Welsh Government Tier 4 Review PHASE 1. Provider & Commissioner Questionnaire

Transcription

1 Welsh Government Tier 4 Review PHASE 1 Provider & Commissioner Questionnaire

2 1. Context and Setting 1.1 For the purpose of this review, Tier 4 services in Wales include the provision of Inpatient Detoxification (IPD), Inpatient Stabilisation Programmes (ISP) and Residential Rehabilitation (RR) for individuals who are dependent on drugs and/or alcohol and require 24-hour care and support. Further details on definitions of treatment tiers are included at Annex A. 1.2 Tier 4 services are provided by statutory and voluntary organisations. Commissioners and planners of substance misuse services need to ensure that clients are able to access the following services: Inpatient drug and alcohol detoxification facilities, preferably, with dedicated and specialist staff Drug and alcohol residential rehabilitation to meet the needs of service users Residential rehabilitation that includes the provision for detoxification Stabilisation programmes for individuals whose substance misuse is chaotic with detrimental consequences to their health e.g. liver disease. 1.3 Inpatient treatment interventions usually involve short episodes of hospital-based (or equivalent) drug and alcohol medical treatment. This normally includes 24-hour medical cover and multidisciplinary team support for treatment such as: Medically supervised assessment Stabilisation on substitute medication Detoxification/assisted withdrawal from illegal and substitute drugs and alcohol in the case of poly-dependence Specialist inpatient treatments for stimulant users Emergency medical care for drug users in drug-related crisis. 1.4 Residential rehabilitation consists of a range of treatment delivery models or programmes to address drug and alcohol misuse, including abstinence orientated drug interventions within the context of residential accommodation. Although the treatment philosophy, structure and intensity of residential rehabilitation services can vary, there are three broad types of rehabilitation provision: rehabilitation programmes based on Social Learning Theory 12-step programmes based on the Minnesota Model of addiction recovery treatment faith-based therapeutic communities. 2

3 2.0 Funding 2.1 The Welsh Government ring fences 1m of its 22m Substance Misuse Action Fund (SMAF) budget for Tier 4 services. Since April 2013, this funding has been allocated to the 7 Substance Misuse Area Planning Boards (APBs) in Wales. Prior to April 2013, the SMAF was allocated to the 22 Community Safety Partnerships (CSPs) across Wales and was required to be signed off by the 7 APBs m of the 7 Local Health Boards discretionary allocations is ring fenced for substance misuse services and an element of this funding is used to fund inpatient detoxification and inpatient stabilisation programmes depending on established local need. 2.3 In addition Local Authorities may use their non-ring-fenced social care budgets to fund additional residential rehabilitation places. 3. Background 3.1 In the summer of 2007, the Welsh Government commissioned a review of Tier 4 services in Wales to ascertain how they were funded and accessed in order to provide an overall picture of how treatment journeys varied on a region by region basis. The review conducted by Wilkinson & Mistral was published in December 2007 and briefly described the evidence base for IPD, ISP and RR, and reported on needs assessments and concerns about Tier 4 services in Wales. 3.2 In response to the review, the Welsh Government developed and issued guidance (in conjunction with an external Tier 4 Steering group) for the planning and provision of Tier 4 Services to assist partners in the implementation of the report s recommendations. This guidance was published in August Subsequently CSPs were tasked to assess current provision of Tier 4 services against the findings and recommendations of the report and to prepare detailed plans to address areas that had been identified for improvement in conjunction with the providers. 3.3 In 2010, a review of the initial residential rehabilitation and inpatient detoxification modules of the Substance Misuse Treatment Framework (both published in 2004) was initiated to refresh them with updated evidenced based practice and bring them together into to one comprehensive guidance document. (Annex B) In February 2011, a Welsh Government organised seminar brought together planners, providers of community and residential treatment agencies and users of substance misuse services, in order to launch this guidance, review progress against the review and subsequent guidance and to share best practice information regarding Tier 4 services. 3.4 From the seminar it was evident that there had been definite progress made by both providers and commissioners since the Wilkinson and Mistral (2008) review but there was still concern about assessment 3

