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Population Needs Assessment

Substance Misuse

Overview and key messages

Alcohol misuse is a major preventable public health concern. Over 5% of the global burden of

disease and injury is estimated to be attributable to alcohol misuse. Those at risk of harm from

alcohol misuse come from across the spectrum of society. They include chronic heavy drinkers,

adults at home drinking at hazardous or harmful levels, and children and young adults who

suffer from the consequences of parental alcohol misuse. Each year alcohol misuse is

estimated to contribute to 3.3 million deaths worldwide; on a global level, alcohol represents the fifth leading risk factor for morbidity and mortality (World Health Organization, 2019).

 

Nearly half of all men and over a third of women in Wales are drinking above the recommended

guidelines, with considerable proportions drinking at levels likely to be harmful or hazardous to

health (Welsh Government 2019). Hywel Dda University Health Board (HDdUHB) (17.5%) has

a slightly higher percentage than the All-Wales figure (17.2%) in terms of those claiming to

drink above the guidelines. In Wales, 15% of all hospital admissions are due to alcohol

intoxication and most recent data on hospital admissions for HDdUHB across 2021/22 show

that over 14,000 bed days were taken up by patients where alcohol was a primary or

contributory factor in their admittance, at a cost to the Health Board of over £6.1m per year in

inpatient treatment alone.

 

Key findings for the region include:

  • High Prevalence of Alcohol Harm: Alcohol remains a major concern, with 45% of men and 34% of women in the region reporting drinking above recommended guidelines.
  • Aging Demographic: As of 2024–25, 66.2% of individuals admitted to hospitals for substance-related issues were aged over 50.
  • Rising Treatment Numbers: The adult substance misuse treatment population in Wales reached the highest level since records began in 2024-25, with a 6% rise in adults in contact with services (329,646 total).
  • Regional Focus (West Wales): The Area Planning Board (APB) for West Wales highlights high rates of alcohol and drug misuse in Ceredigion, Carmarthenshire, and Pembrokeshire compared to the Welsh average, with significant impacts from organized crime groups (county lines).
  • Substance Trends: Alcohol is the primary issue, followed by opiate and crack cocaine use, with rising concerns regarding ketamine

 

In Wales, responsibility for planning and commissioning substance misuse services sits with Area Planning Boards (APBs). Established in 2010, there are seven Area Planning Boards across Wales, responsible within their regions for: the assessment of need; review of the evidence base; strategic planning; commissioning and performance monitoring of services and interventions to address drug and alcohol use.

APBs are made up of the statutory responsible authorities who have a duty to ensure there is a local plan in place to tackle alcohol and drug use. They sit within a national structure:

Figure 1. All-Wales Substance Misuse Policy, Delivery and Implementation Structure (Welsh Government, 2019)

 

Within Hywel Dda, the statutory responsible authorities are:

  • Hywel Dda University Health Board
  • Ceredigion, Pembrokeshire, and Carmarthenshire Local Authorities
  • Dyfed Powys Police
  • National Probation Service

These statutory partners, along with the Police and Crime Commissioner and Public Health Wales have signed a legally binding strategic agreement to work collaboratively to tackle alcohol and drug misuse.  The local structure through which that work is delivered is detailed in Figure 3 below.

The 2025 Substance Misuse Health Needs Assessment for Hywel Dda University Health Board aims to provide an updated analysis of substance (including alcohol) misuse needs and to identify any health inequalities and unmet need to inform future decision making by the health board and relevant partners within the APB.

Its objectives are:

  • To provide a descriptive analysis of substance misuse need in Hywel Dda, building upon the previous needs assessment published in 2020
  • To demonstrate the patterns of substance misuse in Hywel Dda including health harms, hospital admissions and the impact upon the criminal justice system
  • To describe the policies and evidence base that impact upon substance misuse and substance misuse services.
Demographics and Trends

Hywel Dda University Health Board consists of the three Local Authority areas of Carmarthenshire, Ceredigion and Pembrokeshire and has a total population of 385,600 people (Public Health Wales (PHW) website, accessed 2025, based on Mid-year population Estimates (MYE) from the Office of National Statistics (ONS)).

