Agenda Item No. 6.0 Part 1 X Part 2 NHS TRAFFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY 29 th October 2013 Title of Report Purpose of the Report RADAR This report provides the background to the RADAR programme, which is one important, innovative and effective way to address the practical significant burden of alcohol presentations to acute hospitals accounting for 35% of A&E attendances (rising to 70% of night time presentations) which are alcohol-related. RADAR has already demonstrated its effectiveness in reducing alcohol-related acute admissions, reducing lengths of stay and preventing re-admissions. Two case examples of individuals in Trafford who have benefited from RADAR are attached, to illustrate why Trafford CCG and other Greater Manchester NHS commissioners should support funding initially to the end of October this year to sustain the programme, and then work with the Association of Greater Manchester CCGs to explore continued funding of this valuable initiative for a further 12 months. Actions Requested Decision X Discussion X Information X Strategic Objectives Supported by the Report Recommendations 1. Consistently achieving local and national quality standards. 2. Delivering an increasing proportion of services from primary care and community services from primary care and community services in an integrated way. 3. Reduce the gap in health outcomes between the most and least deprived communities in Trafford. 4. To be a financial sustainable economy. The NHS Trafford Governing Body is asked to note and confirm continued support with other Greater Manchester NHS commissioners funding initially to the end of October this year to sustain the programme, and then work with the Association of Greater Manchester CCGs to explore continued funding of this valuable initiative for a further 12 months.
Discussion history prior to the Governing Body Financial Implications Risk Implications Impact Assessment Communications Issues Public Engagement Summary Prepared by Responsible Director None although previous updates regarding RAID are pertinent To be determined. As discussed with Greater Manchester DOFs, this may amount to a value of approximately 65k in 2013/14 Not applicable Not applicable Not applicable Not applicable Sandy Bering, Lead Commissioner / Consultant for NHS Trafford CCG (Email: satinderjit.bering@trafford.nhs.uk and Tel: 07500 881685) Gina Lawrence, Chief Operating Officer and Director of Commissioning Page 2
RADAR 1 Background to RADAR The burden of alcohol presentations to acute hospitals is significant. 35% of A&E attendances (rising to 70% of night time presentations) are alcohol-related. 1 in 8 hospital admissions are alcohol-related with the North West having the highest rate of alcohol-related admissions in England. Many patients present repeatedly for shortterm admissions (i.e. are frequent flyers ). Brief admissions are able to address the acute effects of alcohol and alcohol withdrawal but often fail to treat the underlying cause. There is a political drive to look at innovative ways to address this. Existing national objectives include: Targets for reducing alcohol-related hospital admissions and re-admissions; Reducing health burden and inequality relating to alcohol dependence; and Reducing burden on A&E departments and acute hospitals. Targets for acute hospitals include: Reducing alcohol-related admissions rate (formerly NI39); Reducing avoidable admissions (<24 hours); Reducing readmission within 30 days and associated loss of tariff for the previous admission; and Transferring from A&E within 12 hours. Challenges for community services include: Responding to increasing demand as an outcome of growth in RAID services, Frequent Flyer teams and Alcohol Liaison Nurses; Tackling the large drop-out between hospital and community services; and Meeting targets for engaging and retaining hospital discharges. In 2012/13, the NHS North West Strategic Health Authority (SHA) agreed to fund Greater Manchester West Mental Health NHS Foundation Trust (GMW) to pilot a pathway for the rapid transfer of patients from acute hospital beds for inpatient alcohol detoxification. This funding followed a successful application for a share of NHS Bundle Monies (Mental Health and Learning Disabilities). The pilot service, which has subsequently become known as RADAR (Rapid Access (Alcohol) Detoxification Acute Referral), became operational in November 2012. Since 1 November 2012, RADAR has operated as a 10-bedded unit within GMW s Chapman Barker Unit (CBU). CBU is a 36-bedded inpatient detoxification facility based at Prestwich Hospital. CBU has established expertise in delivering safe and effective alcohol and drug detoxification to patients in the North West who present with high degrees of complexity in terms of physical and mental health plus complexity relating to the substance misuse problem. Though RADAR is hosted at CBU, its remit remains distinct from the wider facility. RADAR currently receives referrals from 12 Acute Hospitals, including A&E departments, across Greater Manchester. Namely, Salford, Wigan, Central Page 3
