Health Services Role and Contribution to the Delivery of the Adult Treatment Plan

BOROUGH OF POOLE

Report to the Health Scrutiny Committee

11 October 2005

HEALTH SERVICES ROLE AND CONTRIBUTION TO THE DELIVERY OF THE ADULT TREATMENT PLAN

1. PURPOSE AND POLICY CONTEXT

1.1At the joint meeting of the Community Support and Learning Overview Groups on 22 March 2005, Members requested that the Health Scrutiny Committee examine the role of GPs in supporting drug and alcohol service delivery in Poole, and funding issues which could affect the delivery of the Adult Treatment Plan.

1.2This report provides information on these issues to enable the Committee to consider the issues in more depth.

2. RECOMMENDATIONS

2.1.Members are asked to consider the issues raised in the report.

3. BACKGROUND INFORMATION

3.1Drug Action Teams (DATs) are a partnership of each of the local agencies involved in tackling drug misuse, which includes health, local authority, local education authority, police, probation and prison. Each DAT is responsible for delivering the ten year National Drugs Strategy at a local level. Every year each DAT is required to provide the government with an outline of its plans for the year, which include aims, objectives and targets, together with details of planned expenditure over the four aims of the national strategy.

3.2The Drug Action Team is required to commission drug treatment services locally, through the direction of the National Treatment Agency (NTA). The NTA expects DATs to commission services with reference to a variety of health and criminal justice outcomes to meet both local need and national objectives. The Annual Treatment Plan must be approved by the NTA regional office and is closely monitored, on a quarterly basis, by the Government Office Drugs Team and the NTA in terms of spend and targets.

3.3The NTA has recently published its new ‘Treatment Effectiveness Strategy’ which aims to drive improvement in local drug treatment services and also improve the service users journey through treatment together with a focus on an individuals holistic needs (including housing and employment).

3.4The main responsibilities of the Drug Action Team are:

• Adult treatment planning
• Young people’s substance misuse planning
• Commissioning
• Monitoring and evaluation of service delivery
• Delivery of special projects, i.e. drug awareness in the workplace
• Treatment, throughcare and aftercare for people in the criminal justice system

3.5The Drug Action Team is required to have an understanding of local need and to develop new service provision to reflect the requirements of people within its area. It is also required to strengthen existing partnerships and establish new inter-agency networks with services that impact on drug related issues.

3.6The New ‘Effectiveness Strategy’ also focuses on Drug Action Teams improving understanding of local need and diversity, developing local workforce strategies to build competence and aid retention, performance management of local systems and local commissioning partnerships that have strategic links with providers, users and other mainstream services i.e. housing.

3.7Poole is frequently viewed as an affluent area with little evidence of deprivation and as such funding levels are often very low. This presents a continuing challenge to develop services to meet identified need within limited resources. In order to deliver a locality based service the Drug Action Team established the Poole Addictions Community Team (PACT). This is a specialist addiction service made up of nurses, social workers, an associate specialist (able to prescribe medication), drug and alcohol workers and support staff. Other drug and alcohol services are commissioned through Dorset Healthcare NHS Trust and the voluntary sector. (Details of the specialist services available to Poole residents are set out at Appendix C)

3.8Since the establishment of the DAT the majority of its available funding has been used to ensure that the Poole Addictions Community Team (PACT) is able to meet national requirements in relation to providing a wide range of needs-led services (which include alcohol services, although there is no dedicated funding for this). In the light of increasing demands on PACT, the DAT is faced with the challenge of how it can best maintain the capacity of the service from within existing resources.

3.9 Shared Care provides substance misuse treatment in a primary care setting, with the GP being supported by the specialist service and local pharmacists. Although GP Shared care has worked effectively in rural Dorset for a number of years, GP’s in Poole and Bournemouth have historically not treated their own patients for substance misuse but have referred them to the specialist service. They continue to have concerns about delivering substance misuse services within a general practice setting and this places an increasing strain, both in terms of human and financial resources, on the Specialist Services.

3.10In an effort to increase treatment capacity in Poole, the Drug Action Team is working in partnership with the PCT to try to engage GP’s in formal Shared Care arrangements. A joint PCT/ Social Service post has been established with part of the post holders remit is to take this work forward.

4 ROLES AND RESPONSIBILITIES

4.1 DAT - The NTA is responsible for setting treatment targets for Drug Action Teams and for monitoring progress towards both national and local targets. The Poole Treatment Targets were locally set to provide consistency across the Adult Treatment Plan and the delivery targets included in the PCT Local Delivery Plan (LDP). Subsequent to ‘signing off’ of the Treatment Plan, the NTA has increased the Drug Action Team target for numbers entering treatment, as it considered the previously agreed target did not represent enough of a ‘stretch.’ Therefore, there is now a different, although not significant, target for the Drug Action Team and the PCT.

4.2 The NTA has established Regional Management Boards (RMB), and it is this group that determines whether local Plans meet national criteria. The Strategic Health Authority is a Member of the RMB.

