Re-design – Findings so Far and Business Models for

consideration

Ben Seale

November 2011

Current State• Provision is via a range of providers comprising:

– HHAS (care coordination for complex needs)– Huntercombe Centre (inpatient detoxification)– Counted4 CIC (medical stabilisation / detoxification)– NECA (psychosocial interventions)– DISC (CJ care coordination / psychosocial

interventions)– Lifeline (Harm Reduction)– NERAF (mainly alcohol – peer support)– Turning Point (assessment and engagement with the

treatment system)– City Hospitals Sunderland (mainly alcohol – liaison

nurse post)

Current State - Funding

• Funding is currently from a range of sources:– Drug Intervention Programme (Home Office

and DoH - £688,149)– Pooled Treatment Budget (DoH - £2,380,752)– Alcohol / Mainstream Drugs budget

(Sunderland TPCT - £2,497,546 / £884,536)

Current State - Community

SPOC - Turning Point

Counted4

NECA

Huntercombe Centre

HHAS

Lifeline

NERAF

Res Rehab

Current State – Criminal Justice

• Integrated Offender Management team

DISC

Turning Point

Counted4

ProbationPolice Prison Service

ARREST

RELEASE

Current State – Hospital (alcohol)

Alcohol Liaison NurseTurning Point

Hospital (AMU / Gastro / General…)

Counted4

Community

Current Issues• Alcohol related hospital admissions continue to

rise• Demand for treatment interventions from PDUs

(heroin/crack) is stable – e.g. less demand via test on arrest

• High rates of clients in treatment in excess of 2 years

• Comparatively low levels of planned discharges (as proportion of overall caseload)

• In line with expectations demand for alcohol interventions is rising

• Main diagnostic indicators (waiting times, care planning etc.) remain on target

Current Issues (2)

• Multi agency Care coordination occurs in pockets only – e.g. Integrated Offender Management, Social Work Team

• Pathways are not currently fully enabling recovery / outcome focus

• Excess / duplication of data systems and administrative processes

• Lack of service independent user involvement• Lack of permanent presence in South of

Sunderland

National Developments

• Publication of 2010 Drug (and Alcohol) Strategy - 'Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life‘– Increasing emphasis on recovery and the need to the

volume of those leaving

• Payment by results – national pilots altering the focus of payment for delivery of treatment interventions to outcomes– Increasing emphasis on recovery and the need to the

volume of those leaving

Outcome Definitions – PBR

• Initial outcomes (substance misuse):– Significant reduction in substance misuse

(clarified via 2 TOP reviews/appropriate exits)– Abstinence from all presenting substances

(clarified via 2 TOP reviews/appropriate exits)– Planned Exit – treatment component

successfully completed and heroin/crack use ceased (clarified via NDTMS)

Outcome Definitions – PBR

• Final outcomes– Planned exit and do not re-present to the

treatment or criminal justice system in the following 12 months

Outcome Definitions – PBR

• Initial outcomes (offending):– No proven offending in a 6 month period from the

point of beginning a recovery interventions• Final outcomes (offending):

– No proven offending in a 12 month period from the point of beginning a recovery interventions (can be ‘re-set’ – but 12 months will be measured from prison release or CJS disposal)

• Interim (offending):– Reduction in average offending of cohort (in or

recently discharges from treatment) – can be locally determined

Outcome Definitions – PBR

• Health and Wellbeing (NB – no longevity measure):– Injecting reduced to 0 days (clarified via 2 TOP

reviews/appropriate exits)– NFA/Housing Problems reported at start of treatment

to be rectified (clarified via 2 TOP reviews/appropriate exits)

– Hep B Vac - eligible and completed a course of Hep B vaccinations

– Health and Wellbeing – normative quality of life score achieved (assessed against those successfully leaving treatment - clarified via 2 TOP reviews/appropriate exits)

Commissioning Process so Far

• The need to facilitate structural change was highlighted by the JCG in March

• As such recommended commissioning intentions made to the Safer Sunderland Partnership and Prevention and Staying Healthy Boards were to give notice on current arrangements with a view to a full system re-design and potential re-procurement

• This has been accepted by both boards. The SSP Board required assurance that the Clinical Commissioning Group should be consulted on potential changes and that future financial risks should be clearly identified and managed. However, but also recognised the need for structural change

Results of Consultations So Far

• A range of consultative events / workshops have helped gather together input to the process of re-design. Output from these have included:– Summary of current issues– Vision– Characteristics / components of proposed

new system

Characteristics• Greater coordination of care to assure that the client is assisted on a needs led

recovery journey from point of access to the system• Locality based delivery• Minimised complexity in pathways• Duplication removed• Increased alignment with other elements of holistic delivery, such as Jobcentre plus

and Housing• Unified information systems and clearly governed information sharing arrangements• Multi-disciplinary / integrated teams providing access to all necessary core treatment

modalities - namely:– Collaborative care/Care navigation for all clients– Substitute prescribing / clinically assisted detoxification– Education, Training and Employment– Therapeutic/Psychosocial interventions– Residential rehabilitation/detoxification– Harm reduction/Needle Exchange– Peer support/Mutual aid– Specialist family interventions– Outcome/Recovery monitoring methodologies used throughout