4 procedures and the number of Welsh clients being referred to Tier 4 establishments outside of Wales. 3.5 In Spring 2012, the then Minister for Local Government and Communities wrote to Area Planning Board Chairs and substance misuse commissioners and providers to advise that the Welsh Government would be reviewing Tier 4 referral and assessment procedures and exploring the reasons why welsh clients are being referred outside of Wales. 4.0 Methodology 4.1 The Review has been split into two phases. For the initial phase, two structured questionnaires were developed, one for welsh Tier 4 substance misuse service providers and one for welsh substance misuse service commissioners. 4.2 The provider questionnaire focused on service promotion, costs, numbers treated and client outcomes, whilst the commissioner questionnaire focused on assessment, pre treatment support, involvement of social services and rationale for referral. 4.3 Questionnaires were completed over the summer of 2012 and copies of the two questionnaires can be found at Annex C and D. 4.4 Publication of the questionnaire findings and recommendations for the second phase of the review were delayed to ensure that findings from the substance misuse strategy process evaluation could be built into the review process. The timing has also allowed the Welsh Government to ensure that the Substance Misuse Delivery Plan , published in February 2013 included actions that respond to phase 1 of the Tier 4 review. 5.0 Response Rates responses were received from the 5 Tier 4 provider questionnaires issued, 3 from residential rehabilitations and one from an inpatient detoxification unit. (The questionnaire was not sent to NHS providers). It should be noted that two of these responses were from the same provider (Cais) as they operate both a residential rehabilitation and inpatient detoxification unit. In addition, since the questionnaires were completed Rhoserchan Residential Rehabilitation Unit has gone into liquidation responses were received from the 22 commissioner questionnaires issued, although Dyfed Powys and North Wales regions provided combined responses signifying that the views of 17 of the 22 areas were represented. 4

5 6.0 Summary of Provider Responses Number of Clients Treated. 6.1 Providers were asked to provide anonymised data detailing the numbers of clients treated over the last two years, split between privately and publicly funded places. From the information supplied, which covered different time periods over a two year period, the vast majority of both residential rehabilitation (217 cases equating to 92% of referrals) and inpatient detoxification (627 cases equating to 96% of referrals) clients were publicly funded. Table 1 Publicly and Privately Funded Tier 4 Placements Organisation RR/IPD Year Privately Funded Publicly Funded Rhoserchan RR April (Aberystwyth) March 11 Rhoserchan RR April (Aberystwyth) March 12 Ty n Rhodyn RR Jan (Bangor) Dec 2011 Brynawel RR Jan (Llanharry) Dec 2011 TOTAL RR Hafen Wen IPD April (Wrexham) March 2011 Hafen Wen IPD April (Wrexham) April 2012 TOTAL IPD Client Outcomes 6.2 Providers were asked to provide details of outcomes for their clients over the past two years, where known. As with client funded places the information supplied covered different time periods over the two year period. 126 (54%) of residential rehabilitation and 495 (75%) of inpatient detoxification clients had successful planned discharges. The other 109 (46%) of residential rehabilitation and 166 (25%) of inpatient detoxification clients left against medical advice, breached provider rules or were medically discharged. 5

6 Table 2 Client Discharges Organisation RR/IPD Year Discharges Planned Unplanned Rhoserchan RR April March 11 Rhoserchan RR April March 12 Ty n Rhodyn RR Jan Dec 2011 Brynawel RR Jan Dec 2011 TOTAL Organisation RR/IPD Year Discharges Planned Unplanned Hafen Wen IPD April March 2011 Hafen Wen IPD April April 2012 TOTAL Advertising 6.3 All providers advertised online and made use of social media. All had direct engagement with commissioners and / or referral agencies. Table 3 Advertising Methods Used by Tier 4 Providers Organisation Brynawel Rhoserchan Ty n Rhodyn Hafen Wen Advertising Methods Website Social Media Newsletters Commissioner Engagement Literature/Leaflets Interactive Website Social media DVD Targeted leaflets/ s Day placements Commissioner engagement Cais Website Social media Commissioner engagement Cais Website Social media Leaflets Referral Agencies 6