Generally, Hywel Dda has an older population than the rest of Wales with 9.8% of Hywel Dda residents aged over 75, compared to the Welsh average of 8.6%, with this figure expected to increase in the next decade. According to the Public Health Outcomes Framework (PHW, 2025), Hywel Dda shows the following health statistics (alcohol and other substances will be highlighted in further sections of this needs assessment):

  • 13% of the adult population smoke, compared to 12.8% all-Wales average

 

  • 4% of children smoke

 

  • 9% of the adult population achieve the physical activity guidance compared to 55.45% all-Wales average

 

  • 7% of young people achieve the physical activity guidance

 

  • 3% of the population eat five portions of fruit and vegetables a day, just under the all-Wales average of 28.5%

 

  • 1% of working age adults are of a healthy weight, the same as the all-Wales data

 

  • 1% of young people are of a healthy weight

 

The age distribution across Hywel Dda generally reflects that seen across the rest of Wales but with fewer adults aged between 25 and 49 and more adults aged 55+.

Local, regional and national data was analysed for trends and summarised alongside national policy documents in producing the HDdUHB alcohol and drug misuse health needs assessment, which informs much of this chapter. Key data sets included those published by the Office for National Statistics (ONS), the National Census and the Public Health Wales Observatory. National Survey for Wales (previously the Welsh Health Survey) was also utilised. Data sets were explored for alcohol and drugs to give the local context. Policy guidance was predominately obtained from publications produced by Welsh Government including Working Together to Reduce Harm and its subsequent review papers.

** NOTE: The information in the needs assessment is the most up to date available as of 1st July 2025. Some of the data is collected annually or bi-annually whilst some is collected once every ten years. The most recent iteration of each data point has been sourced to inform this document **

According to the Office of National Statistics (2024), for Wales and England, the following key points were observed during the year ending March 2024:

  • The Crime Survey for England and Wales (CSEW) estimated 8.8% of people aged 16 to 59 years (around 2.9 million people) reported using any drug in the last 12 months for the year ending (YE) March 2024; there was no statistically significant change, compared with YE March 2023.

 

  • Around 3.0% of people (approximately 1 million people) reported using a Class A drug in the last 12 months; there was no statistically significant change from the previous year.

 

  • Cannabis use decreased to 6.8% of people (around 2.3 million people) from 7.6% (around 2.5 million people) in the previous year, returning to levels seen a decade ago.

 

  • Use of nitrous oxide and crack cocaine decreased, compared with the previous year from 1.3% to 0.9%, and 0.1% to 0.03%, respectively; magic mushroom use increased from 0.8% to 1.1%.

 

  • Around 1.8% of people were frequent drug users (more than once a month); this is a decrease from the previous year (2.3%).

 

  • Drug use was higher among people aged 16 to 24 years, with 16.5% reporting any usage; there was no statistically significant change, compared with previous year.

ONS (2024) also note that most people who used drugs in the last year had done so infrequently.

Specifically for Wales, the most recent available data is from the Crime Survey for England and Wales (2023). Data from the CSEW for 2022/23 suggests that use of illicit drugs has increased from 8.5% in 2019/20 to 9.3%. The proportion of adults self-reporting the use of illicit substances in Wales is comparable with England overall (9.5%), particularly the Northwest (8.9%). Compared to 2015/16, the self-reported use of:

  • Any Class A drug has increased from 2.4% to 2.8%
  • Powder Cocaine has increased from 1.8% to 2.2%
  • Cannabis has increased from 6.2% to 7.2%

In Wales, the proportion of adults who self-reported use of non-prescribed prescription-only painkillers for medical reasons has reduced from 10.7% in 2015/16 to 5.0% in 2022/23, comparable to England overall in 2022/23 (4.9%).

 

Care and Support Needs

In Wales, to reflect the cross-cutting nature of the issue, there is a joint strategic approach to tackling harms related to both drugs and alcohol. The Welsh Government Drug and Alcohol Strategy “Working Together to Reduce ” ended and Welsh Government launched its new Substance Misuse (drug and alcohol) Delivery Plan for 2019 – . The 2019 plan built on the progress made during the lifetime of the 2008-2018 strategy, the key learning from an evaluation of the strategy undertaken by Figure 8 Consultancy and the findings of a Healthcare Inspectorate Wales Review of Substance Misuse Services (published July 2018).  The five main priority areas of the delivery plan remain as in the original strategy.

