Morecambe Bay Primary Care Trust PROPOSED DEVELOPMENT OF ALCOHOL SERVICES IN MORECAMBE BAY EXECUTIVE SUMMARY

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1 TRUST BOARD MEETING AGENDA ITEM NO 7(c) Morecambe Bay Primary Care Trust PROPOSED DEVELOPMENT OF ALCOHOL SERVICES IN MORECAMBE BAY EXECUTIVE SUMMARY 1. Public consultation on proposals for the development of Alcohol Services in Morecambe Bay concluded on 20 th January This paper sets out for the Board: Consideration of issues raised in the consultation A proposal to progress service development in line with commissioning objectives, taking into account the issues raised during the consultation 2. The proposed position, following consultation, is that the treatment system should develop in line with the four tier framework of the draft national Models of Care for Alcohol Misusers. This will enable it to meet a range of needs in relation to different types of alcohol use problems. It will require enhancing the role of Tier 1 and 2 services (brief intervention, screening and advice) and expanding the Tier 3 community-based specialist alcohol services to provide additional capacity for providing treatment in local settings. Reconfiguration of Tier 4 services is proposed, with a reduction in the level of inpatient provision to that which is needed to support managed inpatient detoxification, alongside the enhanced role for Tier 3 services within the new model. 3. A number of issues raised in the consultation are set out in the paper. There is generally broad support for the enhancement of community services. However, there is much concern about the reconfiguring of Tier 4 services. A number of issues raised have been incorporated in the revised development proposals. Further issues will need careful consideration within implementation planning. A proactive change management approach in taking forward these developments will be necessary to reduce risk of service disruption in the initial implementation stages. 4. It is recommended that the Board: Notes the issues that have been raised during the consultation period and the responses to these issues Approves adoption of the four-tiered service model outlined in the consultation document Approves the service reconfiguration which is outlined in this paper as necessary for delivery of the service model Agrees to receive detailed commissioning specifications and implementation plans based on the proposed model and reconfiguration (anticipated date: May 2006) Agrees to receive a progress report on negotiations with other stakeholders on their commissioning intentions and any implications for service provision in Morecambe Bay (anticipated date: May 2006).NHS. Frank Atherton Director of Public Health Andrew Bennett Director of Commissioning & Performance Improvement 1

2 AGENDA ITEM NO 7(c) TRUST BOARD MEETING PROPOSED DEVELOPMENT OF ALCOHOL SERVICES IN MORECAMBE BAY 1. BACKGROUND 1.1 At its meeting of 28 th September the PCT Board agreed to publicly consult on proposals to develop alcohol treatment services, which were to: develop community based treatment services, enabling the closure of the Castle Unit at Ridge Lea Hospital, Lancaster and a reduction in the level of residential support provided at Harvey House in Lancaster. 1.2 A consultation paper, outlining proposals for development of the alcohol treatment system in Morecambe Bay was distributed in October The consultation period ended on 20 th January. 1.3 The service development proposals were set out with an aim of meeting a number of objectives: To provide a more equitable and consistent service for Morecambe Bay residents To provide a high quality, flexible and effective treatment system that can meet a range of individual needs in relation to different types of alcohol use problems To expand the delivery of brief interventions in primary care, social support and voluntary sector contexts and in non-specialist secondary care To ensure consistency with national policy directions in Choosing Health and the National Alcohol Harm Reduction Strategy. 1.4 This paper considers proposals for the development of Alcohol Services, setting out for the Board: A consideration of the issues raised in the consultation (details of the consultation process and how issues have been responded to, are the subject of a separate paper to the Board) Proposals to progress service development, taking into account issues raised during the consultation 2 CONTEXT 2.1 The World Health Organisation uses three specific categories to define alcohol use problems: 2.2 Hazardous drinking: people drinking above recognised sensible levels, but not yet experiencing harm; Harmful drinking: people drinking above sensible levels and experiencing harm Alcohol dependence: people drinking above sensible levels and experiencing harm and symptoms of dependence. 2.3 The National Alcohol Harm Reduction Strategy (March 2004) and the Choosing Health White Paper on improving public health (Oct 2004) both place emphasis on tackling alcohol misuse and improving services. The recent White Paper Our health, Our care, Our say places emphasis on prevention, and providing care where appropriate in local, convenient settings, including the home. A particular issue in the approaches highlighted 2