7 Pricing 6.4 Residential Rehabilitation 1 st stage prices varied from 625 in Ty n Rhodyn to 750 per week in Brynawel. 2 nd stage prices varied from 500 per week in Brynawel to 720 per week in Rhoserchan. Typically inpatient detoxification prices varied depending whether they were publicly or privately funded and the length and size of the contract. 6.5 Providers also identified issues around financial stability, Tier 4 representation on Area Planning Boards, waiting times and the quality of client assessments and / or detoxification resulting in low motivation and early discharge. Table 4 Residential Rehabilitation and Inpatient Detoxification Prices (As at 31 st March 2012) Organisation Public RR Private RR Public IPD Private IPD Rhoserchan 720 per week 1 st stage ( week programme) 720 per week 2 nd stage (6-18 week+) 720 per week 1 st stage ( week programme) 720 per week 2 nd stage (6-18 week+) 2,500 alcohol only 2,500 alcohol only Ty n Rhodyn 625 per week 625 per week N/A N/A Brynawel 750 per week (1st stage) 500 per week (2 nd stage) 750 per week (1st stage) 500 per week (2 nd stage) N/A N/A Hafen Wen N/A N/A per night^ NB/ +Depending on need *Discount applicable for block booking ^ Varies depending on size of contract 250 per night* 7.0 Summary of Commissioner Responses Tier 4 Groups 7.1 Commissioner responses advised that the North Wales, Dyfed and Gwent regions have Tier 4 groups in place and other areas are developing them. From the information provided the assessment process across Wales remains inconsistent, although some areas are developing regional assessment processes such as Abertawe Bro Morgannwg University (ABMU) Area Planning Board (APB). 7

8 Tier 4 Processes 7.2 Processes for securing Tier 4 placements also varied across Wales; some follow the National Guidance on Community Care assessment processes, whereas others have single assessment processes in place. Waiting Times 7.3 Responses identified that the length of time clients wait for Tier 4 treatment depends on their personal circumstances and the availability of places with the preferred Tier 4 provider. Some clients may for example prefer to have treatment at a particular time, such as Christmas, holidays etc which may have a delay in their placement. In some instances places can be arranged within a week if urgent, but the normal period is between 1 and 3 months from referral to placement. Lack of funding was not identified as a reason to delay a client entering residential rehabilitation. Social Work/Other Substance Misuse Service Involvement 7.4 In all areas who responded, Commissioners reported that Tier 3 providers were involved in the process for Tier 4 placements, although at which stage varied. Tier 2 substance misuse providers are not necessarily involved in the assessment process although they are engaged with the clients while they wait to enter residential rehabilitation. Following the initial assessment by Commissioners and Tier 4 assessment panels, a further assessment is usually carried out by the Tier 4 providers themselves to ensure that both client and provider are compatible. Where clients are in the Criminal Justice System, the assessment is usually carried out over the telephone. The involvement of Social Services within the assessment process depends on the client and whether they have been offered and received an assessment under the NHS Community Care Act In one area it was stated that a Substance Misuse social worker refers directly to Tier 4. Pre Treatment 7.5 Responses showed a lack of consistency for clients receiving preresidential rehabilitation treatment across Wales. In some areas the assessment process is reported as a 4 dimensional relationship using social work theories and methods. Though it is referred to as an assessment, it is a developing therapeutic relationship between the client that may involve Cognitive Behavioural Therapy (CBT), brief therapy or motivational interviewing. In some instances clients maybe able to access Alcoholics Anonymous, as service providers offering the 12 Step approach have determined it as is a critical factor in achieving successful outcomes. 8

9 7.6 In North Wales a level of pre-treatment work is required for all placements for detoxification; this is outlined in their Integrated Care Pathway (ICP). Rehabilitation preparation is tailored to the individual needs and circumstances of the client, as assessed. Factors to be considered in this are also outlined within the ICP. 7.7 In all areas, service users are engaged with Substance Misuse Services pre Tier 4 treatment but more in relation to general support. Although some areas are developing new processes for both assessment and motivation enhancement to improve service users chances of completing a successful placement. 7.8 The pre-treatment information given to clients varies from a Tier 4 brochure Facts to know and questions to ask which answers questions that clients may ask when applying for residential rehabilitation or inpatient treatment to leaflets from the Tier 4 providers, setting out information on what is available and what to expect. Clients also visit the preferred provider prior to admission. Some providers provide a copy of their procedure for accessing a placement as well as a copy of the residential rehabilitation contract. Reported Use of English Providers 7.9 The responses provided show a variety of reasons are given for choosing an English provider over a Welsh provider. Clients are referred to a provider which is best suited to meet the need of the client. The more a provider has to offer whether in the first stage and / or 2 nd stage, the more attractive the place is to the client. Offering more support for aftercare, supported accommodation and training and other qualifications were also quoted as reasons for selecting an English provider When considering places, responses indicated that the client preference and need is always considered as is the flexibility of the provision offered, i.e. tailored to individual need, length of programme, flexible pricing, value for money, accessibility and robust assessment processes. Client preference maybe for detoxification and rehabilitation in one location. This is sometimes viewed as better for the client and for co-ordination In addition to the lack of integrated inpatient detoxification and residential rehabilitation services in Wales, it was reported that some English providers have excellent links to supported accommodation or directly managed such projects to enable clients to access these following rehabilitation. Other English providers also offer training and vocational qualification opportunities and links which are attractive to the clients It is also thought important to consider that the client may not wish to access placements where they may know people or who they have previously drunk or used drugs with, during their time in rehabilitation. 9

