol liaison team for in-patients.

The criminal justice system Addaction CJT and soon No gaps identified in GPS scheme Social services Knowledge of IBA skills No gaps identified and provision in these settings Higher education. Knowledge of IBA skills No gaps identified and provision in these settings Other public services Knowledge of IBA skills No gaps identified and provision in these settings

Assessment and access to specialist alcohol treatment for adults  Interventions should be demonstrable and easily accessible

Intervention Availabilty Gap Standardised triage In place, Addaction No gaps identified assessment SADQ Used by Addaction to No gaps identified assess dependence Care co-ordination and Addaction Recovery co- No gaps identified management ordinator and supervision Goals for treatment agreed In place, Addaction No gaps identified (standardised care plan) Regular reviews using a In place, Addaction No gaps identified validated tool e.g. TOPS

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 257 OFFICIAL

Intervention Availabilty Gap Wernicke’s encephalopathy Thiamine prescribing No gaps identified prevention available through GPs and specialist treatment services Staff delivering specialist Addaction staff No gaps identified interventions should be supervision, able to demonstrate commitment to on- relevant training and proof going training, evidence of competencies to commissioners of staff competencies in accordance with NICE

Wernicke-Korsakoffs syndrome  NICE advises that people with Wernicke-Korsakoff syndrome should be offered long-term placement in the venues shown below:

Venue Availability Gap Supported independent Care provided through May need to establish living for those with mild either Adult Social Care adequacy of specific care cognitive impairment or CFT long term for WKS within Cornwall placement under residential units and generic dementia community provision. services, commissioned by KCCG Supported 24-hour care for Care provided through May need to establish those with moderate or either Adult Social Care adequacy of specific care severe cognitive or CFT long term for WKS within Cornwall impairment. placement under residential units and generic dementia community provision. services, commissioned by KCCG

Co-Morbid conditions Condition Availability Gap Depression DAAT mental health Pathways into CFT MH strategy developed services remain inadequate Other Mental Health DAAT mental health Pathways into CFT MH Disorder strategy developed services remain inadequate Nicotine addiction Pathways into stop No gaps identified smoking services clearly defined and used Drug dependency Addaction offer all Tier No gaps identified 3 interventions for dual dependency

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 258 OFFICIAL

Psychological interventions

NICE Recommendation Availability Gap Cognitive behavioural Addaction provides this It is not certain that the therapies focused on and additional day programmes delivering the alcohol-related problems support services. above are county wide and should usually consist of quality assured one 60-minute session per week for 12 weeks Behavioural therapies Addaction provides this It is not certain that the focused on alcohol-related and additional day programmes delivering the problems should usually support services. above are county wide and consist of one 60-minute quality assured session per week for 12 weeks. Social network and Addaction provides this It is not certain that the environment-based and additional day programmes delivering the therapies focused on support services. above are county wide and alcohol-related problems quality assured should usually consist of eight 50-minute sessions over 12 weeks. For harmful drinkers and Addaction provides this It is not certain that the people with mild alcohol and additional day programmes delivering the dependence who have a support services. above are county wide and regular partner who is quality assured willing to participate in treatment, offer behavioural couples therapy

Pharmacological Interventions Intervention Availability Gap Nalmefene Prescribing approval No specific pathway/ from specialist services recommendations or monitoring of the use of this drug in CIOS. Addaction do not use it, and Naltrexone may be preferable Disulfuram Clear protocol in Not widely used in CIOS specialist services including CHAD Acamprosate Clear protocol , widely No gaps identified used in CIOS

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 259 OFFICIAL

Intervention Availability Gap Naltrexone Clear protocol Not widely used. Prescribing in both specialist services and GP led services is monitored through prescribing data. Primary Care lead GP and Consultant Psychiatrist for Addictions offer regular supervision and training for other medical staff including GPs

Assisted Alcohol Withdrawal Type Availability Gap Comments Unpanned RCHT ALT and in-patient No gaps All detox options use NICE alcohol stabilisation for identified recommended pharmacological acute admissions. Recent interventions: diazepam and pathways developed to chlordiazepoxide, with ensure continuity of care validated symptom monitoring post hospital discharge tool (CIWA-AR) and at least minimum level of supervision during the detoxification in place

