TAMESIDE & GLOSSOP NATIONAL ENHANCED SERVICE FOR ALCOHOL MISUSERS

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1 TAMESIDE & GLOSSOP NATIONAL ENHANCED SERVICE FOR ALCOHOL MISUSERS

2 THE NEW G.P. CONTRACT

3 The new GP contract Provision of specialist services Minor surgery; depression; drug dependency Payments Accreditation Training Local Enhanced Service (L.E.S.) National Enhanced Service (N.E.S.)

4 10 G.P. PRACTICES

5 PENNINE CARE NHS TRUST

6 ALCOHOL & DRUGS SERVICES

7 TAMESIDE & GLOSSOP PRIMARY CARE TRUST

8 Key Documents Alcohol Needs Assessment Research Project (ANARP) 2005 Standards for Better Health (2005) DoH The management of harmful drinking and alcohol dependence in primary care. SIGN (2003) Alcohol Harm Reduction Strategy for England (2004) Models of Care for Alcohol Misusers (MOCAM) National Treatment Agency (2006).

9 In the beginning ADS half-time primary care counsellor Community detox. programmes Ad hoc prescribing Most GPs co-operative & support Small no. of GPs non-referrers SMS responsive & accessible

10 Service remit Screening for problem drinking Specialist assessment Minimal / Brief interventions (6 8 sessions) Input to 50 patients per annum Community detoxification Prescribing: disulfiram / acamprosate Referral on (e.g. in-patient treatment)

11 Staffing 10 primary care clinics (circa 20 GPs) Primary care alcohol worker x 1 (managed by SMS) -provides triage assessments -targets those with complicating factors Alcohol counsellors x 1 & ½ (managed by ADS) -provide 6-8 session brief interventions -offer detox. preparation & follow-up

12 Remuneration NES specification: 1,000 p.a. per practice per p/t. = 11,000 p.a. (based on 50 patients treated) Tameside & Glossop NES: 3,000 p.a. per practice savings used to fund ADS SMS support staff

13 Training GPs accredited by PCT/SCMG) Training day provided by Leeds Addiction Unit Provider Fora Continuing Professional Development Practice nurse / receptionist training Target training RCGP course???

14 Information sharing Need to ensure effective communication between NES and non-nes GP Non-NES GP advised to provide info. on relevant medical & prescribing issues Electronic systems utilised (Emiss, etc.) Separate casenotes systems (SMS vs. ADS) Consent to share info. obtained at assessment - childcare concern issues (etc.) explained Need to advise service users on use of medical records before enter service

15 Referral process Self-referrals accepted Third party referrals accepted Standard referral form Filter process (e.g. to SMS) Triage assessment NB need to avoid unnecessary contacts - need to ensure appropriate skills available - need to avoid delays

16 Service criteria Minimal complicating factors Mild / moderate severity of alcohol problems Home detoxification requested No known child care issues Minor/no mental health problems Minimal social problems Stable lifestyle Reasonable physical health

17 Typical referral. 35 years old single male, drinking 65 alcohol units weekly, denies experiencing any physical withdrawal symptoms, appears to be in good health, liver function test results within normal limits, working full time and with no obvious mental health problems..

18 Service exclusion Child care issues Pregnancy especially if complicated In-patient detoxification requested Significant mental health problems Significant high risk factors Serious alcohol-related health problems Dual dependency i.e. heavy drug use Need for regular home visits Other major complicating factors Significant cognitive deficits

19 Typical inappropriate referral. 63 years old widowed female, drinking 300 alcohol units weekly, reports experiencing withdrawal seizures and hallucinations, describes jaundiced sclera and ascites, cares for 3 year old grandchild, describes suicidal plans and reports report overdose of paracetamol and describes confusional episodes..

20 FAST AUDIT CAGE National Enhanced Service (NES) for Alcohol Misusers Screening Patient registration / health checks Opportunistic screening: gastritis; pancreatitis; cardiac arrhythmias; hypertension; peripheral neuropathy; accidents (including falls in the elderly); head injuries; anxiety; low mood; cognitive deterioration. NB Confidentiality

21 Assessment Triage vs. comprehensive assessment Drinking history S.A.D.Q. CIWA-Ar LFT s Breath testing Physical examination

22 Medical reviews Not required in all cases e.g. alcohol reduction programmes Necessary when prescribing offered Medical reviews / assessment convened prior to community detoxification Key-workers present & provide relevant clinical background info. Reviews used to clarify assessment findings/etc. Patients seen as part of GMS provision (provided that they are registered with the practice)

23 Home visits Most contacts clinic based Home visits provided if mobility problems, very poor health/debilitation, severe agoraphobia SMS used in many cases

24 Provider Fora Bi-monthly meetings Half include NES for drug misuse Address difficulties in service delivery Provision of training Up-dates on local / national developments Improve communication

25 Service activity Approx. 50+ referrals monthly (25 64) Attendance rate for new referrals = 60% Attendance rate for follow-ups = 75% Very few BEM referrals Minority of referrals registered with Non-NES GPs Average waiting times 2 3 weeks Some clinics underused (n.b. location) Treatment completed in 65% discharges 3 deaths in last 6 months

26 The plus points Recognition of role of GP (inc. financial) Avoid postcode lottery i.e. all patients can receive primary care treatment if appropriate GPs now trained & better supported Provides alternative venue (to drug services) Accessibility improved - closer proximity to service user s homes

27 The down side Screening -> increase in service pressures Failure to capture very early stage problem drinkers Confusion regarding appropriateness of services Non-NES GPs reluctant to provide input to problem drinkers Possibility of communication breakdown -> inappropriate prescribing Security of future funding? Response to staff vacancies / absenteeism

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