Re-designing services for the future

1. Re-designing services for the future Annette Dale-Perera Strategic Director of Addiction and Offender Care Effective treatment, changing lives

2. Biggest change to the NHS since its creation • Health Spending Review settlement “generous compared to other departments …but less in `real terms’ and £20 billion `productivity gains’ required” Kings Fund Oct 2010 • Death of NHS regions as we know them • `Slash & burn’ of NHS commissioning • Commissioning by ‘GP clusters’ or `super groups’, aided by (private) companies • New Public Health …………………. • Patient choice emphasis: personalisation or personal budgets to follow patients • Deliberate widening of provider market: private, NHS, & ‘not for profit’ • More devolution of responsibility (eg to local areas, NHS Trusts) • Allied increased role of regulatory (and inspectorate?) bodies (eg NICE, Care Quality Commission)

3. NHS provider land NHS Foundation Trusts • Existing Trusts `swallowing’ other NHS orgs • Smaller no of Trusts providing primary + secondary care • `rules’ changing eg more private work, can have charitable arms, freedom from national pay scales Financial efficiency savings required by all Health eg CIPs Payment by Results (PbR) • Clustering patients based on `diagnosis & severity’, defining treatment packages (tariffs to be set ie £) • What results: MH mixture of outcome, process + other measures • What results for drug & alcohol treatment services: current danger `health’ outcomes missing for drugs

4. ..ARE WE PLANNING WISELY FOR THE FUTURE?.. Changing substance misuse trends: West London Alcoholhuge existing and growing treatment demand Drugs: • Heroin users fall in injecting – rise in non-injectors: (NB Asian users) • `hard core’ of IDUs using heroin & crack often with complex needs • Elusive primary crack users Are we chasing `unwilling’ PDUs at the expense of others who need help • Clusters of non-PDUs not seen as important • Calls for help eg GHB detoxes, ketamine users • Methamphetamine use: gay male population • Clusters of adult cocaine & cannabis users:

5. Review of CNWL PDU population 2009: an aging and ill population 4,077 PDUs in community drug treatment Age: Mean 36, almost half (48%) 40+: almost a third (31%) over 45 BBV 1,083 (58% of IDUs) have Hep C; 281 (15%) Hep B; 73 (4%) HIV Severe mental health problem: 1,158 (27%) severe depression; 343 (8%) psychosis; 1,587 (37%)Personality Disorder. Smoking: almost all Socio-demographics: • 24% NFA or housing problem • 79% unemployed at intake • A third (34%) to 40% have severe physical health plus severe mental health issues plus long term unemployment and are over 40 At least 25% HCV + expected to get chronic liver disease 20 - 30yrs after infection: NOW People with severe mental illness die15 -20 yrs early Heavy smoking reduces life by average of 8.8 yrs Only 15% previous regular employment

6. CNWL Review: audits & stakeholder surveys We were: • good at core aspects eg community & in-patient prescribing, retention, staff competence, health inputs and clinical governance but • poorer on value for money, performance management, working with primary stimulant users, unplanned discharges and relationships/image • Planned exits: some discharge drug free but mainly referral to GPs (the commissioned pathway) SOLID but `old fashioned’ & expensive NHS provider: needed to modernise • CNWL TOP Outcomes on GOOD on reducing drug misuse, crime, & injecting:limited improvement in housing and employment local systems issues

7. New Vision “CNWLprovide high quality, evidence-based specialist addiction treatment that helps clients tackle their dependency and promotes recovery” In partnerships and local systems of treatment and recovery, CNWL lead on: Specialist prescribing, health & expert psycho-social, & Clinical governance CNWL recognise • We are have an aging, increasing group & other complex population needs • Recovery is a process with personal goals: it is NOT abstinence: learn from Mental Health • Long term opioid-maintenance will be needed by some: we have to ensure its quality: • Working with partners (including peer support & mutual aid) is essential to embed recovery principles into practice • Drug users are already STIGMATISED – we need a balance between ambition in outcomes and being realistic: we must not add to stigma and feelings of failure • We have a commitment to improving our services by regular audit, review and planning

8. CNWL redesign phase 1 & 2 • Phase 1: Slimmed & restructured management and `infrastructure’, stopped agency nurses, more financial & performance accountability • Result: units cost fell & KPI performance improved within 1 year • Phase 2: work in progress • Embed the vision • Expand range of psycho-social interventions with more client focus • Extend core health interventions • Improve and develop prescribing options • Increase service user & mutual aid role • Improve access to volunteering & employment • Local sector redesigns in line with the vision and in partnership with local commissioners, providers and service users

9. Key Learning points • Trust Board support essential • `Selling the Vision’ to the staff & building a `Leadership team’ crucial • Keep stakeholders on board crucial (commissioners, users, partners) • Management & staff restructure painful, took time: due HR process • Culture shifts occurring when: • service managers and lead clinicians asked to redesign their services on 0%, -10%, -20%, -30% • Teams saw examples of how service user led services can work (SUDRG & Inituative recovery) • Debate in the senior team on the purpose of treatment and what outcomes we are trying to achieve (ongoing) • Regular feedback of audit, performance and outcome data: comparing services • We did very close planning and work with partners on service models • Extra grant resources allowed for `non-commissioned’ work

10. Two partnership models Model 1 • New drug & alcohol service with ETE, day programme & volunteering • Several months designing service: 3 partners playing to strengths • Multiple providers: one centre, one service, one team • True partnership: one NDTMS code, one information/case management system, one shared clinical governance system • CNWL: strong, quite small team • Clear and explicit emphasis on recovery and building recovery capital • Very cost-efficient model Model 2 Peer-led services taking over drug services at evenings and weekends Social club, drop-in, trained volunteers, linked to training Needs time to grow

11. Redesign of services can lead to improvements in services and efficiency gains especially if done in partnership BUT FIRST DO NO HARM We need balanced systems