3 AGENDA ITEM NO 7(c) TRUST BOARD MEETING in these policies is to provide more effective evidence-based interventions to modify drinking among people who are drinking at harmful or hazardous levels. 2.4 Within national policy, it has been acknowledged that alcohol treatment services in the UK have not developed within a rational commissioning framework and a wide range of service systems have developed as a result. In an attempt to support a commissioner s move towards a more consistent, evidence based and cost effective approach, the Department of Health has commissioned the National Treatment Agency to produce a National Models of Care for Alcohol Misusers (MOCAM). A draft MOCAM was produced for public consultation in May 2005, and is expected to be finalised in early It proposes a four-tier framework, where lower tiers respond appropriately with brief interventions, screening and referral as appropriate, and higher tiers relate to specialist services which respond to higher levels of need related to alcohol dependence. A summary of the draft four tiers MOCAM framework was set out in the consultation paper. 2.5 Initial review work of Morecambe Bay s local alcohol treatment system began in October The proposals for services changes contained in the public consultation were developed with the input of a small working group of commissioners, providers, clinical and finance staff. 2.6 The major shift for service provision set out is to: Expand the capability and capacity of the specialist community alcohol team, enabling a strengthening of community based treatment, partnership and shared care working with staff from Tier 1 and 2 Expand capacity for alcohol detoxification (detox) by investing in home based detox, maintaining an appropriate level of provision for those requiring inpatient treatment (with an estimated requirement of 3 beds needed for Morecambe Bay) Develop alternative programmes for supporting people with longer treatment and/or rehabilitation needs within a joint health and social care framework Reconfigure the provision of the local element of a drug detox service, transferring the resources from the current inpatient provision, to an increase in capacity within the community drug team to enable a greater resource for drug detox. 2.7 It is proposed to achieve the reconfiguration of inpatient alcohol detox programmes by transferring provision at the Castle Unit at Ridge Lea Hospital (currently providing short term alcohol and drug detox treatment) to Harvey House. This inpatient provision will replace the rehabilitation programmes which are currently provided at Harvey House. 2.8 The aim of the review was to identify how services might be focussed on meeting commissioning objectives and the range of services developed within the MOCAM framework, while possibly reducing costs. Initial costings in relation to the new service model were calculated by the Review Group and suggested some scope for cost reduction. However it was acknowledged that these would need to be revisited and refined as details of the future model was shaped by the consultation. 3

4 TRUST BOARD MEETING AGENDA ITEM NO 7(c) 3 CONSULTATION PROCESS AND ISSUES RAISED Details of the consultation process and issues raised in relation to the proposed service developments have been set out in a separate paper to the Board. A number of key themes emerged in the consultation from both the meetings and the written responses. The key issues and how they have been responded to in setting out service proposals in this paper are as follows: 3.1 Lack of detail in the proposals A number of people commented on the lack of detail in the consultation paper. The consultation s focus at this initial stage was on the overall model of provision. Should the Board agree with the overall direction proposed, a more detailed commissioning specification and implementation plan will be developed with further input from key stakeholders, including staff within current alcohol treatment services, within a robust change management process. 3.2 The draft nature of Models of Care for Alcohol Misusers The National Treatment Agency (NTA) is finalising the MOCAM, for release in early A number of respondents indicated that the Trust should wait for the final version to be released before agreeing to take forward developments. In mid January the NTA s senior policy lead indicated that the final MOCAM will mirror the draft version, with an amendment that tier 4 should be focussed on the provision of short term inpatient detox services and managed residential rehabilitation. It will be for local commissioners to determine the requirement for other therapeutic inpatient services which may be considered suitable to meet local needs. During the consultation, there was widespread support for the draft MOCAM model. However, concern was expressed that the community based model would be undermined unless adequate resources were made available. The commissioners agree that that the enhanced level of community provision is critical in order to provide a workable and cost-effective treatment system. The issue of how support is provided for people who need prolonged and intensive help is considered in section Estimation of need There is no single method of categorising individuals who may be in need of alcohol treatment and local surveys have not been conducted to enable precise mapping of the type of drinkers in Morecambe Bay. The national prevalence figures 1 set out in the consultation paper, are suggested in the draft National Models of Care as most appropriate for estimating local levels of need, although it is acknowledged that there will be significant local variations in the prevalence and types of drinking problems. These figures indicate that 0.5% of the adult population will be in the category of severe or moderate dependence, with a further 20% drinking in the hazardous or harmful category. An earlier Department of Health paper 2, indicated higher estimates based on Office of National Statistics survey data. This also 1 Department of Health and National Treatment Agency for Substance Misuse. Models of care for alcohol misusers Consultation document 1 st April Department of Health. Alcohol Needs Assessment Research Project

