Skills for the future – a look into
the crystal ball
Dr Emily Finch, Clinical Director,
Addictions, South London and
Maudsley NHS Trust
What did it use to look like?
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Strong emphasis on opiates, focus on numbers in treatment
Alcohol services less prominent
Joint commissioning influenced by health and criminal justice
Financial growth in the sector, ring fenced budgets
Strong national control from the National Treatment Agency
Strong political interest
Workforce
• Long careers in one organisation
• Professional groups assured of careers in addiction
• DANOS, University MSc courses
The people we treat?
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Opiate use declining
Ageing treatment population – prematurely aged
Increasing physical health needs
Increasing mental health needs
Increasingly socially disadvantaged
Polydrug use increasing
• Addiction to medicines – associated with other
physical and psychiatric comorbidities
• NPS – range of problems some complex some not
Alcohol is different?
• Vast amount of unmet need
• Broader range of interventions and needs
• Harmful and hazardous drinkers need evidence based brief
interventions
• Treatment in non-treatment and non specialist situations
• Patients in different environments e.g acute hospitals
• Dependent drinkers requiring evidence based psychological
and pharmacological treatment interventions
• Most severe drinkers require a full range of harm reduction
and social interventions
How are we organised?
• Commissioning moved to local authorities with strong influence from
public health
• NTA moved into Public Health England
• Creation of PHE Tobacco, Alcohol and Drugs
• Escalation of competition in the sector, regular retendering of services
• Strong emphasis on local political decision making
• Many innovative models emerging e.g. integrated care, focus on well
being, “parity of esteem” – unsure of impact on substance misuse
• Less political attention
• Role of “Francis”. Drive to quality in health
• Fewer but larger non-statutory organisations, less role of the NHS
The Money
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Removal of ring fenced money
Part of public health grant
Competing with other public health priorities
Use of retendering to remodel services and to
reduce costs.
What is public health?
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Focus on health of the whole population
Benefits for large groups not individuals
Reducing inequalities
Obesity, tobacco, exercise
Prevention and wellbeing
• Alcohol – but generally at a population level
• Infectious diseases e.g. HCV
• Important benefits for our clients but little emphasis on
more intensive treatments. This may disadvantage our
treatment population
Gaining the skills
• Most training internal – within large organisations. But risk of TUPE
• Universities need to adapt and find ways to provide specialist
education
• Broader range of skills needed e.g. smoking and brief interventions
• Professional groups are responding e.g. SMMGP.
• Role of Health Education England (HEE)?
But…
• Change expected – populations less predictable and systems less
predictable. Innovation necessary
• Need a long term view – retaining managers and leaders through
uncertainty is difficult
• Need system leaders
• Maintaining a high quality motivated workforce a priority.
Focusing on outcomes and using the
evidence
• Skills in evidence based interventions e.g RP, MI,
12 step facilitation, recovery skills
• Transferable skills
• New pharmacologies e.g. for tobacco and alcohol
• Health interventions e.g. for HCV
• Mental health interventions e.g. CBT
• New populations e.g. in the acute hospital and in
primary care
• NICE and other evidenced based and
recommended interventions
Recovery and beyond
• Broader range of skills to support clients full
recovery
• May not need all skills in one person
• Embedding former service users into the
workforce and supporting them properly
• Skills in working in partnership
Who is the workforce?
• Generalists e.g. in acute hospitals and primary
care. Substance misuse skills may be one of
many
• New specialities e.g. pain clinics, liver clinics
• Those with careers in substance misuse need
to adapt with core skills embedded.
• Ex-service users
• Professionals who are specialists.
Doctors, nurses, psychologists
• Specialist training still remains e.g. RCPsych and
RCGP
• But rapidly decreasing placement and training
opportunities
• Sector is less attractive due to uncertainly and
disruption
• Psychology and nursing – fewer speciality
placements
• But more interest in generalist training e.g. for
medical and nursing students
The role of addiction specialist doctors in recovery orientated
treatment systems
A resource for commissioners, providers and clinicians
• Outlines contribution of
doctors
• Set out standards for
training and supervision
for commissioners
• Expectations of
contracts
• Outlines ways of
providing training for
doctors
Solutions
• Specialists and generalists need different
solutions. Clarity of who does what and who
needs which skills.
• Preserve standard of training for specialists and
professionals
• Use all opportunities to set standards
• Encourage universities and other training
organisations to provide sustainable specialist
training.
• Opportunities for generalists to train in SM both
undergraduate and post graduate.
It’s a bit fuzzy but……
• Money is likely to be the biggest problem but..
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Keep supporting and motivating staff
Acquire new skills where needed
Building high standards in contracts at all opportunities
Allow opportunities for creativity and innovation. New
career paths in recovery
• Use every opportunity to create careers in the sector