13.1 Introduction

13.1.1 Background

This chapter summarises the data collected by the National Drug Treatment Monitoring System (NDTMS) in the West Midlands region for the year which ended on 31st March 2005.

With their consent, the NDTMS collects data on all clients and patients who are receiving structured care for drug misuse in registered treatment agencies (NTA 2002). An initial dataset is collected when the person is first seen, and follow-up information is collected as they receive and complete treatment.

Treatment agencies provide data about their clients to the NDTMS as part of their obligations to the National Treatment Agency for Substance Misuse (NTA). The range of substances for which any individual agency provides treatment may vary, but the focus of treatment – and therefore of this chapter - is illicit substances, and in particular those categorised as Class A under the Misuse of Drugs Act 1971. The vast majority of clients discussed in this chapter are heroin users or poly users. Clients for whom alcohol was the main problem substance are excluded from this analysis.

A feature of drug treatment, and therefore of NDTMS data, is that clients may not necessarily receive treatment in the area where they live. Where results are presented geographically in this chapter, they are shown according to the location of the clients’ residence.

13.1.2 Recent trends in data collection

In recent years NDTMS results have continued to grow in importance: the government’s 10 year drug strategy includes a commitment to double the number of people in treatment between 1998 and 2008 (UK Parliament 1998), and it is critical for NDTMS to be able to record progress towards this achievement. In addition, NDTMS results are now used to assess the performance of NHS Primary Care Trusts, as part of the Healthcare Commission’s star rating process.

Alongside more widespread use of NDTMS results, recent years have also seen the introduction of improved methods of data collection from treatment agencies.

In particular, the continuing adoption of improved systems of Electronic Data Transfer (EDT) has meant that many more treatment providing agencies transfer information directly from their own electronic systems to NDTMS. This is raising the quality and accuracy of the information collected, as well as the consistency between agency records and NDTMS reports.

The extent to which Electronic Data Transfer has already been taken up has also assisted the timeliness of data submission – information is now collected from all agencies on a monthly basis by the West Midlands regional office of NDTMS. In a process paralleled in other parts of the country, information on clients treated in the region is then passed to NDTMS national office, where a consistent national dataset is produced. It is the part of this dataset which relates to the West Midlands which has been used as the basis of this chapter.

As might be expected, the way in which data about treatment for drug misuse is collected has also adapted to changes in government policy in this area. One aspect of this which has become increasingly important is the monitoring of individuals entering treatment directly from the criminal justice system, in particular through the Government’s Drug Interventions Programme started in 2003.  Although this chapter does not particularly highlight the effects of these changes, future reports from NDTMS will reflect this development.

13.1.3 The structure of data collected

The information collected by NDTMS is organised into three sections: data about individual clients; data about each episode of treatment experienced by a client; and data about the types of treatment received within each episode (within NDTMS, treatment types are known as ‘modalities’ and are each recorded within one of the pre-specified categories. A client may experience more than one modality at a time).

For the purposes of this analysis, the ‘clients in treatment’ in a particular period are defined as those who experienced a treatment episode (or part of an episode) for drug misuse during that period.

During the year 2004/5, there were 15,864 clients in treatment living in the West Midlands region (This total differs by a small amount from the 15,905 published by the NTA. This is principally because the lower total excludes records for which a D(A)AT of residence was absent). The fact that 20,006 episodes were underway at some part during the year illustrates that some clients experienced more than one episode: in fact, one in every five (21%) did so.

Each episode, in turn, typically consisted of a number of different treatment types, and the nature and duration of each of these is also recorded. In 2004/5, each treatment episode in the West Midlands involved an average of 1.2 types of treatment, leading to a total of 24,467 being recorded for the region.

Table 13.01: Prevalence of drug misuse and treatment

13.1.4 Prevalence and treatment in the English regions

Evidence from the British Crime Survey shown in Table 13.1 suggests that the actual prevalence of misuse, i.e. the proportion of individuals in the population misusing drugs, in the West Midlands may also be lower than in any other English region (Roe 2005).

For the size of its resident population, the number in treatment in the West Midlands is certainly not high compared to other regions.  Comparing what we know about the numbers in treatment with the total population in 2004 of 5.3 million for the West Midlands region, we can estimate a treatment rate of nearly 3 per 1,000 (2.98 or, expressed differently, about one third of 1%). NDTMS data is currently collected by eight other regional teams in England, and the equivalent estimates, shown in Table 13.1, indicate that the treatment rate in the West Midlands is slightly below the average for England as a whole.

