3.4.1 Clinical services
There is currently a range of clinical services (Tiers 2, 3 and 4) available to:
Provide appropriate clinical management of substance misuse problems in all local (remand) prisons
Address the associated wider health issues, which arise from drug use, such as blood-borne viruses, deep vein thromboses, abscesses and dental disease
Engage in the care programme approach (CPA) to those substance users with serious mental health problems (dual diagnosis).
3.4.2 CARAT services
CARAT (counselling, assessment, referral, advice and throughcare) services are available in all prisons holding those over the age of 18 and provide Tier 2 and Tier 3 treatment. CARAT services use a keyworking role, working with prison clinical services, community treatment providers and others as appropriate. The CARAT service will:
Build on previous assessments of the individuals’ needs
Provide a range of psychosocial support and interventions
Refer to drug treatment programmes in custody where these are available and appropriate, and maintain contact while the client is participating in these programmes
Build and maintain effective throughcare arrangements with drug service providers in the community – through CJITs where appropriate.
A model has been developed for the closer linking of clinical and CARAT services in prisons to form an Integrated Drug Treatment System (IDTS).
The principal features of IDTS are integrated screening, triage assessment, comprehensive substance misuse assessment and care planning to provide access to a wide range of prescribing and psychosocial treatment, incorporating early effective clinical intervention and enhanced psychosocial support for the first 28 days of custody. Guidance on the psychological support in IDTS will be available from NOMS.29 The clinical elements of IDTS are described in detail in Department of Health guidance – Clinical Management of Drug Dependence in the Adult Prison Setting – scheduled for publication in 2006.22
3.4.3 Drug treatment programmes
These are available in over 100 prisons and provide a range of programmes, including:
Short duration programmes (Tier 3) available for those on remand or short sentences, who are unable to engage in longer programmes. These will be an important component of the short custodial periods available under the Custody Plus
Models of care for treatment of adult drug misusers: Update 2006
sentence when this is implemented in 2006. Short duration programmes may also be used as a booster, prior to release, for those who have previously completed another programme (Tier 3)
Cognitive-behaviour therapy programmes (Tier 3), e.g. P-ASRO (Prison – Addressing Substance-Related Offending), for those serving longer sentences, designed to give the thinking skills needed to help drug misusers to overcome drug dependency and to adopt a more sustainable lifestyle
The 12-Step programme (Tier 3 and Tier 4), based on the Minnesota Model of addiction (e.g. as used by Alcoholics Anonymous)
Therapeutic communities (Tier 4), designed for those with the most severe drug-misuse needs, delivered over eight months to a year.
Primary care interventions across four tiers
Many clients’ initial or main contact with drug treatment is through primary care. GPs and primary healthcare teams are valuable in delivering a wide range of interventions and can provide interventions covering all four tiers, where appropriate, provided the GPs or practitioners are competent to do so. This may involve:
Tier 1 interventions – screening drug-using clients and referring them on to other service providers; provision of general medical services (GMS). Under the terms of the GP contract, all GPs must provide Tier 1 interventions.
Tier 2 interventions – triage assessments, harm reduction. All practices can provide at least some Tier 2 interventions via the primary healthcare team as a whole (e.g. simple harm minimisation advice, brief interventions and immunisations).
Tier 3 interventions – prescribing for drug users within the context of a care plan. Many GPs provide Tier 3 services under specific contractual arrangements.
Tier 4 interventions – medical monitoring of residential rehabilitation or detoxification services, provided by a few GPs where there is local need.
3.5.2 Different contractual arrangements for shared care and primary care based treatment
Changes in GP contracts since Models of Care (2002) have implications for the commissioning and delivery of drug treatment services. Changes introduced as a result of the new contracts should ensure the stability, ongoing development and continued expansion of drug treatment systems to meet the key targets of doubling the number of people in treatment and increasing the proportion appropriately retained or completing treatment.