Anne Charlesworth, Public Health and Joy Ainsworth, CGL, to present
Minutes:
Anne Charlesworth, Head of Public Health Commissioning, Joy Ainsworth, Deputy Director CGL North East and Michaela Bateman, Associate Nurse Director for the Rotherham Care Group, Rotherham Doncaster and South Humber (RDaSH) delivered the following presentation:-
Original purpose of scrutiny spotlight review
“To ensure that the drug and alcohol service, operating within a reduced budget, would provide a quality, safe service under the new contract”
Specific updates from the commissioning perspective
• CGL were still having monthly Performance and Quality meetings with Public Health to ensure transparency of performance, look at serious incidents and ensure implementation of recommendations of CQC Report.
• After the CQC inspection delivered its findings of ‘Requires Improvement’ a joint report was produced with Bradford Services, but this was amended to have a Rotherham specific report to enable specific Rotherham improvements.
• ‘Requires Improvement’ was due to issues in at least two areas, and some related to building specific concerns which had been rectified. CGL had an internal team that prepared for CQC and were expecting a return visit this year.
By the end of August all tasks that had been identified by the CQC should have been completed. With regards to the concerns around the building, the CQC inspectors were used to looking at secure mental health facilities where the standard was different rather than community-based drugs and alcohol services.
• There were several performance areas of concern – ‘exits’ generally. Non-opiate exits were under particularly scrutiny as it may have received less focus due to a push to improve opiate exits.
• Alcohol pathways needed more work, as did keeping the number of patients flowing through into Shared Care as Rotherham had quite a tight target for making sure as many patients as possible were with their own GP.
• Original predictions were that it would take 18 months to see any real improvement with regard to opiate exits due to the clinical time required to change long term care packages. Rotherham was still within that timeframe, but a close eye was being kept on progress.
• Despite looking for trends and patterns in the deaths information, no clear picture was emerging as yet. The overview of deaths in service were being built into the Strategic Suicide Review Group, chaired by the Strategic Director for Adult Social Care and Healthto ensure strategic oversight.
• Pre-tender soft market testing was now taking place regularly – a recent example was Children’s Weight Management, as a result of which the approach was changed significantly.
Service Perspective from CGL
Background – CGL Rotherham
April 2018
ü Fully integrated Drug and Alcohol Services
ü Shared Care provision - 24 GPs/46 % of Service users
ü Pharmacy Contracts for Supervised Consumption and Needle Exchange – 28 pharmacies
Service Users
1,537 clients entered structured treatment April 2018-March 2019 (NDTMS)
q 1,018 opiate users (66%) – National average 52%
q 361 alcohol clients (23%) – National average 29%
q 103 Non-opiate or crack users (Non-OCU) (7%) – National average 9%
q 55 Non-OCU & Alcohol clients (4%) – National average 10%
891 clients were recorded as receiving a brief intervention equalling a total of 2,428 people who had engaged with CGL Rotherham in the first year. A brief intervention was someone who did not require access to a service but required advice and information on substance or alcohol use.
Graphs and Pie Charts
- Opiate Successful Completions (Public Health Outcome Framework -PHOF)
- Opiate Successful Completions May 2019 (CGL Data)
- Opiate Representation Rates May 2019 (CGL Data)
- Non Opiate Successful Completion Rates May 2019
- Rotherham: Expected and Unexpected Deaths
The target for opiate exits in the first year was an increase of 1.5%. Successful completions were going in the right direction with re-presentations remaining low and the PHOF indicator would catch up.
Targeted work with all Service users on low doses of medication was taking place. Staff completed a detox readiness tool and, through their medically assisted treatment modules on the case management system, identified the cohort of people that were ready to reduce and would be the next people to successfully leave the Service.
Expected deaths tended to be deaths of service users with really complex health issues and who had an end of life care package in Hospital, not through an overdose.
Drug Related Deaths - Reporting, Investigating, Shared Learning
Reporting
• Incident Reporting Framework
• CQC Notification process
• Commissioner Notification
Investigating
• Death Learning Tool – all deaths
• Collaborative Approach, shared timelines
Learning
• Internal - Integrated Governance
• Collaborative - Death Review Meeting, Suicide Prevention Group, Loss of Life Forum
Actions in Rotherham to reduce drug related deaths
ü Accessible Services
ü Evidence based Clinical interventions
ü Continued roll out of Naloxone to those most at risk via pharmacists/ GPs/housing providers
ü Blood Borne Virus (BBV) Testing to all Service users in Rotherham;
ü Smoking Cessation via Get Healthy Rotherham.
ü Multi-Agency Working and Shared Learning: Death Review Panel, Suicide Prevention Group, Loss of Life Forum
ü Development of a Dual Diagnosis pathway
Dual Diagnosis Pathway – RDaSH and CGL
Purpose
• To improve care and outcomes for Service Users with both drug/alcohol and mental health issues.