However, when the comparatively low estimated prevalence of misuse in the region is taken into account, it may be that the number in treatment exceeds the national average.

Whatever the relative position of the West Midlands, in common with other parts of the country the number of individuals recorded as receiving treatment for drug misuse has seen a substantial expansion. A 22% annual increase in the numbers in treatment in the West Midlands has been reported by the NTA, with an equivalent increase in England of 27%. 

The recorded growth in treatment is also echoed in a comparison of the number experiencing treatment in the West Midlands in 2004/5 (15,864) with the total of 9,505 clients reported in 2001/2, although it is important to keep in mind that these figures are not calculated on a consistent basis (NDTMS West Midlands 2002). Historically, there have also been concerns with the completeness of NDTMS data, and it is therefore difficult to say how much of the rise might be the result of more comprehensive recording, particularly as there have recently been efforts to improve data quality.

13.2 The Scale and Distribution of Treatment in the West Midlands

13.2.1 Agencies providing treatment

At the end of March 2005 there were 86 treatment agencies in the region reporting to NDTMS, based in 71 different locations, and organised within 14 Drug (& Alcohol) Action Team areas. As Figure 13.01 illustrates, the number of agencies within each D(A)AT area varied - from only 1 in Telford & Wrekin, to as many as 23 in Birmingham.

Figure 13.01 The geography of drug treatment

The West Midlands Region showing Drug (& Alcohol) Action Team area boundaries and the location of treatment agencies (as at 31st March 2005)

Figure 13.01 The geography of drug treatment

Agencies providing treatment varied considerably in size, and Table 13.02 lists the five largest (by the number of clients in treatment). These five treated 5,552 clients - more than a third (38%) of the total. Many other agencies were comparatively small - only about half of them provided more than 100 episodes during the year to clients in the region. In some cases however, differences in numbers of clients were the result of different agency specialisms: some treating smaller numbers may have been providing more intensive treatment than others for example.

Table 13.02: The largest treatment providers in the region, 2004/5

13.2.2 Drug & Alcohol Action Team areas

The diversity of scale among treatment providers is also reflected to a lesser degree among D(A)AT areas. Table 13.03 has been compiled using data on the number of clients in treatment in each area.  Each individual is counted only once in each D(A)AT in which they lived, and the total number of clients has then been compared to the resident population to produce a rate for each area.

It is clear from this analysis that there was considerable variation in the proportion of residents receiving treatment: in Stoke-on-Trent for example, the D(A)AT area with the highest proportion, the rate was more than double that for Warwickshire, Staffordshire and Worcestershire. This perhaps illustrates a wider pattern, with urban areas generally having higher rates and, conversely, rural counties hosting proportionately fewer clients in treatment. This conclusion would coincide with evidence found from other parts of the country (Bullock et al 2004).

An exception to this pattern would seem to be the rural county of Herefordshire, which had a rate of treatment comparable with cities such as Wolverhampton and Birmingham.

A great deal of caution is necessary, however, in interpreting these patterns as an indication of the relative prevalence of misuse within the populations of these areas. It is more probable, for example, that the higher rate in Herefordshire is a result of treatment being more readily accessed by those residents who were misusing, rather than of a higher rate of misuse.  Indeed, the extent to which Herefordshire’s treatment system might be unusually accessible might merit further investigation elsewhere.

A further point illustrated by the table is the dominance of Birmingham, which accounts for more than a quarter of West Midlands’ clients. By numbers in treatment, Birmingham is the largest Drug Action Team (or DAAT) in England and its presence puts the West Midlands in a unique position – no other English region is dominated to such an extent by a single D(A)AT area.

The last column in Table 13.03 shows the proportion of the D(A)AT area (in terms of the Super Output Areas used in the 2001 Census of Population) within the most deprived 20% of the country. This has been included as an indication of the character of each area, and to allow drug treatment to be put in a wider social and economic context.

In general terms, deprivation has been cited elsewhere as having a relationship with levels of drug misuse (ACMD 1998), and also appears from Table 13.03 that this relationship may be reflected in West Midlands’ data.  With the exceptions of Herefordshire and, to a lesser extent, Sandwell, more deprived areas do seem to be among those which have proportionately larger numbers in treatment.

13.2.3 Clients who were "new presentations"

One other difference in the character of treatment systems in different D(A)AT areas is the relative size of the population of ‘new presentations’ compared to the number of clients in treatment during the year.

