1. Re-design – Findings so Far and Business Models for consideration Ben Seale November 2011

2. 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)

3. 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)

4. Current State - Community SPOC - Turning Point Counted4 NECA Huntercombe Centre HHAS Lifeline NERAF Res Rehab

5. Current State – Criminal Justice Integrated Offender Management team DISC Turning Point Counted4 ProbationPolicePrison Service ARREST RELEASE

6. Current State – Hospital (alcohol) Alcohol Liaison NurseTurning Point Hospital (AMU / Gastro / General…) Counted4 Community

7. 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

8. 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

9. 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

10. 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)

11. Outcome Definitions – PBR Final outcomes –Planned exit and do not re-present to the treatment or criminal justice system in the following 12 months

12. 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

13. 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)

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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: YearCore ActivityPbR Year 175%25% Year 260%40% Year 350% Year 440%60%

20. 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

21. 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

22. 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

23. 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

24. 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

25. Proposed Model (2) Assessment, Care Planning, Case Management, Assertive outreach, Peer Support Successful Treatment Completion Reduced Offending Employment Improved Health and Wellbeing Residential Rehabilitation Psychosocial Interventions Community Integration /ETE Detoxification – Community or Inpatient Substitute Prescribing Detoxification – Community or Inpatient Self Referral Harm Reduction DIP Hospital Professional referrals Family Interventions

26. 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

27. Risks Associated with Model Potential lack of choice Performance mainly reliant on performance of provider representing pathway function

28. 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.

29. Timelines – e.g. full procurement Continue 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)

30. 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

31. Discussion - Validity of Model - Chosen Business Approach