4.3 Strategic Health Authority (SHA) - The SHA has no direct links with the Drug Action Team, but is responsible to the Department of Health, for ensuring that systems are in place to performance manage PCT’s in the delivery of the key targets of the LDP.

4.4 To support the delivery of PCT CHAI star ratings, the SHA set a target for 2004-06, for an 18% increase in numbers entering treatment across Dorset and Somerset. This was set prior to any consultation with Drug Action Teams as a result of a national directive. However, subsequent discussions have resulted in local agreement between the 4 SHA area Drug Action Teams, that there would be a cumulative increase over 3 years across the whole region rather than individual Drug Action Teams being required to achieve an 18% increase. (NB. Due to the significant year on year increases already delivered by the DAT and the acknowledged capacity of treatment services, the target for Poole is 5.45% in 2004/5 and 8.06% in 2005/06 - See Appendix A)

4.5 Primary Care Trust – The PCT is a partner of the Drug Action Team and is also a ‘Responsible Authority’ of the Crime and Disorder Reduction Partnership, and as a result, is a major contributor to the work of Poole Safe Together. To inform Drug Action Team planning and commissioning, and the development of LDP’s, the PCT is expected to have an understanding of local need and to work as part of the Drug Action Team, to develop new service provision to reflect the requirements of people within its area.

4.6 The PCT is responsible for supplying data to the SHA and DoH in support of its LDP targets.

4.7 In addition to its Strategic Role as part of the Drug Action Team, the PCT is also responsible for the implementation of the new GMS contracts with local GP’s. These contracts cover core work, additional services and enhanced services. Enhanced services cover specialist services such as substance misuse, which should be provided in every area but not necessarily by every GP. In effect, this means that GPs can ‘opt-in’ to the service but cannot be compelled to participate in Shared Care arrangements.

4.8 As part of a wider remit, a new joint PCT/Social Service post has been established to work with the Drug Action Team and to ‘lead’ on the establishment of Shared Care (which is the joint participation of GPs and the specialist addiction services in the planned delivery of care for drug users). It ensures a planned delivery of care and ensures that GPs do not feel that they are providing a drug service in isolation. GPs are required to prescribe to their own level of competence as either a specialist, a GP with special interest or a generalist GP.

4.9 As part of the process of implementing the new GP Contracts the PCT/DAT have begun work to introduce formal shared care arrangements. Informal discussions have taken place with a small number of GPs who have registered an interest in developing this work in becoming early implementers of a local shared care scheme in an effort to identify and address any concerns and to establish local training needs. All participating GPs are required to undertake training as part of a certification course and, to support this; the DAT and PCT have jointly funded a local trainer to deliver the substance misuse accreditation programme in Poole. The trainer has also been commissioned to undertake personal visits to all practices to try to identify areas where further support would be required. However, the commencement of this work is dependant on a letter of introduction from the Shared Care lead being sent to each GP.

4.10. To fully develop shared care and to support GPs where appropriate, the Drug Action Team has identified the need for two dedicated posts within the specialist service to support the process. Effective shared care would mean that stable clients could be seen in a primary care setting and this would then increase the capacity of PACT to work with the more chaotic clients. Strong links between GP’s, Pharmacists and PACT would provide effective continuity of care for clients, a support network for practitioners and enable the DAT to meet NTA targets in relation to treatment effectiveness.

4.11 Unfortunately, although funding through the DAT and DHCT mainstream spend has been made available for two shared care support posts within PACT, a number of vacant posts have resulted in this crucial element of support not being available to GPs at the current time. However, through the introduction of a new Service Specification for the locality team, it is anticipated that the short term difficulties can be addressed.

4.11 Despite the lack of capacity with PACT, work is continuing in an effort to engage and support GP’s and the specialist service. Pan Dorset DATs and PCT pharmaceutical Advisors have submitted a proposal to the Workforce Development Confederation to support two Poole based pharmacists and one nurse to train to provide ‘supplementary prescribing’. The PCT is also contributing to a pharmacist becoming a supplementary provider in advance of the WDC bid. It should be noted that effective supplementary prescribing would need involvement/supervision from a trained GP.

4.12 Dorset Healthcare NHS Trust (DHCT) - DHCT is commissioned by the Drug Action Team, through the S&E Dorset PCT, to deliver specialist drug and alcohol inpatient detoxification and structured day care services for Poole residents. It also delivers services as part of PACT. The funding of £1,004,200 is via historical mainstream drug and alcohol funding for East Dorset. The funding is apportioned as 56% Bournemouth, 17% Dorset and 27% Poole, with the apportionment being made on a national formula based on historic drug user prevalence data.