5 AGENDA ITEM NO 7(c) TRUST BOARD MEETING indicated that prevalence of harmful and hazardous drinking problems could vary across regions from 18% to 29%, while alcohol dependence varied between regions ranging from 1.6% to 5.2% Service demand is not necessarily a good indicator of need. However, within current community alcohol service capacity, 920 people are supported in Morecambe Bay each year, and there are unacceptably long waiting lists of up to 6 months. Further national research indicates that up to 71 % of patients with alcohol disorders were not referred by GPs because of either perceived difficulties in access and waiting times for specialist treatment, or because of clients reluctance to access specialist treatment. This suggests that there are significant gaps in provision, which commissioners believe could be better met through enhancing community treatment capacity, as under the proposed model. 3.4 Support for community enhancement, alongside concerns about the adequacy of the level of tier 4 provision proposed The move to enhance the community provision was given widespread support. However, there is a lot of concern that even the enhanced community service will be inadequate to cope with the intense treatment needs of more severely alcohol dependent people. A number of patients who have received services at Castle Unit and Harvey House spoke of the value of having time out of their normal situation, and questioned how this provision would be available for those that need it in the new model A robust community based model of treatment for alcohol misusers is evidenced as good practice and reflects developments within treatment services across other PCTs and as recommended within the draft MOCAM. It is recognised that some alcohol misusers will require more intensive inpatient detox and national needs assessment work indicates that 3 beds within Morecambe Bay will provide the necessary element of the treatment system A reduction in inpatient provision will enable growth in the community based teams and direct resources to those people who are categorised as using alcohol harmfully (potentially 10,508 people). This group of people, will benefit from an increased community team and developed brief intervention programme with the aim of reducing further harm from alcohol. More people will be able to access alcohol treatment by increasing the community based service and clients requiring an in-patient episode will be able to access and receive follow up on discharge The enhanced capacity of the community alcohol team is critical to achieve the necessary capability to address the needs of the patients requiring help at different levels of intensity and to enable effective engagement with Tiers 1 and 2. Concerns about the new community teams not being able to achieve the caseload proposed were noted in the consultation and assumptions reexamined. The following information table demonstrates the expected increase in capacity: Service in brief Staff resource WTE Estimated number of clients seen Current level Phase Phase