Manchester (MRI), North Manchester (Crumpsall), Oldham, Bury, Bolton, Rochdale, South Manchester (Wythenshawe), Tameside, Stockport and Trafford. All 12 hospitals have been closely involved in the development of RADAR and have established referral pathways in place. RADAR provides an innovative pathway for transferring patients presenting at the above acute trusts with alcohol problems and requiring a detoxification to a specialist detoxification facility. These patients would otherwise be admitted to the acute trust. RADAR combines the benefits of a bespoke detoxification programme (5-7 days, NICE compliant, evidence-based and symptom-triggered detoxification) with the delivery of a range of effective psycho-social interventions, physical and mental health treatment (as required), and a strong focus on detailed aftercare planning and engagement in aftercare. This approach has been shown to deliver improved outcomes from detoxification and reduce re-presentations to acute hospitals RADAR is medically-managed and operates a multi-disciplinary team approach to detoxification. 24-hour medical and nursing (Hospital at Night) cover is provided as part of RADAR. RADAR is a unique service. No other organisations are known to provide an equivalent 24-hour service to multiple acute trusts, and the service user data in first 10 months from 272 admissions (as the Unit was not yet operating at full capacity) is summarised below: The increased numbers across Greater Manchester hospitals reflects the gradual roll-out of the service which initially focused on Salford, Wigan and Bolton localities before more recently moving into South Manchester including Trafford. The GMW-led preliminary evaluation 6-10 months into the RADAR pilot has identified a number of positive outcomes. These outcomes demonstrate the significant benefits offered by RADAR in terms of reducing the burden placed on acute trusts from alcohol-related admissions and re-admissions; improving clinical outcomes by increasing successful completions of alcohol detoxification and delivering improved aftercare and adherence to follow-up; improving patient experience; and delivering savings/cost effectiveness. Page 4
The figures and tables below illustrate the significant positive return on investment demonstrated to date: Index Admission 22% transfer from A&E (admission avoided) 33% transfer same day (bed night avoided) 24% stay only one night (reduced length of stay) OBN (p.a) Tariff Liberation 221 161,000 334 245,000 131 90,000 Total 686 496,000 Readmission OBN (if 6 m) Tariff (if 6 m) OBN (if12m) Tariff (if 12m) 75% not readmitted to acute bed in 3 months post カラットlog 좈 琰 茞 Ü RADAR Frequent Flyer 1129 826,443 2257 1,652,886 Acute 139 101,928 376 275,481 presentation Total 1268 928,371 2633 1,928,367 Index Admission 686 496,000 Re-admission 2633 1,928,367 Total 3319 2,424,367 The plan is now to formally follow-up the preliminary internal evaluation with a full independent 12-month evaluation which to date suggests the benefits to investment ratio of 2.5:1. Page 5
Importantly, a review of the integrated care programmes relating to alcohol funds transferred to Local Authorities as part of the Public Health transfer programme notes significant funds have been returned to GM DAATs this year at the core CBU service (which should be considered as part of the wider investment available to respond to the Alcohol challenge. 318 CBU revised bed night price contract model with possible Radar usage 1314 12/13 contract value 2012/13 activity CBU bed nights (excl RADAR) 12/13 activity * 276 bed night price Saving from current contract at 276 bed night price & 12/13 activity Proportional bed night allocation based on 80% occupancy of 10 RADAR beds Cost of RADAR beds based on current usage (Saving) / increase on current contract Ashton, Leigh & Wigan 506,385 1083 298,908 207,477 462 118,734 88,743 Bolton 191,874 570 157,320 34,554 243 62,451 27,897 Bury 95,124 205 56,580 38,544 88 22,616 15,928 HMR 132,499 447 123,372 9,127 191 49,087 39,960 Manchester 658,488 1885 520,260 138,228 805 206,885 68,657 Oldham 273,561 575 158,700 114,861 246 63,222 51,639 Salford 284,757 690 190,440 94,317 295 75,815 18,502 Stockport 85,804 660 182,160 96,356 282 72,474 168,830 Tameside 180,457 551 152,076 28,381 235 64,860 36,479 Trafford 134,583 172 47,472 87,111 73 20,148 66,963 Total Greater Manchester 2,543,532 6838 1,887,288 656,244 2,920 756,292 100,048
