The chapter is based on the Annual Report of the National Drug Treatment Monitoring System (NDTMS)

8.1 Summary

• This chapter is based on the 3rd annual report of NDTMS West Midlands, and it presents results for the period 1^st April 2005 to 31^st March 2006;


• National estimates indicate that both drug misuse and treatment for misuse are not generally as commonplace in the West Midlands as in other regions;


• A total of 18,682 clients living in the West Midlands region received treatment for drug misuse during the year;


• Treatment was delivered by 129 agencies, based in 94 different locations, and organised within 14 Drug (& Alcohol) Action Team, or D(A)AT, areas^(a). Five agencies treated almost half of all clients, and 30% of all clients lived in Birmingham;


• The proportion of residents in treatment varied considerably between D(A)ATs - in some urban areas the rate was more than double that for some rural counties;


• The majority of clients were under the age of 34, and the ratio of men to women was 3 to 1. In several Metropolitan areas there was some over-representation of White clients compared to their resident populations;


• Heroin was the primary problem substance in four out of every five treatment episodes. Almost half of treatment episodes involved clients with at least two problem drugs (the most common combination being heroin and crack);


• Prescribing services accounted for more than half (56%) of treatment types. Other non-residential structured services accounted for a further 42%, while residential and inpatient services accounted for only a small fraction of treatment (2%).

Map 8.1: The Geography of Drug Treatment

The Geography of Drug Treatment

8.2 Introduction

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 31^st March 2006.

With their consent, the NDTMS collects data on all clients and patients who are receiving structured care ^(b) for drug misuse from registered treatment agencies^(c). 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) ^(d). The range of substances for which any individual agency provides treatment varies, but the focus of treatment – and therefore of this report - 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 report are Heroin users or poly users^(e). Clients for whom alcohol was the main problem substance are excluded from this report.

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 report, they are shown according to the location of the clients’ residence. .

8.3 Recent Trends in Data Collection

NDTMS results have grown in importance: the Government’s drug strategy has included a commitment to double the numbers in treatment within the 10 years to 2008^(f), and it has been critical for the NDTMS to be able to record progress towards this goal. In addition, NDTMS results also support the assessment of NHS Primary Care Trusts through such processes as the Healthcare Commission’s annual health check^(g).

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 agencies transfer information directly from their own systems to NDTMS. This has raised the quality and accuracy of the information collected, as well as the consistency between agency and NDTMS records.

Information is collected from all agencies on a monthly basis by the West Midlands regional office of the NDTMS. In a process paralleled in other parts of the country, information about clients treated in the region is then passed to the NDTMS national office, where a consistent national dataset is produced. It is the part of this dataset relating to the West Midlands, which has been used as the basis of this report.

The way in which data about treatment for drug misuse are collected has also adapted to changes in government policy. 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^(h). This report does not particularly highlight the effects of these changes, but future reports from the NDTMS will reflect this development.

8.4 The Structure of Data Collected

The information collected by the 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⁽ⁱ⁾ received within each episode.

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 one) for drug misuse during that period.

During the year 2005/6, there were 18,682 clients in treatment living in the West Midlands region^(j). The fact that 25,569 episodes were underway at some time during the year illustrates that some clients experienced more than one episode: in fact, one in every four (27%) 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 2005/6, each treatment episode in the West Midlands involved an average of 1.4 treatment types - leading to a total of 35,785 being recorded for the region.

8.5 Prevalence and Treatment in the English Regions

Evidence from the British Crime Survey(k) shown in Table 8.1 suggests that the actual prevalence of misuse in the West Midlands, i.e. the proportion of individuals in the population misusing drugs, may be lower than in any other English region.

Table 8.1: Prevalence of drug misuse and treatment

Prevalence of drug misuse and treatment

For the size of its resident population, the number of people 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 2005 of 5.4 million for the West Midlands region, we can estimate a treatment rate of nearly 3.5 per 1,000 (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 8.1, 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 in the region. An 18% annual increase in the numbers in treatment in the West Midlands has been reported^(l), with an equivalent increase in England of 13%. 