6 TRUST BOARD MEETING Drug worker AGENDA ITEM NO 7(c) It should be noted that the numbers expected to access services are estimated based on an average caseload within the current teams. As the model depends on supporting capacity in tiers 1 and 2 from partners and via the specialist community teams, there will be a lead-in time before there is evidence of increased activity whilst the infrastructure is developed The consultation document proposed a phased implementation over two years. Responses highlighted the risk that phased re-investment into the community alcohol services might not deliver improved access to services in year one and might lead to an increase in waiting times. In the light of these comments received it is proposed that the appropriateness of such phasing will be reconsidered as part of the development of the detailed commissioning specifications and implementation plans. 3.5 Incorporating the needs of clients requiring longer term support The withdrawal of the 9 week residential treatment programmes raised strong concerns from clinical staff and some ex-clients. Personal experiences of patients who have benefited greatly from these programmes were heard at the consultation meetings. The evidence base for the current programme is weak and there has been no systematic documentation of treatment outcomes at Harvey House. There is no definitive research that gives a clear protocol for deciding how long a placement should last. There needs to be a clear pathway into managed rehabilitation programmes at the Tier 4 level within the MOCAM model, and it is acknowledged that there needs to be provision made for the small group of patients who require prolonged and intensive help. This is on average 16 people per year, based on current utilisation by Morecambe Bay clients of the 9 week programme at Harvey House. Long term treatment support will become incorporated into the programmes provided within the enhanced community team, possibly working within new innovative service models to be established with Harvey House and/or voluntary sector providers. Consultation highlighted the need to progress negotiations about a social care pathway, which defines more clearly the treatment/rehabilitation interface with Social Service departments. 3.6 Reprovision of drug detox services currently provided from Castle Unit During the consultation, it was clarified that up to 30 clients per year are receiving drug detox treatment at the Castle Unit. This service provides a component within the drug treatment system, where other options are available, such as community detox and treatment commissioned from Drugs North West. It is the quality and local access to this service that is valued by Morecambe Bay clients. Options for the re-provision of this service have been considered. With the closure of this Unit, the Trust will need to consider alternative provision. This will be addressed in the detailed operational planning. 3.7 Service disruption associated with change Service providers raised strong concerns about the period of change while there is a transition from inpatient provision towards community based provision, regarding a potential to increase both waiting times and waiting lists. Sound management of the change over period would be needed to 6

7 TRUST BOARD MEETING avoid this occurring, while work is undertaken to develop an effective reconfigured service. 3.8 Evidence base AGENDA ITEM NO 7(c) The evidence base supporting the proposal has been revisited since the consultation 345 and the following points have been confirmed: A treatment system needs to be flexible in meeting a wide range of needs. A primarily inpatient approach to treatment is not cost effective. Brief interventions provided by a GP or other professional in a community setting can reduce the prevalence of alcohol misuse. About 50-60% alcohol dependence patients show a significant improvement over a twelve month period following treatment contact, whatever the intensity of treatment offered. In 80-90% of cases, detoxification is without complications. Withdrawal at moderate levels of dependence can be handled safely and effectively by a Community Alcohol Team or GP and many cases can be treated without medication. However, in patient detoxification remains the only safe option for a variety of life-threatening and complex cases, and will need to be provided as part of an integrated treatment system. A small number of severely dependent patients respond preferentially to sustained and intensive help, although there is no clear evidence to establish what type of programmes are more effective The current service model does not have adequate resources to provide treatment to people outside of the severely dependent and moderately dependent category. The heart of this proposal is to redress that imbalance and encourage more people into treatment within a flexible community based treatment system. 3.9 The impact on current programmes provided at Harvey House Issues were raised from clinical staff that Harvey House is currently not geared for dealing with the needs of clients that have accessed the short term detox treatment at the Castle Unit, and it will be difficult to mix the two programmes. There are issues of patient safety and lone working that would need to be further explored and addressed. Staffing configuration has been taken into account in the initial costings of the new model. Changes to the building have been suggested as necessary and this issue, along with 3 Christopher CH Cook. Chapter Alcohol Misuse in Health Care Needs Assessment. The epidemiologically based needs assessment reviews. 2 nd Edition Vol 2. Stevens, A, Raftery J, Mant, J and Simpson, S. (Eds) Radcliffe, Oxford National Treatment Agency. Alcohol misuse interventions Guidance on developing a local programme of improvement, Department of health 14 November Raistrick D Personal communication,. Also Chapter Alcohol withdrawal and detoxification in Heather N and Stockwell T (Eds) The Essential Handbook of Treatment and Prevention of Alcohol Problems (Wiley, Chichester)