Table 13.04 illustrates the difference between West Midlands D(A)ATs in this regard. New presentations are defined in this analysis as those clients who experienced an episode which started within the year, although clearly this does not mean that this was their first treatment episode, or even their first episode within any particular D(A)AT.

A wide difference is revealed between the ratios of new presentations to the overall number in treatment in each D(A)AT area. Nearly three-quarters of clients in Staffordshire were new presentations, while in Worcestershire and Telford & Wrekin the equivalent proportion was less than half.  These differences might be explained by the extent to which each local treatment system was expanding during the year, or might reflect the different mix of treatment delivered by each D(A)AT.

13.2.4 The locations of treatment and residence

Something about the character of the treatment system in each area can also be learnt by considering the question of how the D(A)AT area in which a client lived relates to the D(A)AT from which they received treatment. While the vast majority (97%) of treatment episodes were received by clients who live in the D(A)AT of treatment, the small minority were not evenly distributed.

The county of Shropshire, for example, occupied a unique position in the region in delivering almost 15% of its treatment episodes to clients from outside of the DAAT - and almost two in every three of these were from outside the region. This reflected the fact that Shropshire hosts the largest number of residential services in the region, and three out of the five treatment agencies in the county were of this type.

There were also clear geographical relationships between pairs of D(A)ATs: 8% of Stoke-on-Trent’s episodes were received by clients living in Staffordshire, 5% of Walsall’s by clients in Wolverhampton, and 4% of Shropshire’s by clients in Telford & Wrekin.

13.3 A Profile of Clients in Treatment

13.3.1 Gender and age

Clients in treatment were, in general, in their 20s and 30s.  Table 13.05 shows that 29% were under the age of 24, while a further 46% were between the ages of 25 and 34. The ratio of men to women receiving treatment for drug misuse in the West Midlands was approximately 3 to 1 – a ratio which is broadly in line with findings elsewhere, although showing fewer female clients than in some regions. 

As Figure 13.02 illustrates, the age profile of female clients is similar to males, although they tend to be younger - 36% of female clients were under 24, while the equivalent figure for males was only 26%

Figure 13.02: Clients in treatment in the West Midlands by are and sex

Figure 13.02: Clients in treatment in the West Midlands by age and sex

The male-to-female ratio showed some consistency across the D(A)ATs: while Telford & Wrekin, Herefordshire and Stoke-on-Trent showed a slightly larger proportion of female clients and the numbers in Dudley were slightly lower, none of the remaining D(A)ATs showed a deviation of more than two percent from the regional average.

As Table 13.05 shows, age distribution showed a more varied profile across the region. Clients under the age of 24, for example, accounted for more than one in three of all clients living in the Black Country boroughs (Dudley, Sandwell, Walsall, and Wolverhampton), while in some areas only one in five clients fell into that category.

Table 13.05: Clients in treatment and new presentations by drug (& alcohol) action team

13.3.2 Ethnicity and treatment for drug misuse

In terms of ethnicity, it appears that in the West Midlands the proportion of clients from minority groups was, overall, slightly lower than in the resident population. While 88% of clients in treatment were White, only 86% of the resident population aged 15 to 44 were from White ethnic groups.

As Figure 13.03 indicates, this difference tended to be larger in urban areas. It is not clear however whether the difference reflects a higher prevalence of drug misuse within the White population or a high representation of White misusers in treatment.

Figure 13.03: Clients in treatment in the West Midlands by ethnicity

Figure13.03: Clients in treatment in the West Midlands by ethnicity

A small proportion of clients in treatment are recorded by treatment providers as having no fixed abode. In 2004/5 for example, there were 702 clients recorded in this category for the last episode they experienced within the year, and this represented 4.5% of the total for whom a record was made of their status in this regard (for just over 2% of clients, their accommodation status was not recorded). Although clients recorded as having no fixed abode occur in a range of different groups defined by age, sex and ethnicity, they were generally more likely to be White men.

13.04: The Character of Drug Misuse and Treatment

13.04.01: Substances and routes of administration

As a client presents at a treatment agency, the substances which are being misused are recorded as either their primary or secondary problem substance (referred to here as ‘first’ and ‘second drug’). The most commonly recorded substance within the category of first drug was heroin, accounting for four out of every five (81%) treatment episodes in the West Midlands in 2004/5. Crack accounted for a further 3% and cocaine for 2%.