The recorded growth in treatment is also echoed in a comparison of the number of clients experiencing treatment in the West Midlands in 2005/6 (18,682) with the number reported in 2001/2 (9,505), although it is important to keep in mind that these figures are not calculated on a consistent basis. 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.

8.6 Agencies Providing Treatment

At the end of March 2006 there were 129 treatment agencies in the region reporting to the NDTMS, based in 94 different locations, and organised within 14 D(A)AT areas^(m). As Map 8.1 illustrates, the number of agencies within each D(A)AT area varied - from only 3 in Telford & Wrekin, to as many as 25 in Birmingham.

Agencies providing treatment varied considerably in size, and Table 8.2 lists the five largest (by the number of clients in treatment).  These five treated 8,792 clients – almost half of the total (47%).  Many other agencies were comparatively small – fewer than 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 8.2: The largest treatment providers in the region, 2005/6

The largest treatment providers in the region, 2005/6

8.7 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 8.3 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 Staffordshire, and Warwickshire. 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⁽ⁿ⁾.
An exception to this pattern in the West Midlands would appear to be the rural county of Herefordshire, which had a rate of treatment comparable with urban areas such as Walsall 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 possible, 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 causes of these variations in the proportion of residents in treatment in different D(A)AT areas might merit further investigation elsewhere.

A further point illustrated by the table is the dominance of Birmingham, which accounts for almost a third of West Midlands’ clients. By numbers in treatment, Birmingham is the largest Drug Action Team (or D(A)AT) 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 8.3 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.

Table 8.3: Clients in treatment per head of population by Drug (& Alcohol) Action Team

Clients in treatment per head of population by Drug (& Alcohol) Action Team

In general terms, deprivation has been cited elsewhere as having a relationship with levels of drug misuse^(p), and it also appears from Table 8.3 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.

8.8 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 8.4 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 in the proportion of clients in treatment in each D(A)AT area who experienced new presentations. Nearly two-thirds of clients in Wolverhampton were new by this measure, while in Herefordshire 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, or might reflect the different mix of treatment delivered by each D(A)AT.

Table 8.4: Clients in treatment and new presentations by Drug (& Alcohol) Action Team

Clients in treatment and new presentations by Drug (& Alcohol) Action Team

8.9 The Locations of Treatment and Residence

Something can also be learnt about the character of the treatment system in each area 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 (3%) who did not, were not evenly distributed.

The county of Shropshire, for example, occupied a unique position in the region in delivering almost 13% of its treatment episodes to clients from outside of the DAAT - and more than half of these were from outside the region.  This reflected the fact that Shropshire hosts the largest number of residential services in the region, and half of the agencies in the county were of this type.

There were also small geographical relationships between pairs of D(A)ATs: 4% of Shropshire’s episodes were received by clients living in Telford & Wrekin (and vice versa), and 3% of Walsall’s by clients in Wolverhampton.

8.10 Gender and Age

Most clients in treatment (78%) were in their 20s and 30s.  Within this range, almost half (47%) 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.

As Figure 8.1 illustrates, the age profile of female clients had some similarities to that for males, although females tended to be younger - 39% were under 24, while the equivalent figure for males was only 29%.

Figure 8.1: Clients in treatment in the West Midlands by age and sex

Clients in treatment in the West Midlands by age and sex

Among D(A)AT areas, the lowest female-to-male ratio was recorded in Dudley, where only 21% of clients were female.  The highest ratio occurred in four D(A)AT areas where at least 28% of clients were female: Stoke-on-Trent; Telford & Wrekin; Wolverhampton; and Worcestershire.

As Table 8.5 shows, age distribution showed a slightly more varied profile across the region. Clients under the age of 24, for example, accounted for almost 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 8.5: Clients in treatment by age, sex, ethnicity and Drug (& Alcohol) Action Team

Clients in treatment by age, sex, ethnicity and Drug (& Alcohol) Action Team

8.11 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, very similar to that in the resident population. The proportion of clients in treatment who were White was 87%, while 86% of the resident population aged 15 to 44 were from White ethnic groups.