8 AGENDA ITEM NO 7(c) TRUST BOARD MEETING potential costs, will need to be explored in more detailed implementation proposals Implications for other Health and Social Care Commissioners Castle Unit currently provides one bed purchased on a shared basis by Blackpool, Wyre, Fylde, Preston, Chorley and South Ribble PCTs Harvey House provides its programmes through Service Level Agreements to Blackburn with Darwen PCT, Burnley, Pendle and Rossendale PCT, Hyndburn and Ribble Valley PCT, Blackpool PCT, Fylde PCT, Preston PCT Wyre, and Chorley and South Ribble PCT. It also offers the service as Out of Area Treatments to other areas Informal discussions and consultation responses from other PCTs have indicated that some are beginning to assess the new Models of Care direction and are considering a similar approach to that proposed for Morecambe Bay. Two have indicated that they are keen to continue to purchase alcohol detox and inpatient treatment services from Harvey House in the future. Blackpool PCT currently purchases short term detox from both Castle Unit and at Harvey House, and has indicated that it would wish to continue to purchase short term detox and relapse prevention programmes. They are also considering a proposal to withdraw from the 9 week programme One issue highlighted in the consultation is the extent to which the incorporation of the short term detox programme from Castle Unit to Harvey House, would undermine the provision of Harvey House s longer term programmes, which other health or social service commissioners may still wish to purchase from elsewhere Negotiation will continue with other Trusts to clarify their commissioning position with regard to Tier 4 services. Harvey House currently provides flexible programmes of care. The current indication is that the forthcoming MOCAM commissioning framework offers significant opportunities to remodel the suite of programmes it provides in the future 3.11 Lack of involvement of staff in developing the proposals In the initial stages of developing proposals, service managers made staff aware that a review was taking place, but a decision was taken that staff working in the services particularly to be affected would be consulted on the service proposals when the initial options for service reconfiguration had been appraised and defined by the group. During the consultation period, a number of members of staff attended the public consultation meetings. In addition, separate meetings were held with staff involving commissioning and management leads to explore a range of concerns and issues. The development of any further implementation plans based on the proposed model would need to ensure engagement of staff and patients Involvement of Primary Care The service model proposed has the potential to impact on primary care in a number of ways. The specialist community alcohol team will support the development of skills and methods for providing brief interventions in Primary Care, provided as part of routine provision. These are considered to be within the scope of essential services within the GMS contract. 8

9 TRUST BOARD MEETING AGENDA ITEM NO 7(c) With regard to the treatment of patients with alcohol problems, the development opens up the option to establish arrangements for shared care between GPs and the community alcohol teams. In particular there is a need to clarify arrangements for supporting community detox, and prescribing of medication such as Benzodiazepines, Chlordiazepoxide or Disulfiram (Antabuse) 6. This is a particular issue for clients of the Castle Unit, as supervision of Antabuse has become a part of the follow up service offered from the Unit and alternative arrangements would need to be provided from the community alcohol service under the changes proposed A number of options are possible, which will need to be explored as part of working towards the new service configuration: a. Contract with interested practices to provide shared care arrangements using an Enhanced Service Specification (there is a National Enhanced Service Specification which could be used or adapted). This additional cost has not been identified at this stage. b. Develop arrangements for shared care and/or prescribing with no special arrangements for an Enhanced Service. This is currently the arrangement in place in South Cumbria and with some practices in Lancaster and Morecambe. c. Develop prescribing arrangements within the Community Teams ie establish nurse prescribing with links to medical staff within the Drug and Alcohol Service. d. Extend existing Drug shared care arrangements (using medical staff in Drug Treatment Service) Potential to strengthen the role of the voluntary sector The role of the voluntary sector was highlighted in the consultation, both in relation to Tiers 1 and 2, and also in relation to working alongside community specialist teams providing services such as relapse prevention and providing longer term support. The role of local voluntary organisations within the new treatment system will require further clarification and specific commissioning arrangements agreed. 4. COMMISSIONING POSITION 4.1 The commissioning position, following the consultation is that the overall direction of the proposed service model is appropriate to meet the PCT s commissioning objectives, and should be progressed, taking into account a number of the consultation themes highlighted in Section The treatment system should comprise of the following components, operating with clearly defined pathways and links: 4.3 Tier 1 Support for provision of screening, brief advice and referral, which can be delivered by a wide range of workers from agencies whose main role is not alcohol treatment eg primary care and Accident and Emergency staff, social 6 PRODIGY guidance-alcohol Problem Drinking