As such it is important to note the likely consequences/risks of not investing for a further 12 months, minimum, can be summarised as follows: The burden placed on acute hospitals, including A&E departments, in the Greater Manchester area by alcohol-related attendances and admissions will revert back to the pre-radar position. Prior to the commencement of RADAR, the gap between alcohol-related admissions in the North West and other parts of England was known to be widening; The overall burden on the acute hospitals in Greater Manchester will continue to grow at the rate currently forecast; Acute resources (staff and service usage) will again be diverted towards the management of alcohol-related attendances and admissions; Patients presenting at acute hospitals will not be given the opportunity to access the right interventions (i.e. interventions that treat the underlying cause of their presentation/admission) at the right time and in an appropriate setting; Acute hospitals ability to achieve or sustain achievement of the objectives and targets outlined in Section 2 of this proposal will reduce; and The longer-term burden on the wider health system in Greater Manchester as an outcome of alcohol-related disease will increase. 2 Trafford RADAR Case Studies Patient 44 years old male from Stretford Patient admitted 03/09/2013 for a seven day rapid alcohol detox. Previously had detox at Smithfield in January 2013 but relapsed after 5 months. Had not participated in any recovery focused aftercare and after his relapse he had had accessed Trafford A & E on several occasions. He had a history of intentional overdose and suicide ideation which was last recorded in 2007. His detoxification and symptom management treatment plan was CIWA triggered Librium, IV Pabrinex and Vitamin B. Page 7
On his second day he had a psychological assessment by the Therapy Team where recovery & aftercare plans were developed. This patient had a plan in which he wanted to start his own business and build up his family relationships which he felt his addiction had seriously damaged. The patient attended two evidenced based cognitive behavioural focused groups daily and further had a daily individual therapeutic session using motivational interviewing and node link mapping. He used acupuncture and guided meditated for relaxation purposes. He was introduced to mutual aid (AA) and further contacts were established with a peer led Recovery group in Trafford called Target. He was also referred to Phoenix Futures in Trafford for alcohol support. His follow up call on the 14th September 2013 recorded that he was remaining sober was attending AA and the Chapman Barker Support Forum held every Saturday. He had also been reconnecting with his family. Patient 58 year old male The patient was admitted on 8th July 2013 for seven day rapid Alcohol detox He was admitted from Wythenshawe Hospital [vomiting and abdominal pain]. His detoxification and symptom management treatment plan was CIWA triggered Librium, IV Pabrinex and Vitamin B. He has had two previous detoxes where he was abstinent for 18mths, this was ten years ago. Patient had a long term history of depression and was in serious debt to his former business partner. He was psychologically assessed by the Therapy Team on day two and his recovery and aftercare plans were formulated and situated in Trafford where he lives. The patient attended two evidenced based cognitive behavioural focused groups daily and further had a daily individual therapeutic session using motivational interviewing and node link mapping. His recovery plan consisted of Phoenix Futures, AA, CAT and he was place on a twelve week course of CBT called Breaking Free on Line which teaches specific coping strategies for drug & alcohol recovery. Page 8
On his follow up phone call in August 2013 he was very happy to be sober and is building relationships with his family. He is also taking part in Trafford Mental Health Programme and is feeling much better in his mood. He is attending groups at Phoenix Futures, spoke for the first time in an AA meeting the previous day, is accessing CBT and completing the Breaking Free on Line programme. 3 Recommendations The NHS Trafford Governing Body is asked to note and confirm continued support with other Greater Manchester NHS commissioners funding initially to the end of October this year to sustain the programme, and then work with the Association of Greater Manchester CCGs to explore continued funding of this valuable initiative for a further 12 months. Page 9