As Figure 8.2 indicates, there was a larger difference within the client and resident populations in some Metropolitan 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 8.2: Clients in Treatment in the West Midlands by Ethnicity

Clients in Treatment in the West Midlands by Ethnicity

8.12 Drugs Misused

As a client presents at a treatment agency, the substances which are being misused are recorded as primary, secondary, or tertiary problem substances (referred to here as ‘first’, ‘second’, or ‘third’ drug’. The most commonly recorded substance within the category of first drug was heroin, accounting for four out of every five (79%) treatment episodes in the West Midlands in 2005/6. Crack accounted for a further 3% and cocaine for 2%.

Nearly half of all treatment episodes (49%) involved a second problem drug.  Crack was recorded as the second drug in more than a third (39%) of cases, and cocaine in a further 14%.  The single most common combination of drugs being misused was heroin with crack.

While about half (51%) of episodes for which heroin was recorded as the first drug did not involve any other substances, nearly one in every four (24%) involved crack as the second drug, and a further 8% recorded cocaine in the same way. Figure 8.3 shows the distribution of secondary substances within treatment episodes involving clients whose first drug is heroin, as well as those whose first drug was a substance other than heroin.

Figure 8.3: Patterns of Substances - First and Second Drug

Patterns of Substances - First and Second Drug

From April 2005, NDTMS started to record clients’ third problem drug and in the case of 2,429 treatment episodes (9.5% of the total), three substances were recorded as being misused by the client.  Among the third drugs recorded, cannabis (39% of episodes with a third drug recorded) and alcohol (14%) featured prominently.  Among cases where the first two drugs recorded were heroin and crack, the most common third drugs were cannabis and benzodiazepines.

8.13 Routes by which Problem Drugs were being Administered

In the case of the primary problem substance, the route by which the drug is administered is also recorded.  In most cases (59%) in the West Midlands the first drug was smoked.  Less than a third (28%) were injected, while smaller proportions were taken orally (7%) or sniffed (3%).  The largest group of injectors were heroin users (accounting for 97% of all episodes involving injectors). Heroin was however more often smoked (60%) than injected (35%). Crack was overwhelmingly smoked (82%), while other substances recorded as cocaine were either sniffed (62%) or smoked (32%).

8.14 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 8.4 shows such a representation.

Figure 8.4: Distribution of Treatment Types in the West Midlands

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 (56%)(q). Other non-residential structured services (counselling, day care, or other interventions) accounted for a further 42%, while inpatient detoxification and residential rehabilitation made up only a small fraction (2%) of treatments.

8.15 Referral Sources and Treatment Outcomes

The largest single group of clients who entered the treatment system in 2005/6 were self-referred (15% of all clients treated), while other important sources were the criminal justice system (14%), and general practitioners (5%).
As Figure 8.5 illustrates, a substantial number (6,395) 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.

Figure 8.5: Clients Moving Into and Out of the Treatment System in the West Midlands During 2005/6

Clients Moving Into and Out of the Treatment System in the West Midlands During 2005/6

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 might allow the assessment of the existing view that encouraging misusers into treatment is an important aim in itself.

For this reason, there is an intention to continue the development of the NDTMS in order to allow the collection of information about changes in clients’ status in advance of discharge.  However, 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 the meantime, Figure 8.6 is a necessarily narrow comparison of outcomes within West Midlands’ D(A)ATs. Of the 25,569 episodes of treatment which were delivered (or partly delivered) in the region in 2005/6, fewer than half (11,043) had been discharged by year end.  For each D(A)AT area, Figure 8.6 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 8.6: Outcomes of treatment episodes by Drug (& Alcohol) Action Team

Outcomes of treatment episodes by Drug (& Alcohol) Action Team

Notes within chapter:

1. Some of the fourteen Drug Action Teams in the region also include the treatment of alcohol abuse within their remit.
   
   
2. The NDTMS only records data from structured drug treatment providers, i.e. high threshold, Tier 3 and 4 services, as defined by the document ‘Models of Care’ (www.nta.nhs.uk/publications/Models_of_care.pdf). What are sometimes known as ‘low threshold’ interventions, such as syringe exchange and open access services are therefore not included.
   