 The 5 Main Priorities of the 2019-2022 Delivery Plan were as follows:

  • Preventing Harm
  • Support for Individuals – to improve health and aid and maintain recovery
  • Supporting and Protecting families
  • Tackling availability and protecting individuals and communities via enforcement activity
  • Partnership
 

The Welsh Government is currently consulting on a Substance Misuse Treatment Framework (SMTF) The consultation also covers a Substance Misuse Treatment Framework for Children and Young People, focusing on early intervention and prevention. 

Key aspects of the consultation included:

·       Substance Misuse Treatment Framework (SMTF):

The SMTF provides guidance for health, social care, and criminal justice providers to deliver effective, prevention and treatment services for those affected by substance misuse. 

 ·      Children and Young People:

The consultation specifically addresses the needs of children and young people, emphasizing early
intervention and preventative measures to reduce long-term harms. 

 ·       Partnership Working:

The consultation highlights the importance of collaboration between different services, including housing and homelessness services, to provide comprehensive support. 

 ·       Harm Reduction:

The framework is rooted in a harm reduction approach, recognizing substance misuse as a health and social issue, not just a criminal justice one. 

 ·       Community Focus:

The consultation emphasizes the need to reduce the harmful effects of substance misuse on individuals, families, and communities, with a focus on supporting families and carers. 

 ·       Access to Services:

The consultation aims to improve access to services for individuals struggling with substance misuse, including addressing dependence on prescription and over-the-counter medications. 

Despite a prolonged period of consultation, this follow up strategy is yet to be formally published by Welsh Government.  However, that has not prevented local plans to ensure a strategic and partnership focussed approach to tackling the issue of substance use across Hywel Dda.

A Population Health Approach

Population Health is an approach that aims to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across a whole population.  It includes action to improve and protect health, to deliver appropriate health and care services and action on the wider determinants of health and wellbeing.  This is not something the NHS can deliver alone – Population Health is about creating a collective sense of responsibility across organisations, communities, and individuals.

The NHS Wales Planning Framework very clearly and repeatedly emphasises the importance of population health improvement via all means including both preventing problems occurring and preventing existing problems worsening. 

To align with the legislative framework in the Wellbeing of Future Generations (Wales) Act, the Social Services and Wellbeing Act and the Public Health (Wales) Act that ensures organisations across
health, social care and communities work together to improve the health and wellbeing of the population, Hywel Dda Area Planning Board therefore, intends to align its future plans  and strategies with both the Welsh strategy for substance misuse and the strategic goals developed locally. This will include following the approach outlined within the 20-4-7 approach to public health as well as the Hywel Dda Health Improvement and Wellbeing Strategy to ensure a focus towards improving health and wellbeing for our population, not just misuse of substances.

The strong strategic links between the Future Generations Act, the Substance Misuse Strategy for Wales and the Wales Reducing Reoffending Framework , Integrated Offender Management and Prolific and Priority Offender strategies has seen criminal justice services in Wales aligned to become increasingly more involved in deliverables for the whole country. 

Service providers must demonstrate they will be able to work within the principles of an Integrated  Offender Management (IOM) approach, including the proactive sharing of non-clinical information and intelligence with Police, Probation, YOPs, Prisons and other locally identified criminal justice and generic service partners in order to reduce criminal activity by individuals dependent on drugs and/or alcohol.

In April 2018, Welsh Government and Her Majesty’s Prison and Probation Service in Wales were commissioned with Youth Justice Board Cymru to develop two new blueprints for the delivery of justice
services in a way that reflects the delivery landscape, in Wales: one to address offending by women and the other for youth justice. 

There has been considerable work undertaken since then to develop blueprints that include a number of ambitious and innovative recommendations for women and youth justice services.