Emergent Issues

• More ‘one stop shop’ approach required• Need to maintain parity between delivery of drug

treatment and alcohol treatment• Greater access to residential rehabilitation required• Holistic and recovery based approach to assessment

required• More use of family based approaches• Services should be delivered as close to people’s homes

as possible (locality working)• Need for better care coordination across all levels of

need• Need to make greater use of peer mentoring and mutual

Vision

• A cohesive and effective, recovery focused treatment system which offers value for money and benefits individuals seeking treatment, their families and the communities of Sunderland:– Where client journeys are seamless– Which supports people effectively through treatment

and back on their feet – That takes an outcome led approach focussing on

results for clients which aid their recovery– Which is flexible in order to meet the needs of a

changing population

Models / PBR Implementations - Kent

• Re-tendering – aligning of funding streams for whole system approach• Retaining existing local authority care management team and merging with new provision• Single provider model

– Simple pathway– Improved Efficiency– Can sub-contract

• PBR envisaged as a phased implementation:

Year Core Activity PbR

Year 1 75% 25%

Year 2 60% 40%

Year 3 50% 50%

Year 4 40% 60%

Models / PBR Implementations - Stockport

• DAT manages current assessment team – add to team to provide LASAR function with overview of care packages offered to clients

• Existing system wide information system• Adaption of all current provider contracts to

adopt PbR approach (70% allocated via PbR, 30% via existing contracting arrangements – to move to 100%). Also including maximum contract value

• Client group to be segmented by levels of need to allow identification of tarriff / relevant package of interventions

Models / PBR Implementations - Wigan

• Existing SPOC team facilitates referral to system – augmented to become LASAR (triage / setting of tariffs / allocation to providers / tracking outcomes – also following discharge)

• Framework model for providers:– Mental Health Trust (sub misuse and health)– Work Solutions/CRI (employability)– Probation service (DIP and IOM

• Pathway based around 12 month timeframe for review

Models / PBR Implementations - Wakefield

• Treatment system already integrated• Implementation of LASAR using existing staff drawn

from other providers– Assessment (consistent)– Tracking of outcome domains– Including recovered service users leading on development of

asset based assessments

• Development of outcomes framework• Introduction of tariff system• Intending to move to 100% of budgets paid against

outcomes – weighted depending on specialism of provider

Local Developments

• Darlington currently re-tendering for a lead provider integrated system (all services) – not currently built around PbR though. Could lend to single provider delivery or a sub-contracting arrangement

• Middlesbrough – well developed alcohol PbR pilot involving ‘clustering’ of client base according to complexity. Also implementation of LASAR and 2 recovery packages – stabilisation and abstinence

Potential Model for Sunderland• A single recovery pathway containing IOM,

Hospital and Community specialisms• Pathway facilitated by LASAR (Locality Area

Single Assessment and Referral) function containing:– Complex case management– General case management– Peer support

• Treatment modalities drawn in on a needs led basis to support recovery journey (either via sub-contracting or direct provision)

• Delivery within locality bases• Case management assured throughout journey

Proposed Model (2)

Assessment, Care Planning, Case Management,Assertive outreach, Peer Support

Successful Treatment Completion

ReducedOffending

Employment

ImprovedHealth and Wellbeing

Residential Rehabilitation

PsychosocialInterventions

CommunityIntegration /ETE

Detoxification –Community or

Inpatient

SubstitutePrescribing

Detoxification –Community or

Inpatient

SelfReferral

HarmReduction

DIP

Hospital

Professionalreferrals

Family Interventions

Benefits of Model• Simple pathway which assures coordination• Merge of assessment function to pathway management

– as opposed to a hand off process• Recognises the resource required for coordination and

support of recovery journey• Modalities can be drawn on objectively – a needs led

basis• Design will eliminate duplication – also pathway ensures

that duplication does not creep in• Assures integration of all elements of pathway

management into a governable structure• Pathway provides good scope for point of measurement

and unified information system

Risks Associated with Model

• Potential lack of choice

• Performance mainly reliant on performance of provider representing pathway function

Rationale for Procurement• Current contracts expire in April 2013 – it would be usual

practice to test the market and re-procure at this point• Allows maximum scope for re-design and alignment with

emerging policy developments• Process can be adjusted • Facilitates a fair approach• More efficient / safer management of reduced budgets• Allows for market stimulation• Procurement process can be carried out alongside local

authority colleagues to help support transition

• KEY RISK – challenge / delay / commitment of capacity / known unknowns – e.g. BRiC, funding etc.

Timelines – e.g. full procurementContinue consultation and involvement / engage legal and procurement support (14 days)Finalise model to be specified (30 days) Preparation of Pre-qualification documents and service specifications (60 days)Pre-notification of intention to tender (market stimulation) (30 days)Advertisement for expressions of interest (30 days)Pre-qualification process and assessment (30 days)Invitation to tender process and assessment (30 days)Provider presentations and assessment (7 days)Award of contracts (7 days)Stand still period (30 days) Commencement of transitional period and TUPE (180 days)

New system operational (total for timeline - ~15 months from commencement)

Rationale for Re-modelling

• Can be achieved more rapidly• Less likely to be challenged by existing

providers• Less disruption to workforce

• KEY RISKS – limited ability to reduce costs via management / waste efficiencies extension of contracts is also possible subject to challenge

Discussion

- Validity of Model- Chosen Business Approach