   
3. Agencies which are providing Tier 3 or Tier 4 treatment as defined by the NTA’s Models of Care, and which are registered to provide data to NDTMS.
   
   
4. The National Treatment Agency for Substance Misuse (NTA) was established in 2001 as a special health authority within the NHS to lead the performance management of local level partnerships including Drug (& Alcohol) Action Teams in the delivery of treatment for misuse.
   
   
5. Poly users are clients who require treatment for more than one substance.
   
   
6. ‘Tackling Drugs to Build a Better Britain, The Government’s Ten-Year Strategy for Tackling Drugs Misuse’, April 1998. Available from: www.archive.official-documents.co.uk/document/cm39/3945/3945.htm
   
   
7. More information about the Healthcare Commission’s annual health check is available from: http://ratings2006.healthcarecommission.org.uk/Indicators_2006Nat/Downloads/PCTList.doc#_Toc147555320.
   
   
8. More information on the DIP is available from www.drugs.gov.uk/drug-interventions-programme.
   
   
9. 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.
   
   
10. This total differs by a small amount from the 18,726 published by the NTA (at www.nta.nhs.uk/programme/national/perf_info_sept06/nos_in_tment_200506.pdf). This is principally because the lower total excludes records for which a D(A)AT of residence was absent.
    
    
11. The British Crime Survey is commissioned annually by the Home Office to measure the amount of crime in England and Wales. It asks people about any crimes they have experienced in the last year, including those which are not reported to the police, and is based on over 50,000 interviews of people aged 16 or over. More information is available from: www.homeoffice.gov.uk/rds/bcs1.html.
    
    
12. The National Treatment Agency has reported 18,726 individuals in contact with structured drug treatment services in the West Midlands in 2005/6, an increase from 15,905 in 2004/5.
    
    
13. Local Drug (& Alcohol) Action Teams are responsible for identifying local needs and using central government and locally resourced funding to commission or purchase drug treatment to meet those needs. They are consortia of local organisations involved in the delivery of the Government’s drugs strategy including health authorities, primary care trusts, police, probation, prison service and local authorities. The NTA is responsible for monitoring, and advising on how D(A)ATs spend their funding on treatment (more information is available from www.nta.nhs.uk/frameset.asp?u=http://www.nta.nhs.uk/about/regional.htm). D(A)AT areas in the West Midlands correspond to first level Local Authority boundaries (i.e. either Metropolitan District, County, or Unitary Authority)
    
    
14. Bullock et al, 2004 (see Bibliography).
    
    
15. This table is based on the aggregation of treatment providers where they form part of the same National Health Service mental heath trust.
    
    
16. For example, the Advisory Council on the Misuse of Drugs in 1998, as quoted by the Department of the Environment, Transport and the Regions. See www.local.odpm.gov.uk/research/beacyr2/1101.htm.
    
    
17. Expressed as a proportion of individuals receiving adult modalities.
    

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2. European Monitoring Centre for Drugs & Drug Addiction (2005), ‘The State of the Drugs Problem in Europe’, Lisbon: EMCDDA (Available from: http://ar2005.emcdda.europa.eu/download/ar2005-en.pdf).
   
   
3. East Midlands Public Health Observatory (2006), ‘Annual Report 2005/6’, Nottingham: NTA (Available from: www.nta.nhs.uk/programme/docs/NDTMS_Annual_Report_2005-6_Final.pdf).
   
   
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7. West Midlands Public Health Observatory (2004), ‘Indices of Multiple Deprivation 2004: An Overview of the West Midlands Data’, Birmingham: WMPHO. (Available from: www.wmpho.org.uk/information/imd04.asp).
   
   
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