• To improve access to both Services
• To reduce duplication during assessment process
• To ensure Service users/patients received the interventions they needed in a timely way
What do we know about our Service Users?
• High percentage of SU’s accessing both Services
• Many requiring input from Mental Health and Drugs and Alcohol Services due to complexity
• An ageing opiate using population with co-morbidity issues
Strengths
• Expertise across both Services
• Commitment to improving the way we work
• Services were passionate and Service user-focussed
• Familiar relationship between staff in both Services
Barriers
• Lack of co-ordinated approach/joined up care
• Different referrals/paperwork
• Different Data Systems
• Limited joint training
January-March 2019
ü Dual Diagnosis pathway jointly developed and agreed between CGL and RDaSH
Pathway includes:
• Clarity around who co-ordinates care
• Process for escalation, joint ownership and training
• Mutually agreed Service Access
May 2019
ü Training rolled out jointly between CGL and RDaSH to all relevant Mental Health and Substance Misuse Staff
ü Champions from each Service self-nominated to lead on embedding the pathway
ü Joint focus group established to continually monitor pathway effectiveness
40 staff attended and their engagement was really positive with a clear drive and willingness to work more effectively together to support the Service user population. One of the most positive aspects was setting up Champions meetings and groups with staff from both organisations and from different parts of RDaSH to look at joint shared learning on current issues in terms of the local footprint and how to best support people. Some of that progressed on to reflective practice work and how to share referrals in a more timely manner rather than through a traditional system through front-end services. Basic work took place on sharing contact details for both Services and attending each other's team meetings and Service meetings to provide an update on the respective footprints in terms of both Services at the time.
Copies of CGL’s annual report had been circulated to Members which included more information around Service activity. The Dual Diagnosis Pathway flowchart and decision making matrix were also shared.
Members explored a number of issues following the presentation:-
· Changes from joint training and working arrangements were very recent, so how quickly would Service users see the effects of those changes?
- Some were virtually instantaneous, such as direct communication elements and knowing where to seek information and support. If a member of CGL staff felt someone needed mental health input or assessment with this quicker pathway, staff would know how to access that information.
- Staff had been saying they did not have a really clear escalation process from substance misuse to mental health and vice versa, so that was now agreed and in place for staff to refer to. If there were any sticking points or barriers, or somebody felt the pathway was not working/a Service user was unable to go through the pathway as intended, the Champions would act as the point of contact to escalate the issue to either Joy or Michaela so they could understand the issue in more detail. People would see small changes soon and then once embedded it would be standard practice.
· Non-opiate successful completion rates - what was classed as successful and what were the reasons for the differential between successful completions in Rotherham and nationally, which was a concern? Did other areas use the same model of intervention?
- Successful completions were measured on an 18 month rolling basis and re-presentations were over 6 months. It was not the same cohort of people who left and came back because of the different time spans in the data. Services counted everybody who left over a period of time and then checked on an individual basis if they came back. If a person left and then came back in 6 months that would be an unsuccessful exit and would not be counted as a successful completion. As this was the first year it was difficult with the data but the difference over 2 years would be measured in the light blue indicator from the PHOF.
- Engagement work had been undertaken and Rotherham had a really small number of non-opiate users who accessed structured treatment. CGL had carried out a number of brief interventions with people who were not in structured treatment, as seen on the slide earlier, but did look to identify people who would benefit from structured treatment to engage and therefore improve the exits.
- People came into Services who were not opiate users and who might be cannabis/spice/prescription drug users; anything that was not an opiate. For the last 20 years the Service had typically been dominated by opiate use, for which there was a very recognisable structured treatment in Methadone. Rotherham traditionally had had very low numbers of Crack and Cocaine users and lower numbers, for example, of users injecting Amphetamine, as seen in other areas of the country. Typically Rotherham had people who were unsure whether they wanted to come into structured treatment or not or for the more psychological treatments offered e.g. for Cannabis or Spice use. Nationally, it was more recognised that if somebody was involved in Crack Cocaine then escalation into difficulties in other areas of their life became very rapid, so in some ways it was easier to bring structure there than for somebody who was periodically using Cannabis and fairly undecided whether they wanted treatment or not. Thus in some ways, because the number of presentations for this type of treatment was low, it was harder to achieve a good response rate but this was being looked at as something to improve on.
- CGL had recently implemented a specific psychosocial intervention package for non-opiate users within Rotherham, obtained from other services. The specific package was based on their substance of choice, as, for example, work with a Cannabis user would be different to how the Service would work with an Amphetamine user. As the packages had been rolled out very recently within the Service the impact had not yet been seen.
· Characteristics of Naloxone - what did it do and how successful was it? What did it mean that those most at risk could obtain it via a pharmacist, GP or housing provider?