10 7.13 Cultural and intellectual sensitivities are also considered, some rehabilitation providers have private patients and sometimes clients find it difficult to be involved in group work alongside patients of different socio economic backgrounds. Placements within Residential Rehabs and Inpatient Detoxification Units 7.14 Commissioners provided an extensive list of units that were used for clients. Annex E provides a summary of this list. It is noted that the information provided defines what each organisation can offer and not necessarily what welsh clients received as this would have been informed by individual assessment processes. 8.0 Conclusions 8.1 The provider and commissioner responses received within the first phase of this review have provided a rich source of information and highlighted a number of key issues which require further exploration. 8.2 To support the implementation of the recommendations and to advise on the next phases of the review, the Welsh Government will establish a National Tier 4 Advisory Group. Membership of the group will include provider (both residential and community) and commissioner representatives and Welsh Government. Health Inspectorate Wales (HIW) and Care and Social Services Inspectorate in Wales (CSSIW) will also be included to ensure that there is read through in respect to the minimum care standards expected by both registration organisations and any future recommendations made by the working group. 9.0 Recommendations 9.1. The findings from the questionnaires, recommendations from the strategy evaluation and the outcomes from the substance misuse delivery plan consultation have been used to inform the following initial recommendations which will be referred to the National Tier 4 Advisory Group for advice on implementation: The Welsh Government to conduct a risk assessment on the financial stability of Tier 4 Providers and work with Area Planning Board (APBs) and Providers to develop a range of appropriate mitigating actions. The Welsh Government to monitor Treatment Outcome Profiles (TOP)s data in order to assist in the comparison of the outcomes achieved by individuals receiving services in the community and services within residential facilities. The Welsh Government to conduct an audit of people with substance misuse and alcohol problems who have been in contact with social services, to establish whether they have been offered and, where appropriate, received an assessment 10

11 under the NHS and Community Care Act 1990 in line with the Substance Misuse Treatment Framework guidance. Providers to consider expanding the services they can offer, such as detoxification, vocational and training skills etc. Providers to explore the possibility of working with those in Social Housing to enable clients to have greater access to follow up accommodation. APBs should develop a consistent approach to determining the suitability of; and the securing of; Tier 4 services for clients whether the placements are in Wales or England. The clients needs and preferences should be at the forefront of any assessment process. Providers and Commissioners to develop a consistent pretreatment approach to maximise the chance of successful outcome for the client. Providers and Commissioners to develop a process to ensure that clients are informed of the range of treatment options available to their assessed needs. Providers to develop aftercare for clients for planned outcomes, linking clients in with organisations such as Recovery Cymru, The Living Room, ESF Peer Mentoring Scheme and local social enterprises where clients can volunteer and develop their skills. 11

12 Annex A Definition of Treatment Tiers Tier Definition 1 Tier 1 interventions include provision of drug / alcohol-related information and advice, screening and referral to specialised treatment. 2 Tier 2 interventions include provision of drug / alcohol-related information and advice, triage assessment, referral to structured treatment, brief psychosocial interventions, harm reduction interventions and aftercare. 3 Tier 3 interventions include provision of community-based specialised assessment and co-ordinated care planned treatment and specialist liaison. 4 Tier 4 interventions include provision of residential specialised treatment, which is care planned and care coordinated to ensure continuity of care and aftercare. Definitions adapted from Models of Care for Treatment of Adult Drug Mis-users and Models of Care for Alcohol Mis-users both published by the National Treatment Agency

