APPENDIX 1

TITLE:           Additional information on residential rehabilitation services in Brighton and Hove

AUTHOR:     Stephen Nicholson, Public Health Programme Manager

1. Aim of paper

To describe residential rehabilitation provision in Brighton and Hove, including service users and outcomes.

2. Context

There is a range of treatment options for people with alcohol and/or drug misuse, with increasing intensity dependent on need. For those with the most intense and complex needs, residential rehabilitation is an effective evidence-based approach to recovery.

Residential rehabilitation for residents in the city is provided both within Brighton and Hove and out of area. Within Brighton and Hove, there are two providers together offering 48 detox support and recovery places plus up to 32 move-on places.  Providers receive an additional contribution from residents’ housing benefit or their accommodation costs can be self-funded.  The average length of stay through detox and recovery is around 9 – 12 months with an optional 18 months to two years at the move-on, reintegration stage.

Number of people who received treatment for drugs/alcohol during 2020-21 (Nebula)

	Number	male	female
Community	2587^	1665	903
Inpatient detox	35	26	9
Res rehab in-city	110*	81	28
Res rehab out of area	tbc	tbc	tbc

^ Includes 15 unspecified genders and 4 not known

* Includes 1 unspecified gender

The clients using the in-city services are predominantly male (~70%) although there is women only provision; white British; older (35+); with complex needs including homelessness, engagement with criminal justice, mental health issues and previous unsuccessful attempts to achieve and maintain abstinence in the community.

3. Population need and evidence of effectiveness

Brighton and Hove has the 8^th highest rate of deaths related to substance misuse and the 12^th highest rate of alcohol specific related mortality in the country (fingertips.phe.org.uk).

Brighton and Hove has very high need. It has a large population with substance misuse issues and a large population with multiple complex needs in particular a significant proportion of people in treatment have both substance misuse and mental health issues.  The Joint Strategic Needs Assessment (JSNA) of adults with multiple long-term conditions in Brighton and Hove (Nov 2018) reported that:

· In the year ending March 2019, 2,597 residents used the Brighton and Hove substance misuse service.

· Of these, three quarters (74%, 1,909 people) had at least one additional support need that placed them within the definition of having multiple complex needs (MCN).  Of these, 70% (1,336 people) had a mental health need

· Two out of five clients (41%, 1,072 people) had two support needs, over a fifth (22%, 583 people) had three support needs, nearly one in ten (9%, 223 people) had four support needs and less than 1% (31 people) had all five support needs.

· Thirty-eight per cent (729 people) were homeless and among those clients who had three or more support needs, more than two out of five (41%, 352 people) had support needs for substance misuse, mental health and homelessness.

There is a strong evidence base for the effectiveness of residential rehabilitation.

· An evidence review undertaken by the Helena Kennedy Centre for International Justice (HKCIJ) at the Sheffield Hallam University (2017) concluded that an effective and recovery-oriented treatment system must include ready access to residential treatment for alcohol and drug users both to manage the needs of more complex populations and for those who are committed to an abstinence-based recovery journey.

· Residential rehabilitation programmes provide intensive psychosocial support and a structured programme of daily activities which residents are required to engage with to support them to attain a drug and alcohol-free lifestyle and be reintegrated into society.

· There is a strong and consistent evidence base supportive of the benefits of residential treatment that derives both from treatment outcome studies and randomised controlled trials.

· The HKCIJ evidence review finds that the areas of benefit focus primarily on reductions in substance misuse and offending behaviour, but some studies also show benefits in areas including physical and mental health, housing stability and employment.

· Service outcomes are better when mental health issues are specifically addressed as part of the rehabilitation process.

· Although more expensive (than community treatment), there is evidence that the initial costs of residential treatment are to a large extent offset by reductions in subsequent health care and criminal justice costs.

· There are different models and durations of stay.  A minimum effective dose is often argued to be 28 days for detoxification and 90 days for residential rehabilitation. There is a clear dose effect for residential treatment with longer duration of treatment and treatment completion both being strong predictors of better outcomes.

· There is a strong supportive evidence base around continuity of care, whether this is recovery housing or ongoing involvement in mutual aid groups.

· There is almost no evidence for appropriate selection and preparation of clients for residential treatment and this is a major gap in the literature.

· There is a much stronger evidence base around attaining employment, stable housing, and ongoing support and aftercare as predictors of success.

4. Brighton and Hove in-City residential rehabilitation services

· Adult (18+) services are commissioned by BHCC to support drug and alcohol recovery in the City.

· The services are primary targeted at those who are homeless or insecurely housed with the most complex needs.

· The two services in the City offer the same pathway and approximate length of stay.  The services include detoxification support and preparation through a recovery programme and then a move-on resettlement programme to support positive re-integration with society.

· The key difference between the two services is that one offers a predominantly Fellowship based 12-step model of recovery and the other operates a cognitive behavioural therapy (CBT) model.  It is recognised that no one model will meet the needs of all clients and the offer of these two models will maximise the utility of the services.

· It is also recognised that lapse can be a feature of recovery from substance misuse and that there are different approaches to its management.

· Approximately 4% of the in-treatment population access local residential rehabilitation for any substance (Nebula). This compares to 6% of alcohol clients in West Sussex and 3% nationally; and 4% of drug clients in West Sussex, and 2% nationally (West Sussex Substance Misuse Needs Assessment, WSCC, 2021).

· There is no local provision for residential rehabilitation in East or West Sussex, so all referrals are out of area. 

5. Strengths of the current services

· Service costs in the UK vary significantly and can start from approximately £1,000 per week/£4,000 per 28-day programme.  Some private clinics charge in the region of £10,000 per week.  Some providers offer four weeks including detox for £5,500 then £895 per week after.  Other providers offer 28-day programmes from £3,000 upwards.

· The Brighton and Hove model which is longer term and funded jointly by BHCC and clients’ housing benefit (or self-funding) is considered to provide good value for money at a cost to BHCC of approximately £9,000 per bed per year or £4,900 per place in 2020/21. 

· Occupancy rate across the services averages approximately 90% (contract monitoring reports).

· Approximately 70% of clients successfully complete the res rehab programme and move on in a planned way (contract monitoring reports).

· Approximately 70% of clients who leave the service in a planned way maintain their abstinence and do not represent to services within 12-months (contract monitoring reports).

6. Social Value

· The current service providers are established voluntary and community sector organisations providing housing and substance misuse services in the City and across Sussex.  This allows the services to be flexible in the provision of accommodation and avoiding bottle necks in the system.  Both providers bring extensive social value offering training and employment opportunities to clients moving on.

· One of the providers also offers an intern employability training programme with flexible work placements (with 14 organisations across the City) available to clients post rehabilitation.  The programme works with clients who have complex support issues and approximately 70% of annual referrals are for people who have accessed drug and alcohol treatment services.

· The services actively seek service users’ views using a range of methods and service user representatives often attend meetings.  Service user feedback is consistently positive.

7. Service development

· A large proportion of clients starting at residential rehabilitation have diagnosed mental health needs.  The majority of these clients receive treatment from their GP.  Some clients are open to the community mental health team.  For those clients who are not receiving treatment or are yet to receive a diagnosis, access to mental health support is actively facilitated by the services.  Client mental health is closely monitored and supported by staff. 

· A service development action underway is to work with NHS commissioners and providers to strengthen links between substance misuse and mental health services at all stages of the treatment pathway.