- Naloxone was quite a novel drug and had only been available in Rotherham since April of last year. Services had never had anything like Naloxone before that was as easy to administer, including by non-medical staff, which could bring someone back from an overdose. A recent example was a kit in one of Rotherham’s housing providers where a couple of people living there were felt to be at risk of overdose. Having that kit available for non-medical staff to use, including some security staff who operated in some of those housing accommodations, was a means of giving a faster first response than an ambulance could get there because it would bring someone back from overdose. Obviously there was a role for a Naloxone kit to be given to family members if they had an opiate user in the family and were worried they might overdose.
- Naloxone basically reversed the effects of opiates, so whereas before someone would call an ambulance and a paramedic would come and administer an equivalent to the Naloxone, once people were trained it was very easy to administer and quicker. CGL trained staff, family members and anybody who might come into contact with someone in this situation so they could use and administer Naloxone. It did save lives and nationally CGL had recorded that it had saved hundreds of lives. Naloxone was being made available nationally in police cells because of the risk that someone might come into police custody or in prison. It reversed the overdose effect initially but the person would still need medical attention as opiates were still in their system so they could not go out and use again straight away without experiencing a really negative impact. People would be given that advice once it had been administered.
· Borough-wide figures for expected and unexpected deaths – were these broken down by the Service, for example by Ward, to spot any local patterns or trends within a specific area and then responded to proactively target any specific issues?
- Although they seemed large numbers, they were relatively small for services to start to break down, with a risk that it might make Service users identifiable. They would be looked at in the detail of the review. For example, checking addresses to make sure it was not people in close proximity to one another as there might be a connection/knew each other or had a relationship. No emerging trends had been identified but Services were second in that process after the Coroner whose job it was to look at that in great detail.
· Was there specific learning from each case even if some may have looked similar?
- Every death was investigated separately and the learning shared separately even though trends and themes were looked for. No staff member would be investigating 2 deaths at the same time although they might involve some of the same people e.g. if it was the same prescriber that was involved. Learning from each death informed Service quality improvement plans, not just around the themes of deaths but the themes around improving Service quality as a whole.
· Contacts - had there been any delays when the new Service commenced or were there pathways in place if someone presented with depression or suicidal ideation?
- Everybody who was with the RDaSH Substance Misuse Service on the 31st March automatically transferred on 1st April, so their case went live immediately. It was a seamless transfer for everyone in Service at the time. The dual diagnosis pathway had been implemented recently and before there had been a process of staff individually making contact and making a referral through to the other Service in the same way as others such as a GP would. The pathway had been there but was less responsive and not as quick to access. Staff in CGL could now bypass some of that lengthy pathway because they already had a Mental Health Assessment which RDaSH would accept, remembering that the CGL service had a consultant psychiatrist.
· At the last meeting, Members learned that a pharmacy had withdrawn from providing the prescription drugs and this meant some people had to travel a lot further. Had that been looked at since?
- This had been the unexpected closure of the pharmacy at the Community Health Centre from which a high number of substance misuse service users picked up their prescriptions. The pharmacy gave the minimum term of legal notice to NHS England. All those Service users were successfully relocated, with the majority not needing to travel very far having gone to a pharmacy near the old football stadium which offered the same flexibility in terms of opening hours. In the end it was useful because it led to reviews with all Service users to check if this was still the best place for them to go.
· Regarding the low positive Service exit rate, was there confidence in achieving where we needed to go. Offset against this it was positive that Rotherham maintained success longer than the national picture, so what was being done differently here?
- On transition to CGL the first priority was to have a safe service so that all drug-users transferred safely to the new Service provider. It was reassuring that once people were leaving the Service they were not re-presenting; if the re-presentation rate had been higher that would have been more of a concern. The Commissioning Officer visited the Service several times a month, met with Service Managers monthly and reviewed the Service Improvement Plan in great detail. Clinical tools to determine which Service users were most recovery ready had been introduced in a safe manner. Rotherham had a legacy of Methadone users who were concerned that if they gave up their Methadone the Methadone offered a second time around might not be as good because the ethos around Methadone had changed. It was a difficult task but the tools used by CGL showed some slight improvement and it would be more concerning if exit numbers were doubling in case this meant people were leaving treatment too early. Any issues raised by GPs were considered and as almost half the client group had care with their own GP that provided assurance their care was safe. CGL and the GP jointly agreed the best course of action for each Service user.
- The number in shared care could act against us because as people were receiving long term care from their GP, they were quite comfortable. Many were in work and had had their children returned to live with them and were stable and safe and, therefore, not exposed to the recovery community at Carnson House. In the longer term it might be a case that more people would have to be brought in centrally to get them talking around recovery.
· With regards to the dual diagnosis pathway, domestic abuse did not feature despite the close links between mental health, domestic abuse and drug use in terms of being quite a toxic trio. Was that something that could be looked at going forward and why had it not appeared as a risk factor, even in terms of family history.