4.13 Although the Drug Action Team is responsible for commissioning all drug services within its area, the funding for DHCT does not currently form part of the DAT Joint Commissioning Pooled Budget. This has resulted in the Drug Action Team having to fund the development of the locality service from its Pooled Treatment Budget as the mainstream spend is provided by S&E Dorset PCT (as lead commissioner for the SHA) to DHCT. The only contribution from DHCT to the locality team is in relation to one part time shared care nursing post, the prescribing budget and two sessions per week medical cover. Three full time PACT posts are funded by Social Services and the remaining staff are funded from a range of Drug Action Team budgets. This has resulted in a lack of investment in new treatment and support services

4.14 However, the implementation of new Service Specifications with DHCT, commissioned by the three Dorset DATs, has resulted in priority access and an improved service for Poole residents referred to the Flaghead and Sedman Units.

5 OBJECTIVES AND RISKS TO DELIVERY

5.1In order to deliver the Annual Treatment Plan 2005 the Drug Action Team will continue to develop treatment services to meet local need but has identified areas that present a risk to successful delivery.

Objectives / Risks to delivery
Continue the monitoring and development of the Poole Addictions Community Team to ensure that it has capacity to meet the needs of local residents.
NB A Pan Dorset Group has been established to develop a ‘cross border’ Workforce Recruitment and Retention Strategy. / High turn over of staff and difficulty filling posts has led to a reduction in service delivery and an increase in waiting times (particularly for alcohol clients). The Drug Action Team has identified the need for a Workforce Recruitment and Retention Strategy to be developed as staffing is affected by a lack of funding to facilitate competitive salaries, relocation expenses and a lack of affordable housing and career progression opportunities.
Engaging with GPs to implement a fully developed ‘Shared Care’ system for joint working between the specialist service and primary care and pharmacists. / GPs within Poole are accustomed to referring patients with drug and alcohol issues to a ‘specialist service’ and have concerns about treating this client group within a GP practice setting, although some limited prescribing takes place on a named client basis.
Agenda for Change (A4C) – this is a national review of healthcare staff roles, responsibilities and salaries. / Agenda for change (A4C) has had a significant impact on the DHCT drug spend and also on Drug Action Team budgets. A number of nursing staff have received significant salary increases (above those expected) Within PACT a high number of nursing posts are funded from the Pooled Treatment Budget and the increase will need to be met from within existing finances. The SHA provided additional funding to DHCT to cover the increased costs but the Trust predicts that there will still be a shortfall, which may result in cuts to services.
Further develop needle exchange services in Poole and extend the specialist service Harm Minimisation Clinic to provide immunisation for Hepatitis A and B and screening for Hepatitis C (subject to available funding). / The specialist needle exchange/harm minimisation service has not been operating due to staff shortages – the Drug Action Team is therefore unlikely to be able to meet its annual target to provide immunisation to 415 clients.
Ensure that the dedicated young people’s service (YADAS) is adequately funded to ensure its continued development to meet local need. / The medical cover provided will cease in its current form in November due to the retirement of the post holder. Additional funding will need to be identified to ensure continued cover via CAMHS. No budget has been identified for this.
In partnership with Bournemouth and Dorset DATs and the NTA, seek agreement with Dorset Healthcare NHS Trust over the level of mainstream funding available for alcohol service provision in East Dorset and use Poole DATs allocation, together with the agreed drug spend, to commission and provide effective services within the locality. / Alcohol funding is still to be determined.
The retirement of senior medical staff will require consideration to be given to future provision and associated funding implications.

6 Achievements

6.1 Whilst recognising the challenges of continual development and improvement to treatment and support services, it should also be acknowledged that considerable achievements have been made over the past year. The Drug Action Team has been responsible for:

• Ensuring that the increasing number of clients presenting with substance misuse problems are able to receive appropriate treatment within national waiting time guidelines (See Appendix A)
• Developing a range of treatment options to meet the diverse needs of all residents including a stimulant clinic, women only clinic with childcare facilities, and an complementary therapy clinic (acupuncture, reiki, yoga, head massage etc)
• Establishing a new harm minimisation service (Needle exchange, Hepatitis B immunisation, safer injecting advice and general health care)
• Facilitating and funding the move of the specialist service to new premises
• A joint initiative with ’Faithworks’ which targets the homeless population with substance misuse issues
• Providing supported accommodation for clients leaving treatment prior to full return to independent living
• Working with Housing and Community services to secure supported accommodation for Addiction Team clients engaged in treatment
• Providing services to meet the needs of clients in the Criminal Justice System (including joint work with HM Prison Service)
• Facilitated the establishment of service user and carer forums (see Appendix C)
• Funded a new electronic data collection and case management system to meet the needs of the Drug Action Team, the PCT in relation to its CHAI Star Ratings and the Local Authority for its BV KPI’s and LPSA drugs target
• Joint work with Bournemouth and Dorset DATs to establish new Service Level Agreements with Dorset HealthCare NHS Trust which, for the first time, give priority access to inpatient detoxification to Poole residents
• Leading the development of joint work, on behalf of the Dorset DATs, with the Dorset Prison Cluster and SW Dorset PCT in relation to the seamless transition between treatment services in Dorchester Prison and the Dorset Community Teams

7 CONCLUSION