13 Annex C Tier 4 Questionnaire (Providers) 1. Name of organisation. 2. Please provide anonymised data detailing numbers of clients treated over the past two years, split between private and public funded places. 3. Please provide details of outcomes for your clients over the past two years where known, including planned discharge, those who have dropped out (positive and negative outcomes). 4. Please provide details of how you advertise your business. E.g. The web, literature, conferences etc. How do you liaise with communicate with commissioners? 5. Please provide details of your costs for both private and public funded treatment places. Block prices should also be included. 6. Please provide any other information you feel will be useful. 13

14 Annex D Do you have a Tier 4 group in your area? What are the processes to get to Tier 4? What is the average waiting time for: Assessment Referral Placement Are Social Services involved? Tier 4 Questionnaire (Commissioners) Are any other services involved? Are the Tier 4 providers involved? Are Clients offered pre-treatment support and or can they attend group work prior to going into rehabilitation? What information (for example leaflets etc) is given to the client prior to rehabilitation? If possible please can you provide a copy. Which providers do you use? If an English provider is used please provide the rationale for using them. Is it cost? Location? Clients preference? Other> 14

15 Annex E Residential Rehabs and Inpatient Detoxification Units Listed as being used by Commissioners Organisation Location Model Local Authority Area Brynawel (RR) Llantrisant Social Learning RCT Blaenau Gwent Merthyr Ynys Mon Rhoserchan (Alcohol IPD & RR) Sefton Park (RR) St James House (RR) Frenchay Mews (RR) Broadway Lodge (RR & IPD) Aberystwyth 12 Step (Eclectic / Integrated) 12 step (CBT / Social Learning) Weston Super Mare Holistic Therapeutic Community Integrated 15 Blaenau Gwent Gwynedd Ynys Mon Conwy Denbigh Flintshire Blaenau Gwent Bristol 12 step Weston Super Mare Weston Super Mare Therapeutic 12 step CBT / Social Learning Eclectic / Integrated Therapeutic Integrated Blaenau Gwent Nelson House Gloucester (RR) Swansea Clouds (RR) Salisbury 12 step Phoenix Alpha (RR & IPD) Somewhere House (RR) Hope House (RR) Yeldall Manor (RR & IPD) Campania (Residential Care Home) Serenita (Residential Care Hampshire Burnham on Sea London Reading Weston Super Mare Weston Super Mare CBT / Social Learning Therapeutic Community 12 step Solution focused 12 step (Female only) Dual Diagnosis Holistic (Male only) Respite residential care for those aged over 40 and living with alcohol related problems such as Korsakoff s Respite residential care for those aged over 40

16 Home) Western Counselling (RR) Willowdene Farm (Drug RR) New Roads (RR & Detox) Ty n Rhodyn (RR) Turning (RR) Point Weston Super Mare Shropshire and living with alcohol related problems such as Korsakoff s 12 step Eclectic / integrated Christian philosophy Bristol 12 step Integrated Bangor Therapeutic Gwynedd Conwy Denbigh Flintshire Chester CBT / Social Learning Gwynedd Ynys Mon Conwy Longreach (RR) Plymouth Eclectic / integrated CBT / Social Learning Therapeutic Community Closereach (RR) Plymouth Eclectic / integrated CBT / Social Learning Bridge (RR) Project Therapeutic Community 3 phase bio-psychosocial intervention (projected targeted at homeless population) 16 Denbighshire Hafen Wen (IPD) Wrexham Holistic North Wales Ysybyty Gwynedd Psychiatric Ward (IPD drug) Bangor Holistic North Wales Park view (RR & IPD) Cranstoun Oak Lodge (RR & IPD) Phoenix Futures (RR & IPD) Turning Point (RR & IPD) Turning Point (RR & IPD) Phoenix Futures Liverpool London Eclectic / integrated CBT / Social Learning Therapeutic Community 12 step Eclectic / integrated CBT / Social Learning Therapeutic Community Gwynedd Gwynedd Wirral CBT / Social Learning Ynys Mon Therapeutic Community Flintshire Wokingham Therapeutic Community Conwy Ealing Therapeutic Community Conwy Sheffield Therapeutic Community Conwy (RR & IPD) PCP (RR & IPD) Chelmsford 12 step Conwy Littledale Hall Lancaster Therapeutic Community Wrexham

17 (RR) THOMAS (RR) Blackburn Eclectic / integrated CBT / Social Learning Therapeutic Community 12 step Withnell House Chorley Integrated Abstinence (RR) Model including CBT, MI, 12 Step, SMART, ITEP and humanistic interventions Wrexham Wrexham 17