- The pathway included a sheet for staff for escalation between Substance Misuse and Mental Health Services and behind that sat a full assessment that would ask about domestic abuse, which was a priority.The escalation risk matrix was taken from national guidance and was not a standalone document but one supported by a range of assessments and information about the whole picture around that person.
- From an RDaSH perspective, if they were providing advice, support or conducting any assessment, that would definitely be a key feature and they had really positive links with the 3 non-statutory organisations in Rotherham so there were very clear pathways. Going forward in terms of the Champions’ work, discussion had taken place with the Trauma and Resilience Service staff to look at embedding some of that work. The pathway was a starting point and would develop to incorporate many non-statutory organisations within it for that whole breadth of knowledge and experience to support anybody along their journey.
· What was the routine questioning and data collection around domestic abuse?
- At CGL when questions were asked at assessment that would be recorded on their system. It was not something routinely asked about by commissioners but the facility was there to ask CGL specifically about their current caseload, to make sure that section was completed and to ask how many people had disclosed domestic abuse. Usually it was a relatively low figure in terms of numbers coming in to Service but did form part of the assessment.
- CGL undertook full risk reviews which captured that information in a separate module on the database. They also had a designated Safeguarding lead in the Service who had links with the Domestic Abuse Services and could also people who had experienced domestic abuse.
· It would be good to make sure the pathways were really clear and in place and to develop our understanding about the inter-connectivity and complexity of people's lives and what their most pressing issue was at that time.
· Some measures described in the slides were not very specific and talked in general terms about reduction or improvement. Were these more specific in the action plans and were people content with the rate of improvement?
- The 1.5% improvement target on Opiate exits had not been reached by CGL in the first 12 months of the contract, so they had been asked to roll that requirement forward into the next year, which would make year two of the contract delivery more challenging. The current rate of improvement showed the number of Opiate exits were going up and had been for the last 3 months. It was hoped this improvement seen at Service level would be borne out in the national end of year data from NDTMS. It was difficult to do anything other than compare itself with neighbouring areas because strictly speaking there could not be an enforceable target. When Opiate exit recovery was first talked about, some areas set very high targets for Services and Public Health England had concerns as the only sure fire way to get someone off Opiate use was to stop their prescription, which would lead to high rates of re-presentation. The performance improvement plans demonstrated that CGL were doing all the right things based on good practice from elsewhere in the country. Not meeting the target was disappointing but it was felt that it would happen and officers knew it would take time to change the culture.
· Was there confidence in being able to meet the target in year 2 after incorporating the deficit from year one?
- There was an absolute number that the Service would have needed to meet to get the 1.5% increase last year and Services were actually working with all the people that would be the target group but they were just not ready to leave yet. Looking at the overall number of people who were prescribed in Rotherham, it was right to be ambitious because the Service was so far behind the national picture that it had to keep pushing to get somewhere near it. It had been the case for too long that people on Methadone in Rotherham were less likely to exit than in other places in the country. There was no reason for that other than cultural history around Service users getting a Methadone offer and sticking fast to their prescriptions. CGL had been very keen to work with the Service and in other areas had pushed the rate up quite quickly from 3.5% to 7%. The tools used in some other areas were the same ones being implemented here and as they had worked elsewhere that gave the confidence, coupled with a detailed Service Improvement Plan that adhered to national guidance.
· Was it possible to separate out historical cases from ones coming through more recently or which were not so embedded.
- The longer somebody stayed on a prescription the more difficult it was for them to exit treatment. When the recovery process started about 5 years ago the average length of stay on a Methadone prescription in Rotherham was around 6 years and if people had not left the average grew longer every year. For someone starting a method of substitution prescription today it would be a different offer to the one 5 years ago, with people now quicker to come into Service, become stabilised, reduce and go back out. It was the legacy numbers that were the most difficult and linked back to the earlier point about GP care and shared care. People’s general health had improved as a result as they could have all their other health issues sorted out. Rotherham had an ageing drug-using population with people now in their forties and fifties so it got more difficult with every year. The aim was to get somewhere in the region of statistical neighbours and the national position and to make sure everybody had had that offer in the Service and to understand that recovery was possible.
Councillor Roche, Cabinet Member,reminded Members that CGL had come into Rotherham at very short notice to establish a “holding service” when Lifeline, the previous provider of recovery services, entered administration. They had made a good start but things needed some time to bed in. They were moving in the right direction but the figures needed to improve.
Resolved:- (1) To note the information provided with regard to progress on the outstanding recommendations from the spotlight review.
(2) To note current performance and service developments in the Drug and Alcohol Treatment and Recovery Service.
(3) To be updated on pathway developments to include wider issues such as domestic abuse.
William Brown assumed the Chair for the following agenda item.