Planned Choice of Boswyns, No gaps All detox options use NICE CHAD, Home Detox; clear identified recommended pharmacological pathways and protocols interventions: diazepam and for all options for alcohol chlordiazepoxide, with detoxification. Available validated symptom monitoring in different settings tool (CIWA-AR) and at least according to level of minimum level of supervision need. Recent innovative during the detoxification in Home Alcohol Detox place pathways developed to increase numbers able to access this option. Capacity for 160 CHAD, approx. 300 Boswyns and 300 Home detoxs per annum

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 260 OFFICIAL

Alcohol related disease Disease Availability Gap Comments Type Alcohol Commissioned Need data on levels Conditions for referral, related through KCCG of delivery and diagnosis (including liver on a generic outcomes biopsy) and treatment are disease Gastroenterology met within GP pathways contract and service offered through RCHT/Derriford care pathways for hepatology, including access to liver transplant. Alcohol Conditions for Some service users realted referral, describe complex pancreatitis diagnosis and prescribing of pain - Chronic treatment are relief which may not met within reflect good practice current RCHT for drug and alcohol pathways co-dependency (i.e. high levels of opiate/opioid analgesics). Alcohol Conditions for Need data on level of realted referral, activity and pancreatitis diagnosis and outcomes - Acute treatment are met within current RCHT pathways. Both interventions commissioned through KCCG on a generic Gastroenterology contract

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 261 OFFICIAL

Appendix H: Frequent Attenders – Case Studies Top 40 Alcohol-related

Case Review of care/plan of Summary/did it work? Study action/what was done 1 Regularly phoned ambulance for Completed CHADs alcohol detox and has Oramorph, abusive, in pain reduced alcohol intake Ambulance Service have written warning Regular attender in Treliske for falls letter and have had no calls since after drinking and problems with 20/11/2016. gastric band Last hospital admission - 18/11/2016 Carers’ dispense medication, has brain Referred to CHAD, MD working, GP to injury and CT brain due Feb 2017. review meds, CMHT input, increased All medication that client was no longer engagement, prescribed has been removed from property by Carers who attend to personal care twice daily. Currently prescribed anti-depressants by Consultant GP has stopped Oramorph and Diazepam prescription due to addictive tendencies Multi-agency approach including Addaction, Social Worker, GP, Consultant Psychiatrist, Ambulance Service and Blue Bird Agency. Regular 1-2-1 appointments with Addaction; contact in between appointments on the phone 2 Was an arrest referral in December Contact Prison for Care plan, re-engage and has now been sentenced to once released 22/5/17 custody This client dropped into the office once Attended only one appointment and was then sentenced. Will be able to make contact with the Prison and see if a plan can be put in place pre-release date. 3 Several attempts to engage Unaware client was a ‘frequent attender’ This client was referred by arrest and if the team had been aware there referral and didn’t engage in would have been a much more pro-active treatment. Tried to engage via approach taken due to levels of risk. Probation, Offender Manager, but were unsuccessful.

4 Client was referred via the Improvement in health, now open to magistrate’s courts for an ATR community team assessment. Visited at home to carry out this assessment and an ATR was deemed unsuitable. Due to improvement in health the decision was made to re-allocate the case to the community team 5 Self referral; attended one Street homeless, disengaged; intel that appointment. he is out of area; not engaged with any Known to H4H; last seen by them in other services and not registered with GP May 2016 No reports of admissions to hospital or linked in with St Petroc’s in Truro not presentation to A&E seen since May