10 AGENDA ITEM NO 7(c) TRUST BOARD MEETING services, general hospital wards, police eg custody cells, probation and prison service, educational and vocational services, and occupational health services. to identify hazardous and harmful drinkers provide information, brief advice to reduce alcohol related harm referral to higher tiers if need more than brief advice partnership or shared care with staff from higher tiers 4.4 Tier 2 Provision of open access support to reduce alcohol-related harm, assessment and referral services, delivered by agencies with the necessary competency eg A&E units, some primary healthcare services, psychiatric units, social services, antenatal clinics, prison and probation services and occupational health services. 4.5 Tier 3 A specialist community alcohol team encompassing: Assessment and care planning within a pathway that is flexible and individually tailored community detox (withdrawal and stabilisation) and referral to inpatient services within criteria enhanced treatment for clients with intensive treatment needs relapse prevention and follow on-care from discharge support to GPs and primary care staff who identify clients with alcohol misuse in relation to referral or shared care arrangements targeted brief intervention, and intensive brief intervention for groups where evidence indicates that this approach would be useful Training to primary care, hospitals, voluntary sector and community groups Clear pathways, agreed in conjunction with Social Services, and possibly involving the voluntary sector, for providing continuity of support for patients with longer term support needs There should be a clear commitment to strengthen the involvement of the voluntary sector in developing the new treatment system. 4.6 Tier 4 Morecambe Bay clients should have access to 3 dedicated alcohol beds, providing focussed inpatient treatment programmes within a day model of service. Follow up by the community alcohol team will be available for all discharges and programmes will be provided in the community teams for relapse prevention and other treatment programmes as required For drug mis-users there is also a need for a dedicated in-patient detox service, it is anticipated that this will be provided within the existing contract with Drugs Northwest, which is a specialist commissioned service. An option for this reprovision includes increasing capacity in the community drug team. It is recognised that clear pathways from in-patient services to community drug and alcohol teams and robust care planning will be essential for the success of this model of a treatment system. 10

11 AGENDA ITEM NO 7(c) TRUST BOARD MEETING There needs to be a clear pathway into managed rehabilitation programmes established within a joint health/social care framework for clients with prolonged support needs. 5 CHANGE MANAGEMENT ISSUES 5.1 The transition from an in-patient alcohol detox service to a community based service will require substantial management; devoting managerial and clinical time to the development of care pathways and shared care protocols, to address service governance issues and build partnership approaches across Tiers 1 and An important part of the change management process will be to build engagement of staff in developing the reconfigured service. Proactive communication and negotiation with a range of stakeholders will also be necessary for success. 6 SUMMARY 6.1 The proposed service model aims to provide a more cost effective system, which is better able to meet a wide range of needs in Morecambe Bay. There is a significant opportunity cost of continuing with present system, which weights the balance of investment towards inpatient services. 6.2 Further work is needed to resolve specific issues, including: Development of detailed implementation plan and financial plan Further communication with stakeholders (including staff) regarding the options for implementing the model Negotiation with other commissioning Trusts regarding the options for future provision of Tier 4 Services from Morecambe Bay Further exploration of options for the reprovision of inpatient drug detox programmes Options for provision of alternative support for serves currently provided by inpatient services eg prescribing Options for engagement of primary care in shared care Negotiation with Social Services regarding the support needs of people requiring prolonged and intensive help 6.3 It is proposed that further work on these issues be brought back for further Board consideration (anticipated date May 2006). 7. RECOMMENDATIONS FOR CONSIDERATION OF PCT BOARD 7.1 It is recommended that the Board: Notes the issues that have been raised during the consultation period and the responses to these issues 11

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