Two out of every five treatment episodes (42%) involved a second problem drug. Of these, a third (36%) recorded their second drug as crack, and in a further 14% recorded it as cocaine.  The single most common combination of drugs being misused was heroin with crack.

While a small majority (58%) of episodes for which heroin was recorded as the first drug did not involve any other substances, nearly one in every five (19%) involved crack as the second drug, and a further 7% recorded cocaine in the same way. Figure 13.04 shows the distribution of secondary substances within treatment episodes involving clients whose first drug was heroin, as well as those whose first drug was a substance other than heroin.

Figure 13.04: Patterns of substances - first and second drug

Figure 13.04: Patterns of substances - first and second drug

In the case of the primary problem substance, the route by which the drug is administered is also recorded. In most cases (56%) in the West Midlands the drug was smoked.  About a third (31%) were injected, while smaller proportions were taken orally (7%) or sniffed (2%). The largest group of injectors were heroin users (accounting for 97% of all episodes involving injectors). Heroin was however more often smoked (57%) than injected (36%). Crack was overwhelmingly smoked (81%), while substances recorded as cocaine were either sniffed (48%) or smoked (40%).

13.4.2 Types of treatment provided

One way of representing the kinds of treatment which a client within the West Midlands’ system is likely to receive is to plot the distribution of clients by the last treatment they received within the year – in effect a ‘snap-shot’ of the typical profile of the treatment types offered. Figure 13.05 shows such a representation.

Figure 13.05: Distribution of treatment types in the West Midlands

Figure 13.05: Distribution of treatment types in the West Midlands

Prescribing services (either by general practitioners or specialist services) are the most common type of treatment, accounting for more than half (57%). Other non-residential structured services (counselling, day care, or other interventions) accounted for a further 40%, while inpatient detoxification and residential rehabilitation made up only a small fraction (3%) of treatments.

13.4.3 Referral sources and treatment outcomes

The largest single group of clients who entered the treatment system in 2004/5 were self-referred (19% of all clients treated), while other important sources were the criminal justice system (12%), and general practitioners (7%).

As Table 13.6 illustrates, a substantial number (6,749) of clients had left the treatment system by the end of the year.  Although we know that a proportion of these were discharged drug free, a fuller assessment of the outcomes of the treatment system is a more complex challenge.

Table 13.6: Clients moving into and out of the treatment system in the West Midlands during 2004/5

One question to consider is whether the success of treatment for an individual should only be assessed on the occasion of their discharge.  Leaving aside what we know about clients often going through several treatment episodes (and therefore several discharges) before they become drug free, it is worth taking into account benefits which accrue earlier in the treatment process.  These might include reduced health risks as well as levels of criminality.  While these are less easy to measure, they support the view that encouraging misusers into treatment is an important aim in itself.

While the position of clients at their final discharge from the system is nevertheless an important test of the success or otherwise of the treatment provided, our monitoring systems require some development before it will be easy to take into account clients’ full journeys through the various typical stages of treatment.

In this context, Figure 13.06 is a necessarily narrow comparison of outcomes within West Midlands’ D(A)ATs. Of the 20,006 episodes of treatment which were delivered (or partly delivered) in the region in 2004/5, more than half (11,135) had been discharged by year end.  For each D(A)AT area, Figure 13.06 represents the proportion of episodes which had not been discharged, as well as those which had been discharged with either successful or unsuccessful outcomes. For the purposes of this chart, successful outcomes are defined as being those which result in the client completing their treatment or being referred on for further treatment.

Figure 13.06: Outcomes of treatment episodes by drug (& alcohol) action team

References

Advisory Council on the Misuse of Drugs (1998). As quoted by the Department of the Environment, Transport and the Regions

www.local.odpm.gov.uk/research/beacyr2/1101.htm, accessed 11th April 2006.

Bullock T et al (2004) Drug Treatment in the North West of England, 2003/04. Liverpool John Moores University. Liverpool.

NDTMS West Midlands (2002) Regional Report: April 2001 to March 2002. National Drug Treatment Monitoring System. West Bromwich

NTA (2002) Models of Care for Treatment of Adult Drug Misusers. National Treatment Agency for Substance Misuse. London.

Roe S (2005) Drug Misuse Declared: Findings from the 2004/5 British Crime Survey. Home Office Statistical Bulletin 16/05. London.

UK Parliament (1998) Tackling Drugs to Build a Better Britain, The Government’s Ten-Year Strategy for Tackling Drugs Misuse. The Stationery Office. London.