·      Youth Justice 

https://gov.wales/supporting-young-offenders https://llyw.cymru/cefnogi-troseddwyr-ifanc 

  •       Female Offending 

https://gov.wales/supporting-female-offenders 

https://llyw.cymru/cefnogi-troseddwyr-benywaidd

The Police and Crime Commissioner, within his Police and Crime Plan, indicated his continued commitment to tackling substance misuse within his key priorities:

Keeping our communities safe

·      Reduce the impact and harm caused to communities through substance misuse by commissioning services to support individuals to become less dependent on substances.

Protecting our communities from serious threats

·      Educate young people on the dangers of using substances, including the potential links to organised crime activity that might lead them to a lifestyle of exploitation.

 ·      Identify and dismantle the threat posed by OCGs and work with others to disrupt OG activity in particular the trafficking and supply of Class A drugs.

Current care and support provision

Key actions for 2025/26 Hywel Dda UHB Strategic Priorities & Action Plan include:

  • Harm Reduction & Vulnerable Groups:Specific initiatives to support homeless individuals and those with substance misuse issues.
  • Expanding Services:Expanding screening for HIV and Hepatitis B and C, along with improving access to treatment services.
  • Co-occurring Needs:Addressing the overlap of mental health and substance misuse through better pathways, particularly in partnership with Dyfed Powys Police and local authorities.
  • Preventative Focus:A strategic shift towards prevention, addressing substance misuse and mental health challenges, particularly among young people

 

Information on the services provided by Hywel Dda UHB can be found here.

 

Generic Referral Data 2024/25

Generic referrals average around 1000 people per quarter. This figure is growing consistently year on year. There has been an 11.62% increase of referrals when compared to the previous 12 months.  Whilst most of the referrals are from Carmarthenshire, all three counties have grown significantly, all have received their highest number of referrals in the last five years. Carmarthenshire has increased by 21.02% (318 people since 2020/21. Ceredigion has increased by 22.39% (159 people) since 2020/21. Pembrokeshire has increased by 27.46% (240 people since 2020/21).

Figure 4. Generic Referrals received 2024/25

There are more males referred than females but both are showing an increase on the previous year. The main age group for both men and women is 30-39 followed by 40-49 and then 50-59. This ties in with what is known about those most at risk of DRDs but also with the growing link between menopause and addiction.

Most of those individuals who engage with services do so with a self- referral. This is the preferred method as it demonstrates motivation to change behaviour. The figures for male and females using this method are generally similar. The number of GP referrals is surprisingly low, and work is currently ongoing to engage more effectively with Primary Care colleagues.

Figure 5. Generic Referrals Received by Referral Source 2024/25

Generic Assessment Data 2024/25

The number of assessments completed by drugs and alcohol services has stayed generally steady for the last number of years, possibly indicating that the service is operating at capacity. 560 assessments took place in the last quarter of 2024/25 with a total of 2288 assessments carried out across Hywel Dda.

Figure 6. Assessments Completed, by Year, by County, 2024/25

Being the most populous area, Carmarthen sees the greatest number of assessments but with a slight reduction during the last year. Pembrokeshire has seen a minor upturn in assessments completed during the last twelve months.

There are more alcohol assessments that drug assessments carried out across Hywel Dda. It is often the case that alcohol assessments will account for over 60% of all those carried out. Alcohol remains the biggest substance issue in the three counties despite a 6.91% reduction in assessments over 2024/25. Drug assessments rose by 7.12% for the same period.

The gender split between drugs and alcohol assessments is relatively similar but generally it is an older cohort engaged with alcohol assessments. This may be due to those who have been long term drug users do not see services as being for them and the complex case work initially piloted in Llanelli is a vehicle to engage with this group more effectively.

Figure 7. Alcohol and Drug Assessments by Gender and Age, 2024/25

Impact of Covid-19 Pandemic

Whilst there is no direct correlation with the pandemic, the data below indicates that since 2020 there has been an increase in drug and alcohol related school exclusions and increase in the number of referrals coming into Dyfed Drug and Alcohol Services (DDAS) from criminal justice.