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 262 OFFICIAL

Case Review of care/plan of Summary/did it work? Study action/what was done 6 Lack of proactive work Work not overly proactive 7 Vulnerable; multiple health concerns; Currently in Boswyns; plans to move on multi-agency approach; Housing plan; to rehab Detoxification Cornwall Housing worker supporting the housing plan which is in progress (meeting with Stonham) Social worker supporting Referred by Recovery worker to CMHT – assessment in 3 weeks time Addaction taking an assertive outreach approach to keep engaged in treatment in the community Paramedics called at beginning of Dec 2016 after self harm incident Last admitted in to Treliske at beginning of Dec 2016 with broken ankle 8 18/11/2016 released from HMP Multi agencies approach including: Eastwood Park and linked in with Probation Addaction recovery worker; Community Mental Health Team prescription set up for release date WRSAC Continuing to drink GP 13/01 seen in custody by PC – breach Addaction of CBO Referred to Addaction’s Life-skills Service Referred to the Mermaid Centre by GP after lump found - non cancerous Addaction taking an assertive outreach approach and working closely with other services. Client is engaging well 9 Multi-agency approach; Had been registered with Dangerous Historically very hard to engage Patients Scheme – recently taken off and Moved around and linked to a number now registered in local GP surgery of different partners – domestic abuse Being seen regularly by Addaction worker allegation with Police involvement who works closely with GP Previous partner died – drug related Referrals made to CMHT but no appointment offered Assertive outreach approach- although too risky to be seen outside of GP premises by lone worker No recent admissions to A&E 12 Personality Disorder; history of OD; Reallocated to a new Addaction worker as dependent drinker previous relationship with worker broke Does not engage well with down professionals Recent home detox, supported by recovery worker and doctor regular 1-2-1 sessions and telephone contact – good therapeutic relationship Engaged with Addaction’s structured day programme and MAP Has returned to work 16 Closed in 2015 and not referred back in by Psych Liaison Team or Alcohol Liaison Team RCHT. 18 Close back in 2015 and not referred back in by Psych Liaison Team or Alcohol Liaison Team RCHT.

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 263 OFFICIAL

Case Review of care/plan of Summary/did it work? Study action/what was done 22 Closed in August 2016 after not responding to several attempts to engage. Not referred back by Psych Liaison Team or Alcohol Liaison Team RCHT. 23 Did not want to engage – was receiving support elsewhere 24 Alcohol/drug free Attends Addaction Structured Day DV issues Programme Regular 1-1 with Addaction Recovery Worker Uses MAP and AA Joint working with Probation Some IDVA involvement 26 Closed in Feb 2016 - aware that he was a frequent attender. No attempts other then phone/letter to engage 27 Alcohol free and fairly stable Last OD and A&E admission 09/16 Multi agency approach Reviewed medication with GP and pharmacist to ensure correct meds are prescribed correct meds for pain relief Involvement with CPN 28 Not identified as frequent attender, not been working with Addaction since 09/15 and not referred since by PLT or ALT. Had reduced alcohol use and was linked in with CMHT 31 Very transient: engaging at the St Petrocs clinic; working with H4H; drinking and using crack. Previously dropped out of Addaction and other services; re-appearing briefly in other parts of the county but disengaged completely in 09/16 32 Client just been discharged again. 33 New referral, Addaction to set up Addaction recovery worker being meeting with CMHT as client known to supported by manager to ensure there is them a pro-active care-plan around the person, Previous engagement with criminal to include other relevant agencies justice services Disengaged from services last year 09/16 as was working Previous recovery CJ worker referred him to CMHT and CRUISE bereavement counselling; worked closed with Probation Last admission to A&E in 08/16 after suicide attempt 38 No admissions to hospital for most of last year Completed detox and rehab; currently inrecovery support; attending Addaction’s women’s group,MAP and AA 39 Needs assertive outreach and Last admission 19/01/2017

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 264 OFFICIAL

Case Review of care/plan of Summary/did it work? Study action/what was done engagement 40 Drugs and alcohol; PPO; multi health Intensive support from Addaction CJ concerns worker – assertive engagement Multi agency approach with Probation, GP, housing and treatment services Successfully completed detox and is currently in rehabilitation service and doing extremely well

Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 265 OFFICIAL

If you would like this information in another format please contact:

Community Safety Team, Cornwall Council

Fire and Community Safety Service HQ, Boswithian Road, Tolvaddon, Camborne, Cornwall TR14 0EQ.

Telephone: 0300 1234 100 email: [email protected]

www.safercornwall.co.uk

If you would like this information in another format please contact:

Community Safety Team, Cornwall Council

Fire and Community Safety Service HQ, Boswithian Road, Tolvaddon, Camborne, Cornwall TR14 0EQ. Cornwall and Isles of Scilly Alcohol Needs Assessment 2016/17 266 OFFICIAL Telephone: 0300 1234 100 email: [email protected]