Models of care for treatment of adult drug misusers: Update 2006
Commissioning substance misuse services
A revised framework for drug treatment services
Models of Care 2002 outlined the four-tiered framework for commissioning drug treatment. This was intended to provide a conceptual framework and be applied to local areas with flexibility. Implementation of the four-tiered framework has contributed in a large part to ending the wide variation in access to different types of treatment, so that each local area now has a broadly similar basic range of drug treatment interventions.
The four-tiered framework has been well received and has enabled a better articulation of provision of treatment. However, the four tiers were a conceptual framework and were not intended to be a rigid blueprint for provision. They have been interpreted rather rigidly at times, with some unintended consequences which need rectifying. It is important to note that the tiers refer to the level of the interventions provided and do not refer to the provider organisations (e.g. referring to a “Tier 3 agency” may not be appropriate as many agencies will need to provide Tier 2 interventions alongside Tier 3 interventions).
Key differences between Models of Care 2002 and Models of Care: Update 2006
More focus on harm reduction with interventions integrated into all tiers
Feedback from consultation indicates that some harm reduction activities have been marginalised into being provided only by what have been called “Tier 2 services” (such as needle exchanges), at a time when there is evidence that rates of BBV infection are rising. Models of Care: Update 2006 advocates a far greater emphasis on the need to reduce drug-related harm including risks of BBV infection, overdose and other infections at all points in the treatment journey, alongside other interventions and across a range of tiers. Harm reduction interventions are required for drug users before, during and after all structured drug treatment.
The term “harm reduction” can also cover a wide spectrum of interventions. Models of Care: Update 2006 advocates the commissioning and provision of a wide range of interventions to reduce the adverse effects of drug misuse on drug users, with particular focus on reducing the risk of immediate death due to overdose and risks of morbidity and mortality due to BBVs and other infections. This may include responses at a commissioning and strategic planning level, and expansion and improvements in the provision of interventions to reduce drug-related harm. The latter may include increasing the availability of clean injecting equipment, interventions to encourage drug injectors not to share injecting equipment, to use ingestion methods as an alternative to
injecting, and to attract drug users into oral substitute treatment when appropriate.
Widespread vaccination of drug users at risk of hepatitis B infection is advocated and it is recommended that treatment services encourage and enable clients already infected with BBVs to take action to improve their health, reduce risks of transmission of BBVs to others and link into appropriate medical services. Initiatives that involve empowering service users or ex-users in initiatives to reduce the risks of BBV infection and overdose, through peer support or peer-led interventions, are generally
welcomed by service users.
Models of Care: Update 2006 also advocates a harm reduction approach is adopted with local communities (e.g. minimising discarded used injecting equipment) and service users’ families and significant others (e.g. minimising risks to the children of drug-misusing parents).
3.2.2 The four tiers revisited
In Models of Care 2002, the four tiers were based upon a combination of setting, interventions and the agency responsible for providing the interventions. This has led to some differing interpretations and particularly over-rigid interpretation. In Models of Care: Update 2006, the tiers describe drug “interventions” and the context for those interventions is described.
Providers spanning tiers Some commissioners and providers have viewed community- based agencies as delivering only one tier of interventions. Models of Care 2002 clearly stated that an agency may provide interventions from more than one tier, or a range of interventions within a tier. Many community based specialised providers now, appropriately, provide a range of interventions spanning Tier 2 and
Tier 3. This flexibility is welcomed.
More flexible opening times
With Tier 2 being classified as “open access”, there may also have been a loss of focus on commissioning and providing flexible access to some Tier 3 community structured interventions – the majority of which are still only available during office hours. We would welcome an extension of the opening hours of community- based services to include evenings and weekends.
Tier 1 drug interventions and generic services The emphasis in Models of Care: Update 2006 is that Tier 1 interventions are not the generic services themselves (e.g. housing, social services). Rather, Tier 1 consists of a range of drug-related interventions that can be provided by generic providers depending on their competence and partnership arrangements with specialised drug services. Given this change in emphasis, interventions that were previously described as “Tier 4b” (e.g. care provided in inpatient hepatology units for drug users