In 2022/23 (academic year), the number of school exclusions related to drugs or alcohol increased overall from 869 in 2021/22 to 939 (8.06%), specifying type of exclusion as fixed term or permanent. This is the highest number of exclusions since 2011-12. There is no data for 2019-20 as schools were closed for much of the academic year due to the COVID-19 pandemic. The number of permanent pupil exclusions due to drugs or alcohol increased slightly to 27 cases and the number of fixed term exclusions over 5 days increased to 86 cases up from 24 and 60 respectively. The number of exclusions of 5 days or less increased by 5% in the last year, from 785 to 826, following a very large jump in the previous academic year. Of all school exclusions (any reason), drug and alcohol related exclusions accounted for 2.9% in 2022/23, a slight reduction compared to the previous year.

Referrals from criminal justice include prison release, probation and direct from Dyfed Powys Police (see Figure 61 below). These figures will continue to grow in coming years due to the development of the Out of Court Disposal process and drug test on arrest in custody. Most of the referrals are for the Carmarthenshire area which has also seen a considerable increase in referrals over the last year.

Figure 8. Breakdown of Criminal Justice Referrals 2024/25

Most of the referrals (615 in 2024/25) continue to be male, with 128 females referred during the same period. The 30–39-year-old age bracket has the most referrals, but this is a reduction from the previous year of 12.41%. The age group with the biggest growth in 2024/25 was the 60-69 age group with a 66.67% rise followed by the 50-59 year old group with a 34.69% rise. This is reflective of both an ageing population generally but also an ageing substance using population more specifically.

Needle exchange interventions had been declining across Wales since the pandemic. However, in Hywel Dda, we are beginning to see the slightest of increases over the past 12 months. The total number of unique clients has grown by 3.24% over the last year and the total number of exchange transactions that have occurred has also risen, by a notable 13.13% since 2023/24. As with Naloxone, each needle exchange is an opportunity to engage with the person and to impart further harm reduction messages and perhaps draw them into services.

 

The Gaps: What's missing (gaps and areas for improvement).

Future service development plans, care and support provisions and needs should focus on the following interventions:

  • Turn the curve and reduce the inequalities gap in smoking prevalence through prioritising specific groups who are at high-risk of tobacco related harm. High-risk groups include inpatients, people with mental ill-health, people with conditions made worse by smoking, people with smoking related illness and pregnant women who smoke
  • Support pregnant smokers to quit
  • Continue to target smoking cessation interventions in those areas with the highest smoking prevalence
  • Use social marketing to maximise reach
  • Use asset-based approaches to work with local communities to assess barriers and facilitators to prevent uptake and reduce prevalence
  • Treat smoking at the point of diagnosis for a wide range of diseases to improve outcomes. The evidence suggests that smoking quit attempts in healthcare settings are effective as smokers are overrepresented in the population of people who use NHS services
  • Support the development of digital or electronic aids to cessation
  • Support the development of opt-out models across secondary care settings and maternity
  • Work with partners to ensure full implementation of public health and wellbeing legislation
  • Work with partners (Local Authority, Education, Housing, Emergency Services) to reduce exposure to environmental tobacco smoke through supporting smoke free legislation, maximising the delivery of brief advice as support smoking cessation
  • Work in partnership to improve the strategic alignment of policy and services across the health and wellbeing continuum for tobacco control
  • Ensure evidence-based smoking cessation services are available for everyone who smokes, including brief advice, behavioural support
  • Implement the recommendations of the NHS Future Forum which emphasises the value of having brief opportunistic ‘healthy lifestyle chats’ including raising the issue of stopping smoking. Providing Very Brief Advice to every smoker is recommended by the Department of Health is effective in general care settings and can be adapted to mental health settings
  • Support staff in primary and secondary care settings who already have the necessary therapeutic skills to engage patients in conversations about behaviour change. We know that offering support to stop smoking, rather than merely asking a smoker if they are interested in stopping or telling them they should stop, leads to more people making a quit attempt. Raising the issues of smoking can be done opportunistically with patients, such as during protected engagement time; at the end of a home visit or during clinical visits. It can also be helpful to link these brief interventions to a current health problem such as a cough, breathlessness or something that is of personal relevance to the patient
  • Support the implementation of harm reduction approaches for those smokers who may not be able to stop in one step (NICE Guidance, 2013).